耐碳青霉烯类肺炎克雷伯菌呼吸机相关肺炎发病及预后危险因素

Risk factors for ventilator-associated pneumonia caused by carbapenem-resistant Klebsiella pneumoniae and prognosis

目的探讨耐碳青霉烯类肺炎克雷伯菌(CRKP)呼吸机相关肺炎(VAP)危险因素及预后影响因素。方法回顾性分析上海市第十人民医院2014年1月-2019年12月重症监护病房(ICU)肺炎克雷伯菌引起VAP患者的临床资料,分为碳青霉烯类耐药肺炎克雷伯菌(CRKP)VAP组和碳青霉烯类敏感肺炎克雷伯菌(CSKP)VAP组,应用单因素分析和多因素Logistic回归分析CRKP所致VAP的危险因素;同时将CRKP组根据VAP发生后28 d预后情况分为存活组和病死组,分析其预后影响因素。结果共纳入研究对象210例,其中CRKP组112例,CSKP组98例。CRKP组病死率27.68%(31/112)高于CSKP组病死率15.31%(15/98),差异有统计学意义(χ2=4.6771,P=0.0306)。多因素Logistic回归分析显示发生CRKP引起的VAP独立危险因素包括:VAP发生前入ICU>10 d、迟发型VAP、二次气管插管、碳青霉烯类的使用、联用抗菌药物和白蛋白<30 g/L(均P<0.05)。CRKP引起的VAP独立预后影响因素包括:年龄、迟发型VAP、二次气管插管、降钙素原(PCT)和白蛋白(均P<0.05)。结论相较于CSKP感染的VAP患者,CRKP感染者28 d病死率更高,尤其对于存在年龄大、迟发型VAP、二次气管插管、PCT升高等危险因素的患者,更应引起临床医生的重视。

OBJECTIVE To explore the risk factors for ventilator-associated pneumonia(VAP) caused by carbapenem-resistant Klebsiella pneumoniae(CRKP) and analyze the influencing factors for prognosis. METHODS The clinical data of the patients with CRKP VAP who were treated in intensive care unit(ICU) in Shanghai Tenth People’s Hospital from Jan 2014 to Dec 2019 were retrospectively analyzed, the enrolled patients were divided into the CRKP VAP group and the CSKP VAP group. Univariate analysis and multivariate logistic regression analysis were performed for the risk factors for the CRKP VAP, the patients of the CRKP group were divided into the survival group and the death group according to the prognosis. RESULTS Totally 210 study objects were involved in the study, with 112 cases in the CRKP group, 98 cases in the CSKP group. The mortality rate of the CRKP group was 27.68%(31/112), significantly higher than 15.31%(15/98) of the CSKP group(χ~2=4.6771,P=0.0306). Multivariate logistic regression analysis showed that the independent risk factors for the CRKP VAP included length of ICU stay more than 10 days before onset of VAP, late-onset VAP, secondary endotracheal intubation, use of carbapenems, combined use of antibiotics and albumin less than 30 g/L(all P<0.05). The influencing factors for the prognosis of the patients with CRKP VAP included the age, late-onset VAP, secondary endotracheal intubation, procalcitonin(PCT) and albumin( all P<0.05). CONCLUSION The 28-day mortality rate of the patients with CRKP infection is higher than that of the patients with CSKP infection, and it is even more necessary for clinicians to pay attention to the patients with such risk factors as old age, late-onset VAP, secondary endotracheal intubation and rise of PCT.