改良序贯器官衰竭评分对肺炎克雷伯菌脓毒症预后的评估价值

Clinical value of improved sequential organ failure assessment in predicting the prognosis of Klebsiella pneumoniae sepsis

目的:探讨改良序贯器官衰竭评分(improved sequential organ failure assessment,ISOFA)对肺炎克雷伯菌脓毒症预后的评估价值。方法:回顾性分析2018年1月1日至2019年6月30日吉林大学第一医院收治的379例肺炎克雷伯菌脓毒症患者的临床资料。按28 d预后情况分为存活组和死亡组,比较2组患者的年龄、性别、C反应蛋白、降钙素原、细菌耐药分级、发生脓毒症休克等指标。统计学分析采用独立样本t检验、曼-惠特尼U检验和χ^(2)检验。logistic回归分析影响患者预后的危险因素;Spearman相关系数判定ISOFA与各评分系统包括查尔森评分(Charlson′s weighted index of comorbidities,WIC)、英国国家早期预警评分(national early warning system,NEWS)、急性生理学和慢性健康状况评分Ⅱ(acute physiology and chronic health evaluationⅡ,APACHEⅡ)、简化急性生理学评分Ⅱ(simplified acute physiology scoreⅡ,SAPSⅡ)、急性脓毒症病死率评分(mortality in emergency department sepsis score,MEDS)、序贯器官衰竭评分(sequential organ failure assessment,SOFA)、急性胃肠损伤分级(acute gastrointestinal injury,AGI)的相关性;采用受试者操作特征曲线下面积(area under receiver operating characteristic curve,AUROC)比较各评分系统对肺炎克雷伯菌脓毒症预后的评估价值。采用Kaplan-Meier生存曲线评价ISOFA风险分层在生存情况中的意义。结果:379例肺炎克雷伯菌脓毒症患者中,存活组278例,死亡组101例。2组患者的年龄、性别、发生脓毒症休克、细菌耐药分级、C反应蛋白、降钙素原,以及WIC、NEWS、APACHEⅡ、SAPSⅡ、MEDS、SOFA、AGI、ISOFA比较,差异均有统计学意义(t=-3.218,χ^(2)=6.781、24.374、27.208,Z=-3.689、-5.022、-4.396、-4.697、-7.438、-6.348、-6.358、-8.676、-6.680、-11.658,均P<0.01)。单因素分析得到ISOFA的计算方法:ISOFA=SOFA+1.5×AGI。多因素logistic回归提示ISOFA、性别、SOFA、降钙素原、C反应蛋白、细菌耐药分级是影响预后的独立危险因素。ISOFA与WIC、NEWS、APACHEⅡ、SAPSⅡ、MEDS、SOFA的Spearman相关系数分别为0.327、0.371、0.614、0.564、0.578、0.847。WIC、NEWS、MEDS、SAPSⅡ、APACHEⅡ、SOFA、SOFA+AGI、ISOFA预测肺炎克雷伯菌脓毒症预后的AUROC及95%可信区间分别为0.646(0.584~0.708)、0.657(0.597~0.716)、0.712(0.654~0.771)、0.713(0.653~0.773)、0.749(0.693~0.806)、0.788(0.737~0.838)、0.872(0.826~0.917)、0.891(0.845~0.937),表明ISOFA预测效果最佳。Kaplan-Meier生存曲线提示,ISOFA低风险水平、中等风险水平、高风险水平间的生存情况差异均有统计学意义(均P<0.01)。结论:ISOFA对预测肺炎克雷伯菌脓毒症预后有重要的临床意义。

Objective To explore the value of improved sequential organ failure assessment(ISOFA)in predicting the prognosis of Klebsiella pneumoniae sepsis.Methods The clinical data of 379 patients with Klebsiella pneumoniae sepsis admitted to the First Hospital of Jilin University from January 1,2018 to June 30,2019 were retrospectively analyzed.They were divided into survival group and death group according to the 28-day prognosis,and the age,gender,C-reactive protein,procalcitonin,grade of bacterial resistance,and the occurrence of septic shock of the two groups were compared.Statistical analysis was conducted by using independent sample t test,Mann-Whitney U test and chi-square test.Risk factors for the prognosis of the disease was analyzed by logistic regression analysis.The correlation between ISOFA and other scoring system including Charlson′s weighted index of comorbidities(WIC),national early warning system(NEWS),acute physiology and chronic health evaluationⅡ(APACHEⅡ),simplified acute physiology scoreⅡ(SAPSⅡ),mortality in emergency department sepsis score(MEDS),sequential organ failure assessment(SOFA),acute gastrointestinal injury(AGI)was determined by Spearman correlation coefficient.The area under the receiver operating characteristic curve(AUROC)was used to compare the evaluation value of each scoring system for the prognosis of Klebsiella pneumoniae sepsis.The clinical significance of ISOFA risk stratification was evaluated by Kaplan-Meier survival curve.Results Among the 379 patients with Klebsiella pneumoniae sepsis,278 were in the survival group and 101 were in the death group.The differences of age,gender,the occurrence of septic shock,grade of bacterial resistance,C-reactive protein,procalcitonin,WIC,NEWS,APACHEⅡ,SAPSⅡ,MEDS,SOFA,AGI and ISOFA score between the two groups were all statistically significant(t=-3.218;χ^(2)=6.781,24.374 and 27.208,respectively;Z=-3.689,-5.022,-4.396,-4.697,-7.438,-6.348,-6.358,-8.676,-6.680 and-11.658,respectively;all P<0.01).The calculation method of ISOFA was obtained by single factor analysis:ISOFA=SOFA+1.5×AGI.Multivariate logistic regression suggested that ISOFA,gender,SOFA,procalcitonin,C-reactive protein,and bacterial resistance were independent risk factors for the prognosis of the disease.The Spearman correlation coefficients of ISOFA and WIC,NEWS,APACHEⅡ,SAPSⅡ,MEDS and SOFA were 0.327,0.371,0.614,0.564,0.578 and 0.847,respectively.The AUROC and its 95%confidence interval for WIC,NEWS,MEDS,SAPSⅡ,APACHEⅡ,SOFA alone,SOFA plus AGI,and ISOFA to predict the prognosis of Klebsiella pneumoniae sepsis were 0.646(0.584-0.708),0.657(0.597-0.716),0.712(0.654-0.771),0.713(0.653-0.773),0.749(0.693-0.806),0.788(0.737-0.838),0.872(0.826-0.917)and 0.891(0.845-0.937),respectively.The results showed that ISOFA had the best predictive effect.The Kaplan-Meier survival curve suggested that there were statistical differences in survival rate among ISOFA low-risk level,medium-risk level,and high-risk level(all P<0.01).Conclusion ISOFA has important clinical significance in predicting the prognosis of Klebsiella pneumoniae sepsis.