耐碳青霉烯类肺炎克雷伯菌血流感染的预后相关因素分析

Factors associated with prognosis of carbapenem-resistant Klebsiella pneumoniae bloodstream infection

目的:分析耐碳青霉烯类肺炎克雷伯菌(carbapenem-resistant Klebsiella pneumoniae,CRKP)血流感染患者的临床特点及其预后不良的危险因素,帮助指导临床治疗。方法:回顾性分析2015年8月至2020年8月安徽医科大学第一附属医院收治的CRKP血流感染成年患者的临床特征、合并感染部位、合并症、实验室检查、抗菌药物暴露情况等资料。将患者分为预后良好组和预后不良组,比较两组患者的临床资料,统计学分析采用秩和检验、χ^(2)检验。使用二分类logistic回归分析影响CRKP血流感染患者预后不良的危险因素。结果:106例CRKP血流感染患者中,预后良好组47例,预后不良组59例。预后良好组与预后不良组的住院时间[39(22,89)d比21(15,38)d]、90 d内入院史比例[17.0%(8/47)比35.6%(21/59)]、有碳青霉烯类药物暴露史比例[42.6%(20/47)比64.4%(38/59)]、合并下呼吸道感染比例[44.7%(21/47)比78.0%(46/59)]、入住重症监护病房比例[34.0%(16/47)比81.4%(48/59)]、感染性休克比例[19.1%(9/47)比69.5%(41/59)]、合并多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)比例[10.6%(5/47)比74.6(44/59)]、处于实体器官移植后状态比例[40.4%(19/47)比18.6(11/59)]、接受外科手术比例[51.1%(24/47)比32.2%(19/59)]、接受机械通气比例[23.4%(11/47)比74.6%(44/59)]、Pitt菌血症评分≥4分[21.3%(10/47)比69.5%(41/59)]、快速序贯器官衰竭评估评分≥2分[14.9%(7/47)比81.4%(48/59)]、血小板计数<100×10^(9)/L比例[31.9%(15/47)比62.7%(37/59)]之间差异均有统计学意义(Z=-3.72,χ^(2)=4.54、5.04、12.46、24.48、26.61、43.02、6.12、3.86、27.44、24.36、46.29、9.93,均P<0.050)。多因素分析提示合并下呼吸道感染[比值比(odds ratio,OR)=3.293,95%可信区间(confidence interval,CI)1.138~9.528,P=0.028]、MODS(OR=21.750,95%CI 7.079~66.829,P<0.001)为CRKP血流感染预后不良的独立危险因素。结论:合并下呼吸道感染的CRKP血流感染患者预后不良的可能性更大,及时维持脏器功能可能改善CRKP血流感染患者的预后。

Objective To analyze the clinical characteristics and the risk factors for poor prognosis of patients with bloodstream infection(BSI)caused by carbapenem-resistant Klebsiella pneumoniae(CRKP),and to guide clinical treatment.Methods The clinical characteristics,co-infection sites,comorbidities,laboratory tests,and antimicrobial drug exposure of adult patients with CRKP BSI admitted to The First Affiliated Hospital of Anhui Medical University from August 2015 to August 2020 were retrospectively analyzed.The patients were divided into good prognosis group and poor prognosis group.The clinical data of the two groups were compared.Statistical analysis was performed using Mann-Whitney U test and chi-square test.Binary logistic regression was used to analyze the risk factors for poor prognosis in patients with CRKP BSI.Results Among the 106 CRKP BSI patients,47 were in the good prognosis group and 59 were in the poor prognosis group.The length of hospital stay(39(22,89)d vs 21(15,38)d),the ratio of history of admission within 90 days(17.0%(8/47)vs 35.6%(21/59)),the ratio of history of carbapenems exposure(42.6%(20/47)vs 64.4%(38/59)),the ratio of complicated with lower respiratory tract infection(44.7%(21/47)vs 78.0%(46/59)),the ratio of admission to intensive care unit(34.0%(16/47)vs 81.4%(48/59)),the ratio of septic shock(19.1%(9/47)vs 69.5%(41/59)),the ratio of complicated with multiple organ dysfunction syndrome(MODS)(10.6%(5/47)vs 74.6%(44/59)),the ratio of solid organ transplantation status(40.4%(19/47)vs 18.6%(11/59)),the ratio of surgery(51.1%(24/47)vs 32.2%(19/59)),the ratio of mechanical ventilation(23.4%(11/47)vs 74.6%(44/59)),the Pitt bacteremia scores≥4 points(21.3%(10/47)vs 69.5%(41/59)),the quick sequential organ failure assessment(qSOFA)scores≥2 points(14.9%(7/47)vs 81.4%(48/59)),the ratio of platelets counts<100×10^(9)/L(31.9%(15/47)vs 62.7%(37/59))had statistical differences between the poor prognosis group and the good prognosis group(Z=-3.72,χ^(2)=4.54,5.04,12.46,24.48,26.61,43.02,6.12,3.86,27.44,24.36,46.29 and 9.93,respectively;all P<0.050).Multivariate analysis showed that BSI complicated with lower respiratory tract infection(odds ratio(OR)=3.293,95%confidence interval(CI)1.138 to 9.528,P=0.028)and MODS(OR=21.750,95%CI 7.079 to 66.829,P<0.001)were independent risk factors for poor prognosis of CRKP BSI.Conclusions Patients with CRKP BSI complicated with lower respiratory tract infection are more likely to have a poor prognosis.Timely maintenance of organ function may improve the prognosis of CRKP BSI.