中心静脉导管相关性血流感染预后相关因素分析

Prognostic Factors of Central Venous Catheter-related Bloodstream Infections

目的探讨中心静脉导管相关性血流感染(CR-BSI)预后相关因素,为临床提供参考。方法回顾2014年2月至2019年7月346例CR-BSI患者临床资料,对其预后相关因素进行分析。结果346例CR-BSI患者死亡62例,病死率为17.92%;单因素分析显示,年龄(t=2.838,P=0.006)、糖尿病史(χ^2=5.966,P=0.015)、感染后拨管时间(t=5.026,P=0.000)、是否入住ICU(χ^2=6.885,P=0.009)、置管部位(χ^2=5.468,P=0.019)、是否使用糖皮质激素(χ^2=4.731,P=0.030)、发生CR-BSI后急性生理与慢性健康评分Ⅱ(APACHEⅡ)(t=3.556,P=0.000)、耐甲氧西林金黄色葡萄球菌(MRSA)感染(χ^2=10.209,P=0.001)、多重耐药铜绿假单胞菌(MDR-PA)感染(χ^2=22.668,P=0.000)、耐碳青酶烯类肺炎克雷伯菌(CRKP)感染(χ^2=16.758,P=0.000)、产超广谱β-内酰胺酶肠杆菌科细菌感染(χ^2=7.784,P=0.005)、真菌感染(χ^2=6.576,P=0.010)、感染发生前使用抗菌药物(χ^2=5.315,P=0.021)、感染发生前联用抗菌药物(χ^2=4.260,P=0.039)、感染后开始使用抗菌药物时间(t=2.805,P=0.006)、感染后根据药敏试验使用抗菌药物时间(t=2.877,P=0.005)、血清白蛋白浓度(t=-2.976,P=0.003)、血糖(t=2.632,P=0.010)等18个因素是CR-BSI死亡的相关因素;多因素Logistic分析显示,高血糖(OR=5.047,95%CI=1.805~14.114,P=0.002)、MRSA感染(OR=18.278,95%CI=3.732~89.527,P=0.000)、MDR-PA感染(OR=42.380,95%CI=9.477~189.528,P=0.000)、CRKP感染(OR=72.834,95%CI=16.061~330.286,P=0.000)、发生CR-BSI后APACHEⅡ评分高(OR=6.615,95%CI=2.625~16.667,P=0.000)、感染后至拨管时间(OR=4.071,95%CI=1.743~9.508,P=0.001)与感染后至根据药敏试验使用抗菌药物时间(OR=5.047,95%CI=1.805~14.114,P=0.001)等6个因素是CR-BSI死亡的独立危险因素,血清白蛋白浓度(OR=0.365,95%CI=0.136~0.978,P=0.045)是CR-BSI死亡的独立保护因素。结论高血糖、低蛋白血症、危重症、多重耐药菌感染是增加CR-BSI病死率的危险因素;早期拨管、早期细菌培养及药敏试验指导使用抗菌药物可减少CR-BSI病死率,临床应采取针对性综合措施。

Objective To explore the prognostic factors of central venous catheter-related bloodstream infection(CR-BSI)and provide reference for clinical practice.Methods The clinical data of 346 CR-BSI patients from February 2014 to July 2019 were retrospectively reviewed,and the prognostic factors were analyzed.Results Of the 346 CR-BSI patients,62 died,yielding a case-fatality rate of 17.92%.Univariate analysis showed that 18 factors including age(t=2.838,P=0.006),history of diabetes(χ^2=5.966,P=0.015),time to withdrawing the tube after infection(t=5.026,P=0.000),ICU stay(χ^2=6.885,P=0.009),catheter placement(χ^2=5.468,P=0.019),use of glucocorticoids(χ^2=4.731,P=0.030),Acute Physiology and Chronic Health ScoreⅡ(APACHEⅡ)after CR-BSI(t=3.556,P=0.000),methicillin-resistant Staphylococcus aureus(MRSA)infection(χ^2=10.209,P=0.001),multidrug-resistant Pseudomonas aeruginosa(MDR-PA)infection(χ^2=22.668,P=0.000),carbapenem-resistant Klebsiella pneumonia(CRKP)infection(χ^2=16.758,P=0.000),infection with extended-spectrumβ-lactamase-producing enterobacteriaceae(χ^2=7.784,P=0.005),fungal infection(χ^2=6.576,P=0.010),use of antibacterial drugs before infection(χ^2=5.315,P=0.021),combined use of antibacterial drugs before infection(χ^2=4.260,P=0.039),time to start using antibacterial drugs(t=2.805,P=0.006),time to start using antibacterial drugs according to the results of susceptibility test(t=2.877,P=0.005),serum albumin concentration(t=-2.976,P=0.003),blood sugar(t=2.632,P=0.010)were associated with CR-BSI death.Multivariate logistic analysis showed that 6 factors including hyperglycemia(OR=5.047,95%CI=1.805-14.114,P=0.002),MRSA infection(OR=18.278,95%CI=3.732-89.527,P=0.000),MDR-PA infection(OR=42.380,95%CI=9.477-189.528,P=0.000),CRKP infection(OR=72.834,95%CI=16.061-330.286,P=0.000),increased APACHEⅡ score after CR-BSI(OR=6.615,95%CI=2.625-16.667,P=0.000),time from infection to extubation(OR=4.071,95%CI=1.743-9.508,P=0.001),and time from infection to use of antibiotics according to drug sensitivity test(OR=5.047,95%CI=1.805-14.114,P=0.001)were independent risk factors for CR-BSI death.Serum albumin concentration(OR=0.365,95%CI=0.136-0.978,P=0.045)was an independent protective factor for CR-BSI death.Conclusions Hyperglycemia,hypoproteinemia,critical illness,and multidrug-resistant bacterial infection are the risk factors for CR-BSI death.Early extubation,early bacterial culture,and early drug sensitivity test may help to reduce the mortality of CR-BSI.