ICU老年患者下呼吸道多重耐药肺炎克雷伯杆菌感染的危险因素分析及对预后的影响

Risk factors analysis of multi-drug resistant Klebsiella pneumoniae causing lower respiratory tract infection in elderly ICU patients and its influence on prognosis

目的分析重症医学科(ICU)老年患者下呼吸道多重耐药肺炎克雷伯杆菌(MDR-KPN)感染的危险因素及对预后的影响。方法回顾性研究。选择2018年1月至2019年9月朝阳市第二医院ICU老年下呼吸道感染患者作为研究对象,均采集痰或肺泡灌洗液标本进行病原学培养,共培养分离出KPN 249株。根据药敏试验结果是否为多重耐药分为肺炎克雷伯杆菌(KPN)组(n=152)和MDR-KPN组(n=97),以患者入ICU 28 d作为预后判断时间点,比较2组预后。同时比较2组一般情况、入ICU时间、抗菌药物使用情况、是否使用呼吸机、呼吸机使用时间等与感染相关的指标,再进一步以是否为MDR-KPN为因变量,有统计学意义的危险因素为自变量,采用多因素logistic回归分析。结果MDR-KPN组患者好转率为32.99%(32/97),低于KPN组(56.58%,86/152),恶化和病死率为67.01%(65/97),高于KPN组(43.42%,66/152),差异均有统计学意义(P值均<0.05)。MDR-KPN组患者标本采集时ICU住院时间>7 d、入ICU时急性生理学与慢性健康状况评分(APACHEⅡ)>20分、入ICU时血糖>7.8 mmol/L、使用呼吸机、标本采集时呼吸机使用时间>7 d、标本采集时广谱抗菌药物使用时间>7 d、标本采集前使用头孢三代抗菌药物患者的构成比均大于KPN组(P值均<0.05)。对有统计学意义的单因素赋值,采用多因素logistic回归分析显示,标本采集时住ICU时间>7 d、入ICU时APACHEⅡ评分>20分、标本采集时呼吸机使用时间>7 d、标本采集时广谱抗菌药物使用时间>7 d是老年下呼吸道MDR-KPN感染的危险因素(OR值分别为7.416、3.702、6.763、8.971,95%CI分别为3.672~18.248、1.951~13.688、4.682~11.609、4.160~27.853)。结论ICU老年患者下呼吸道MDR-KPN感染预后差,病死率高。住ICU时间长,APACHEⅡ评分高、呼吸机使用时间长及广谱抗菌药物使用时间长是MDR-KPN感染的危险因素,因此对有上述危险因素的患者要积极防治MDR-KPN感染,以降低病死率。

Objective To analyze the risk factors for multi-drug resistant Klebsiella pneumoniae(MDR-KPN)causing lower respiratory tract infection(LRTI)in elderly intensive care unit(ICU)patients and its influence on prognosis.Methods Elderly ICU patients with LRTI in the Second Hospital of Chaoyang from January 2018 to September 2019 were selected as the research objects.Strains 249 of KPN by bacterial co-culture were isolated from collecting sputum or specimen of alveolar lavage fluid and for which performing pathogen culture of this patients,the patients were divided into Klebsiella pneumoniae(KPN)group(n=152)and MDR-KPN group(n=97)based on whether MDR as the results of drug-susceptibility test.Twenty-eight days after admission to ICU were viewed as prognostic point,the aim was to compare prognosis of the two groups,and count general situation,ICU hospitalization time,use of antibiotics,whether using ventilator,use time of ventilator.Furthermore,MDR-KPN was taken as the dependent variable and statistically significant risk factors as the independent variable,and multivariate logistic regression analysis was used.Results Improving rate in MDR-KPN group was lower than that in KPN group[32.99%(32/97)vs 56.58%(86/152),P<0.05,respectively];deterioration and mortality were 67.01%(65/97)in MDR-KPN group,higher than that of KPN group[43.42%(66/152)],difference being significant(P<0.05).After admission to ICU,specimen collection was performed,ICU hospitalization time>7 d,acute physiology and chronic health evaluation Ⅱ(APACHEⅡ)score>20,blood glucose>7.8 mmol/L,using ventilator,using time of ventilator>7 d,using time of broad-spectrum antibiotic>7 d,constituent ratio of using third-generation cephalosporins in MDR-KPN group were higher than those in KPN group(all P<0.05).The statistically significant single factor was assigned values,multi-factor Logistic regression analysis showed that the risk factors for MDR-KPN causing LRTI in elderly patients were ICU hospitalization time>7 d,APACHEⅡ score>20,using ventilator,using time of ventilator>7 d,using time of broad-spectrum antibiotic>7 d(OR=7.416,3.702,6.763,8.971;95%CI:3.672-18.248,1.951-13.688,4.682-11.609,4.160-27.853,respectively).Conclusions The prognosis of MDR-KPN causing LRTI in elderly ICU patients is poor,and with high mortality.Risk factor for MDR-KPN causing infection was long time to ICU,higher APACHEⅡ score,long duration of ventilator use and long-term use of broad-spectrum antibiotic,patients with these risk factors should actively prevent infection causing MDR-KPN to reduce mortality.