真菌培养阳性和阴性脓毒症合并慢性阻塞性肺疾病患者的预后分析

Characteristics and outcomes of positive and negative fungal cultures in sepsis patients with COPD

比较脓毒症合并慢性阻塞性肺疾病(COPD)患者中真菌培养阳性与真菌培养阴性脓毒症的特征和预后。方法通过大数据分析的方法进行回顾性分析。选择重症监护医学信息数据库-Ⅲ(MIMIC-Ⅲ)数据库内的入院诊断脓毒症合并COPD、年龄>18岁的患者作为研究对象。根据患者入住ICU后真菌培养(标本类型:呼吸道标本,如痰、支气管吸取物、肺泡灌洗液等)是否阳性分为真菌培养阳性组和真菌培养阴性组,分析两组患者的人口统计学(年龄、性别、种族、身高、体质量等)、合并症、入院24 h的生命体征、病情严重程度,采用Kaplan-Meier生存曲线比较真菌培养阳性和真菌培养阴性患者的生存率。用倾向性评分匹配组间差异。结果共1041例ICU脓毒症合并COPD患者纳入最终分析,真菌培养阳性组134例,真菌培养阴性组907例。真菌培养阳性组较真菌培养阴性组既往合并肾衰竭患者更少,入院第1天的心率更快[次/min:114(95,126)vs.108(93,123),P=0.03]、呼吸频率更高[次/min:29(26,35)vs.28(24,33),P=0.02],序贯器官衰竭评分(sequential organ failure assessment,SOFA)更高[分:8(5,10)vs.5(3,8),P<0.001],真菌培养阳性组较真菌培养阴性组机械通气时间更长[h:171.2(60.2,323.5)vs.105.0(25.6,256.8),P<0.001],住院日更长[d:12.4(7.6,23.7)vs.10.6(5.9,19.1),P=0.016],ICU住院时间更长[d:8.4(3.9,16.2)vs.3.4(1.8,9.3),P<0.001],病死率更高[28 d:38.1%vs.26.6%,P=0.006,60 d:39.6%vs.27.0%,P=0.003,90 d:40.3%vs.27.0%,P=0.002]。经倾向性匹配后,共102对匹配成功,真菌培养阳性组较真菌培养阴性组住院期间机械通气时间更长[h:173.5(57.0,305.3)vs.105.0(19.7,252.0),P=0.01],ICU住院天数更长[d:8.4(3.8,16.2)vs.3.7(1.9,10.4),P<0.001],病死率更高[28 d:38.2%vs.24.5%,P=0.035,60 d:39.2%vs.25.5%,P=0.036,90 d:39.2%vs.25.5%,P=0.036]。Kaplan-Meier生存曲线分析显示,脓毒症合并COPD患者真菌培养阴性组患者60 d累积生存率明显高于真菌培养阳性组(Log-rank检验:χ2=4.88,P=0.03)。结论真菌培养阳性的脓毒症合并COPD患者与预后不良相关,病情更严重,住院时间更长,病死率更高。

Objective To compare the characteristics and prognosis of positive and negative fungal cultures in sepsis patients with chronic obstructive pulmonary disease(COPD).Methods Retrospective analysis was conducted by big data analysis.Patients older than 18 years old who were admitted to the Medical Information Mart for Intensive Care DatabaseⅢ(MIMIC-Ⅲ) and diagnosed with sepsis complicated with COPD were selected as research objects.According to the results of fungal culture(including bronchial tube and respiratory tract secretions: sputum,bronchoalveolar lavage),the patients in ICU was divided into positive group and negative group.Based on the analysis of demography(age,gender,race,height,weight,etc.),complications,vital signs within 24 h after admission,illness severity in two groups,Kaplan-Meier survival curve was utilized to compare the survival rate between fungal culture-positive patients and fungal culture-negative patients with COPD.Propensity scores were used to match the differences of positive group and negative group.Results A total of 1041 sepsis patients with COPD in ICU were included in the final analysis,with 134 patients in the fungal culture-positive group and 907 patients in the fungal culture-negative group.Compared with the fungal culture-negative group,the fungal culture-positive group had more patients with previous renal failure,and the heart rate [times/min: 108(93,123) vs.114(95,126),P = 0.03],the respiratory rate[times/min: 28(24,33) vs.29(26,35),P = 0.02 ],the scores in sequential organ failure assessment(SOFA) [scores: 5(3,8) vs.8(5,10),P < 0.001] were higher on the first day of admission.Sepsis patient with COPD in the fungal culture-positive group had longer periods of mechanical ventilation[h: 105.0(25.6.,256.8) vs.171.2(60.2,323.5),P = 0.001],hospital stays[d: 10.6(5.9,19.1) vs.12.4(7.6,23.7),P =0.016],ICU stays[d: 3.4(1.8,9.3) vs.8.4(3.9,16.2),P < 0.001]and the higher mortality [28 d: 26.6% vs.38.1%,P = 0.006;60 d: 27.0% vs.39.6%,P = 0.003;90 d: 27.0% vs.40.3%,P = 0.002].A total of 102 pairs were successfully matched after propensity matching.Compared with the fungal culture-negative group,the fungal culture-positive group had the longer mechanical ventilation duration during hospitalization [h: 105.0(19.7,252.0) vs.173.5(57.0,305.3),P = 0.01],the longer ICU stays[d: 3.7(1.9,10.4) vs.8.4(3.8,16.2),P < 0.001]and the higher mortality(28 d: 24.5% vs.38.2%,P = 0.035;60 d: 25.5% vs.39.2%,P = 0.036;90 d: 25.5% vs.39.2%,P = 0.036).Kaplan-Meier survival curve analysis showed that the 60-day cumulative survival rate of sepsis patients combined with COPD in the fungal culture-negative group was significantly higher than that in the fungal culture-positive group(Log-rank test: χ2= 4.88,P = 0.03).Conclusions Sepsis patients with COPD had positive result of fungal culture,whose prognosis is poor,diseases are more severe,the hospital stays are longer,and the mortality is higher.