不同类型急性白血病患者血流感染流行病学及预后分析——一项长达九年多中心947例患者回顾性研究

Epidemiological and prognostic analysis of bloodstream infections in patients with different types of acute leukemia——a nine-year multicenter retrospective study of 947 patients

目的:分析不同类型急性白血病(AL)患者合并血流感染的流行病学、临床特征及预后情况,为临床精准诊疗改善预后提供理论依据。方法:收集2010年1月—2018年12月湖南省3家大型医院血液科947例成人AL合并血流感染患者的临床资料,其中急性髓系白血病(AML)613例、急性淋巴细胞白血病(ALL)334例,根据不同AL分类对流行病学、临床特征及预后进行分析。结果:2种类型AL患者发生血流感染的病原流行病学分布及预后相似。在病原菌分布方面,G-菌为2种类型AL合并血流感染患者的主要致病菌,分别占66.6%vs 75.1%,其次为G+菌(25.9%vs 16.5%)和真菌(7.5%vs 8.4%)。耐药菌分布方面,2组均有较高的多重耐药菌占比(61.7%vs 59.9%),2组碳青霉烯耐药G-菌占比类似(9.1%vs 7.7%);临床特征方面,AML组患者年龄≥55岁(17.8%vs 11.1%,P=0.006)、查尔森指数>3(21.4%vs 15.9%,P=0.041)、疾病状态缓解(36.9%vs 21.3%,P<0.001)显著高于ALL组。ALL患者倾向于更差的实验室指标,如Hb<55.0 g/dL、ALB<30.0 g/L、TBil>34.2μmol/L的发生率更高(P<0.05)。2组AL合并血流感染患者均出现较高的30 d死亡率(18.8%vs 17.7%,P=0.677)。预后因素方面,2组患者呈现不一样的特点,除呼吸衰竭、Pitt评分>3分、使用敏感抗生素共同独立预后危险因素外,AML合并血流感染患者的预后独立危险因素还包括疾病状态未缓解(P<0.001)、使用血管活性药物(P<0.001),而ALL合并血流感染患者预后独立危险因素为年龄≥60岁(P=0.006)、胆红素升高≥2倍(P<0.001),中性粒细胞缺乏情况并非2组患者合并血流感染的预后欠佳危险因素。结论:研究结果表明AML与ALL合并血流感染患者的病原菌、耐药分布及预后相似,但预后因素方面,针对不同类型AL合并血流感染患者,除尽早使用敏感抗生素、改善呼吸功能外,AML应注意改善疾病状态、撤离血管活性药物,而对于ALL合并血流感染患者,加强脏器功能支持等治疗有助于改善预后。

Objective:To analyze the epidemiology,clinical characteristics and prognosis of patients with different types of acute leukemia(AL) combined with bloodstream infection,in order to provide a theoretical basis for accurate clinical treatment and prognosis improvement.Methods:The clinical data of 947 adult patients with AL combined with bloodstream infection in the hematology departments of three large hospitals in Hunan Province from January 2010 to December 2018 were collected,including 613 cases of acute myeloid leukemia(AML) and 334 cases of acute lymphoblastic leukemia(ALL),and the epidemiology,clinical characteristics and prognosis were analyzed according to different AL classifications.Results:The pathogenic epidemiological distribution and prognosis of bloodstream infection in patients with both types of AL were similar.In terms of pathogenic distribution,G-bacteria were the main causative organisms in patients with both types of AL co-infections,accounting for 66.6% vs 75.1%,followed by G+bacteria(25.9% vs 16.5%) and fungi(7.5% vs 8.4%),respectively.The distribution of resistant organisms,both AML and ALL had a high proportion of MDR organisms(61.7% vs 59.9%) and a similar proportion of carbapenem-resistant G-bacteria(9.1% vs 7.7%);with regard to clinical characteristics,the proportions of patients in the AML group with ≥55 years old(17.8% vs 11.1%,P=0.006),Charlson index>3(21.4% vs 15.9%,P=0.041),and remission of disease status(36.9% vs 21.3%,P<0.001) were significantly higher than those in the ALL group.Patients with ALL tended to have a higher incidence of worse laboratory indicators,such as Hb<55.0 g/dL,ALB<30.0 g/L,and TBil>34.2 μmol/L(P<0.05).Patients with AL bloodstream infection in both groups showed higher 30-day mortality(18.8% vs 17.7%,P=0.677).Regarding prognostic factors,the two groups presented different characteristics,in addition to the common independent prognostic risk factors for respiratory failure,Pitt score>3,and use of sensitive antibiotics,independent prognostic risk factors for patients with AML bloodstream infection included unremission disease status(P<0.001) and use of vasoactive agents(P<0.001),while independent prognostic risk factors for patients with ALL bloodstream infection were age ≥60 years(P=0.006),total bilirubin elevation ≥2-fold(P<0.001),and neutropenia was not a risk factor for poor prognosis in patients with combined bloodstream infection in both groups.Conclusion:It shows that the pathogenic bacteria,drug resistance distribution and prognosis of patients with AML and ALL complicated with bloodstream infection are similar,but in terms of prognostic factors,for patients with different types of AL bloodstream infection,in addition to early use of sensitive antibiotics and improvement of respiratory function,attention should be paid to improving disease status and evacuating vasoactive agents in AML,and strengthening organ function support for patients with all bloodstream infection will help improve prognosis.