糖尿病足革兰阴性菌感染风险与Texas分期的相关性

Correlation between the risk of gram-negative bacteria infection in diabetic foot and Texas stage system

目的:观察糖尿病足感染(DFI)患者的病原菌特点,探讨Texas伤口分类系统与病原菌特征的相关性。方法:回顾性纳入2014年1月至2019年5月在战略支援部队特色医学中心内分泌科因DFI住院且创面细菌培养阳性的患者,对患者进行Texas分级及Texas分期的分组。收集患者的一般资料及创面细菌培养结果,应用阳性率描述病原菌特点。应用χ^(2)检验比较不同患者Texas分组与致病菌特征的相关性,并用logistic回归分析校正混杂因素。结果:239例患者纳入研究。根据创面深度进行Texas分级分组,Texas 2级组52例(局限于皮肤软组织)、Texas 3级组38例(深达肌腱)、Texas 4级组149例(累及骨和关节);根据是否合并缺血进行Texas分期分组(因5例缺乏缺血相关资料无法分组,故对234例患者进行分期分析),Texas B期组(不合并缺血)81例,Texas D期组(合并缺血)153例。239例中,以单病原菌感染(179例,74.9%)为主,革兰阳性菌(182例,76.2%)为主要致病菌,其中,革兰阳性菌中前3位细菌为金黄色葡萄球菌(71例,39.0%)、表皮葡萄球菌(35例,19.2%)及无乳链球菌(19例,10.4%)。不同Texas分级组患者均以革兰阳性菌感染为主,革兰阴性菌感染亦不少见,3组间的革兰阳性菌、革兰阴性菌差异均无统计学意义(P>0.05)。随分级提高,混合感染所占比例有增加的趋势,但Texas 2~4级组间差异无统计学意义(P>0.05)。按Texas分期分组,Texas B期组和Texas D期组均以革兰阳性菌感染为主,Texas B期组革兰阳性菌感染率(85.2%)高于Texas D期组(71.5%),差异具有统计学意义(P=0.019);Texas D期组革兰阴性菌感染率(43.7%)高于Texas B期组(25.9%),差异具有统计学意义(P=0.007)。校正年龄、糖尿病足病病程、糖化血红蛋白水平、抗生素应用史后,Texas B期组革兰阴性菌感染率低于Texas D期组(OR=0.52,95%CI为0.28~0.97,P=0.041)。结论:DFI病原菌以革兰阳性菌为主,多为单一病原菌感染。DFI病原菌特征与Texas分期相关,D期发生革兰阴性菌感染风险增高。

Objective To describe the microbiological profile of diabetes foot infection(DFI)and to analyze the correlation of Texas wound classification system with the characteristics of pathogenic bacteria.Methods Patients hospitalized in the Department of Endocrinology of PLA Strategic Support Force Characteristic Medical Center from January 2014 to May 2019 for DFI with positive bacterial culture results were recruited retrospectively in this study.The patients were assigned into different groups according to Texas grades and Texas stages.General data and bacterial culture results of the study population were collected.Positive rate was used to describe the microbiological profile.The correlations of different Texas grades and stages with pathogen characteristics were analyzed by Chi-square test.The potential confounding factors were corrected by logistic regression.Results Two hundred and thirty-nine patients were included in the study.According to the depth of the wounds,52 cases were in Texas grade 2 group(limited to skin and subcutaneous tissues),38 cases in Texas grade 3 group(deep into muscles)and 149 cases in Texas grade 4 group(involving bone and joint).According to the existence of ischemia(as 5 cases missed due to the lack of ischemia-related data,a total of 234 patients were divided into groups by Texas stages),81 cases were in Texas stage B group(without ischemia)and 153 cases in Texas stage D group(with ischemia).Among 239 cases,the majority of DFI were monomicrobial infections(74.9%)and Gram-positive bacteria(G+,182 cases,76.2%)were the major pathogens.Among G+cases,the most common three bacteria were Staphylococcus aureus(71 cases,39.0%),Staphylococcus epidermidis(35 cases,19.2%)and Streptococcus agalactiae(19 cases,10.4%).G+infections kept the major infections of patients in different Texas grade groups while G-infections were not rare.There was no significant difference in the positive rate of G+infections or G-infections among the three groups(P>0.05).According to Texas stages,G+infection took the main part in both Texas B group and Texas D group while the infection rate of G+in Texas B group(85.2%)was statistically higher than that in Texas D group(71.5%,P=0.019).On the other hand,The G-infection rate in Texas D group(43.7%)was higher than that in Texas B group(25.9%).The difference was statistically significant(P=0.007).After adjusting for age,course of diabetes foot,glycosylated hemoglobin level and history of antibiotic use,the infection rate of G-in Texas B group was still significantly lower than that in Texas D group(OR=0.52,95%CI 0.28-0.97,P=0.041).Conclusions G+was the main pathogen of DFI.Monomicrobial infections took the major part in DFI,and the risk of G-infection was increased significantly in Texas stage D.