肝胆外科患者耐碳青霉烯类肺炎克雷伯菌感染及感染后死亡的危险因素分析

Risk factors and prognosis analysis of carbapenem-resistant Klebsiella pneumoniae infection for inpatients in hepatobiliary surgery

目的探讨肝胆外科患者耐碳青霉烯类肺炎克雷伯菌(CRKP)感染及感染后死亡的危险因素分析。方法回顾性分析2016年1月至2020年12月在湖南省人民医院肝胆外科住院并发生肺炎克雷伯菌感染的患者的临床资料。对于每例CRKP感染患者, 选择2例非碳青霉烯类耐药肺炎克雷伯菌(non-CRKP)感染患者与之进行匹配。共纳入720例肺炎克雷伯菌感染的患者, 其中男性444例, 女性276例, 年龄(58.0±11.6)岁。依据感染情况分为两组:CRKP组(n=240)和non-CRKP组(n=480)。根据预后情况将240例CRKP组患者分为两个亚组:死亡组(n=34)和存活组(n=206)。记录患者的一般资料、实验室检查结果、抗菌药物使用情况和感染结局等, 以分析感染及感染后死亡的危险因素。结果患有急性胰腺炎(OR=3.473, 95%CI:1.844~6.541)、感染前存在慢性心血管系统疾病(OR=2.028, 95%CI:1.228~3.347)、慢性肾衰竭(OR=1.873, 95%CI:1.142~3.073)、低蛋白血症(OR=3.060, 95%CI:1.869~5.010)、碳青霉烯类抗菌药物使用(OR=3.882, 95%CI:2.518~5.985)、入住重症监护室(OR=1.783, 95%CI:1.034~3.075)和感染前30 d内手术(OR=13.463, 95%CI:7.482~24.223)是肝胆外科患者发生CRKP感染的独立危险因素(均P<0.05)。感染前患有慢性呼吸系统疾病(OR=3.784, 95%CI:1.420~10.089)、接受机械通气(OR=5.085, 95%CI:1.436~18.011)、意识障碍(OR=40.710, 95%CI:3.564~464.943)、接受激素治疗(OR=14.977, 95%CI:3.819~58.743)和接受喹诺酮类抗菌药物治疗(OR=4.102, 95%CI:1.226~13.726)是肝胆外科CRKP感染者死亡的独立危险因素(均P<0.05)。CRKP组阿米卡星、妥布霉素、头孢他啶、头孢吡肟、氨曲南、环丙沙星、左氧氟沙星、复方磺胺甲恶唑和哌拉西林/他唑巴坦的耐药性与non-CRKP组相比差异有统计学意义(均P<0.05)。结论肝胆外科患者发生CRKP感染与基础疾病、抗菌药物使用和自身屏障被破坏等多种因素有关, 并且这些因素影响着患者感染的结局。

Objective To explore the risk factors and prognosis of carbapenem-resistant Klebsiella pneumoniae(CRKP)infection for inpatients in hepatobiliary surgery.Methods The clinical data of patients with Klebsiella pneumoniae infection admitted to the Department of Hepatobiliary Surgery,Hunan Provincial People's Hospital from January 2016 to December 2020 were retrospectively analyzed.For each patient with CRKP infection,two patients with non-carbapenem-resistant Klebsiella pneumoniae(non-CRKP)infection were selected for matching.A total of 720 patients with Klebsiella pneumoniae infection were involved,including 444 males and 276 females,aged(58.0±11.6)years old.According to the infection conditions,they were divided into two groups:CRKP group(n=240)and non-CRKP group(n=480).The 240 CRKP patients were divided into two subgroups according to their prognosis:death group(n=34)and survival group(n=206).The general information,laboratory test results,antibiotic use and infection outcomes of patients were recorded to analyze the risk factors of infection and death after infection.Results Acute pancreatitis(OR=3.473,95%CI:1.844-6.541),chronic cardiovascular disease before infection(OR=2.028,95%CI:1.228-3.347),chronic renal failure(OR=1.873,95%CI:1.142-3.073),hypoalbuminemia(OR=3.060,95%CI:1.869-5.010),use of carbapenems(OR=3.882,95%CI:2.518-5.985),admission to intensive care unit(OR=1.783,95%CI:1.034-3.075)and surgery within 30 days before infection(OR=13.463,95%CI:7.482-24.223)were independent risk factors for CRKP infection inpatients in hepatobiliary surgery(all P<0.05).Chronic respiratory disease before infection(OR=3.784,95%CI:1.420-10.089),mechanical ventilation(OR=5.085,95%CI:1.436-18.011),disturbance of consciousness(OR=40.710,95%CI:3.564-464.943),hormone therapy(OR=14.977,95%CI:3.819-58.743)and treatment of quinolone antibiotics(OR=4.102,95%CI:1.226-13.726)were independent risk factors for death of inpatients with CRKP infection in hepatobiliary surgery(all P<0.05).The resistance of amikacin,tobramycin,ceftazidime,cefepime,aztreonam,ciprofloxacin,levofloxacin,co-sulfamethoxazole and piperacillin/tazobactamand in CRKP group were significantly different compared with non-CRKP group(all P<0.05).Conclusion The occurrence of CRKP infection for inpatients in hepatobiliary surgery is related to various factors such as underlying diseases,antibiotic use and self-barrier destruction,and these factors affect the infection outcome of patients.