降钙素原和危重症评分在腹腔感染脓毒症病原学诊断及预后评估中的价值

Value of procalcitonin and critical illness score in etiological diagnosis and prognosis of sepsis caused by intra-abdominal infections

目的比较多种危重症评分(CIS)及生物标志物降钙素原(PCT)对腹腔感染(IAI)导致血流感染(BSI)脓毒症患者早期和晚期预后的评估价值以及PCT在病原学诊断中的价值。方法收集2014年1月至2019年12月就诊于中日友好医院急诊科最终诊断为IAI且就诊24 h内至少有1次血培养阳性的脓毒症患者的临床资料。根据患者就诊当天首次实验室检查结果计算序贯器官衰竭评分(SOFA)、急诊脓毒症死亡风险评分(MEDS)、Logistic器官功能障碍评分系统(LODS)评分、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)。比较不同革兰染色菌感染者之间以及不同28 d或60 d预后患者之间各指标的差异;用受试者工作特征曲线(ROC曲线)分析PCT对单一细菌IAI导致BSI脓毒症病原学鉴别诊断的价值,以及各种CIS和PCT对IAI导致BSI脓毒症患者28 d和60 d死亡的预测价值。结果共纳入单一细菌IAI导致BSI脓毒症患者221例,28 d病死率为19.9%(44/221),60 d病死率为25.8%(57/221);革兰阳性菌(G+菌)感染患者的病死率明显高于革兰阴性菌(G-菌)感染患者(28 d:34.6%比11.4%,60 d:42.0%比16.4%,均P<0.01)。与G+菌感染患者比较,G-菌感染患者PCT水平明显升高〔µg/L:4.31(0.71,25.71)比1.29(0.32,10.83),P<0.05〕。无论是28 d还是60 d,死亡组患者CIS及生物标志物PCT均明显高于存活组〔28 d死亡组比存活组:SOFA评分(分)为6.0(4.0,10.0)比3.0(2.0,5.0),MEDS评分(分)为11(9,14)比6(6,9),LODS评分(分)为4.0(2.0,6.0)比1.0(0,2.0),APACHEⅡ评分(分)为17.0(15.0,24.0)比12.0(8.0,15.0),PCT(μg/L)为3.48(1.01,26.70)比2.45(0.32,15.65);60 d死亡组比存活组:SOFA评分(分)为6.0(4.0,10.0)比3.0(2.0,5.0),MEDS评分(分)为9(6,14)比6(6,9),LODS评分(分)为4.0(1.0,5.0)比1.0(0,2.0),APACHEⅡ评分(分)为16.5(12.0,20.0)比12.0(8.0,15.0),PCT(μg/L)为2.67(0.98,17.73)比2.22(0.31,16.75);均P<0.05〕。ROC曲线分析显示:①PCT对单一细菌IAI导致BSI脓毒症患者病原学鉴别诊断的ROC曲线下面积(AUC)为0.740〔95%可信区间(95%CI)为0.648~0.833〕;当PCT的最佳截断值为1.82µg/L时,其诊断G-菌感染的敏感度为74.0%,特异度为68.2%;当PCT>10.92µg/L时,其诊断G-菌感染的特异度可达81.8%。②在预测IAI导致BSI脓毒症患者28 d和60 d预后方面,APACHEⅡ评分的AUC最大〔28 d:0.791(95%CI为0.680~0.902),60 d:0.748(95%CI为0.645~0.851)〕;当APACHEⅡ评分>14.5分时,预测患者28 d和60 d死亡的阴性预测值分别为94.9%、88.5%。PCT对IAI导致BSI脓毒症患者预后的预测价值较低〔28 d AUC:0.610(95%CI为0.495~0.725),60 d AUC:0.558(95%CI为0.450~0.667)〕。结论PCT在判断IAI导致BSI脓毒症患者病原菌方面较为可靠;但在评估早期和晚期预后方面,APACHEⅡ评分可能更具优势。

Objective To compare the early and late predictive values of critical illness score(CIS)and procalcitonin(PCT)in septic patients with blood stream infection(BSI)induced by intra-abdominal infection(IAI),and to identify the value of PCT in etiological diagnosis.Methods The clinical data of patients with at least one positive blood culture within 24 hours admission to the emergency department of China-Japan Friendship Hospital from January 2014 to December 2019 and with final diagnosis of IAI induced sepsis were enrolled.Sequential organ failure assessment(SOFA),mortality in emergency department sepsis(MEDS),Logistic organ dysfunction system(LODS),and acute physiology and chronic health evaluationⅡ(APACHEⅡ)scores were calculated based on the parameters on the day of admission.Differences in various indicators among different Gram-stained bacterial infections and among patients with different prognosis at 28 days or 60 days were compared.Receiver operator characteristic curve(ROC curve)was used to analyze the value of PCT in differential etiological diagnosis of IAI induced sepsis caused by single bacterial infection,and the predictive value of CIS and PCT on 28-day and 60-day death of septic patients with BSI induced by IAI.Results A total of 221 septic patients with IAI caused by single bacterial infection were enrolled.The 28-day mortality was 19.9%(44/221),and the 60-day mortality was 25.8%(57/221).Mortality caused by Gram-positive(G+)bacterial infection of patients was significantly higher than that caused by Gram-negative(G-)bacterial infection(28 days:34.6%vs.11.4%,60 days:42.0%vs.16.4%,both P<0.01).Compared with patients with G+bacterial infection,the PCT value of patients with G-bacterial infection was higher[µg/L:4.31(0.71,25.71)vs.1.29(0.32,10.83),P<0.05].Compared with survival group,the values of CIS and PCT in death group were higher,either in 28 days or in 60 days[death group vs.survival group in 28 days:SOFA score was 6.0(4.0,10.0)vs.3.0(2.0,5.0),MEDS score:11(9,14)vs.6(6,9),LODS score:4.0(2.0,6.0)vs.1.0(0,2.0),APACHEⅡscore:17.0(15.0,24.0)vs.12.0(8.0,15.0),PCT(μg/L):3.48(1.01,26.70)vs.2.45(0.32,15.65);death group vs.survival group in 60 days:SOFA score:6.0(4.0,10.0)vs.3.0(2.0,5.0),MEDS score:9(6,14)vs.6(6,9),LODS score:4.0(1.0,5.0)vs.1.0(0,2.0),APACHEⅡscore:16.5(12.0,20.0)vs.12.0(8.0,15.0),PCT(μg/L):2.67(0.98,17.73)vs.2.22(0.31,16.75);all P<0.05].ROC curve showed that:①the area under ROC curve(AUC)of PCT in the diagnosis of IAI induced sepsis with single bacterial infection was 0.740[95%confidence interval(95%CI)was 0.648-0.833].When the optimal cut-off value of PCT was 1.82µg/L,the sensitivity of diagnosis of G-bacterial infection was 74.0%,and the specificity was 68.2%.When PCT value was higher than 10.92µg/L,the specificity of diagnosis of G-bacterial infection could reach 81.8%.②In the prediction of 28-day and 60-day mortality for septic patients with BSI induced by IAI,the APACHEⅡscore achieved the highest AUC[28 days:0.791(95%CI was 0.680-0.902),60 days:0.748(95%CI was 0.645-0.851)].APACHEⅡscore higher than 14.5 could help to predict 28-day and 60-day mortality for IAI patients with negative predictive values of 94.9%and 88.5%.However,the predictive value of PCT for septic patients with BSI induced by IAI was relatively lower[28-day AUC:0.610(95%CI was 0.495-0.725),60-day AUC:0.558(95%CI was 0.450-0.667)].Conclusion PCT is more reliable in the identification of pathogen type among IAI induced sepsis with BSI,while APACHEⅡscore may perform better in predicting early and late mortality.