严重创伤合并侵袭性真菌病的特点及危险因素分析

Characteristics and risk factors of severe trauma complicated with invasive fungal disease

目的 探讨严重创伤合并侵袭性真菌病(invasive fungal disease, IFD)的特点及危险因素,为预防及治疗提供临床依据。方法 回顾性分析2013年1月—2021年12月西安市某三甲医院急诊重症监护室(EICU)的严重创伤合并感染患者1 032例,按有无合并IFD,将其分为侵袭性真菌病组(IFD组)及非侵袭性真菌病组(非IFD组)。比较两组患者临床资料,分析真菌感染的部位特征、病原学特征、合并细菌感染的情况、检出真菌的耐药情况、真菌感染的临床表现、治疗方法及合并IFD的高危因素等。结果 IFD组共346例,男性253例,女性93例;年龄19~63岁,平均48.3岁;非IFD组共686例,男性549例,女性137例;年龄19~58岁,平均47.8岁。两组患者损伤严重度评分、序贯器官衰竭评分(sequential organ failure assessment, SOFA评分)、休克、有创机械通气治疗、有创机械通气时长、输血、使用激素、抗生素使用时间≥7d、接受中心静脉置管、CRRT治疗、EICU停留时长等比较差异均有统计学意义(P<0.05)。严重创伤合并IFD最常见的部位为呼吸道(40.7%)和泌尿道(30.5%);最常见的真菌为白色念珠菌(53.3%);最常合并的细菌为金黄色葡萄球菌(42.8%);念珠菌耐药在临床比较常见;真菌感染的主要临床表现:发热、白细胞升高及G试验、GM试验阳性。创伤后IFD的治疗方法主要有抗真菌药物、拔除或更换体内导管、手术清创等。Logistic多因素分析发现IFD组与非IFD组在入EICU的SOFA评分(OR=3.193,95%CI:1.233~6.561)、中心静脉置管(OR=4.123,95%CI:1.154~5.583)、使用抗生素≥7d(OR=4.171,95%CI:1.423~11.091)、机械通气时长(OR=1.862,95%CI:1.264~2.882)、ICU住院时长(OR=1.324,95%CI:1.052~2.011)等5项指标方面比较差异有统计学意义。结论 入室SOFA评分较高、中心静脉置管、使用抗生素≥7d、更长的机械通气时长、更长的ICU住院时长是创伤患者发生IFD的高危因素。

Objective To explore the characteristics and risk factors of severe trauma complicated with invasive fungal disease(IFD),and to provide clinical evidence for its prevention and treatment.Methods A total of 1032 patients with severe trauma complicated with infection admitted to the Emergency Intensive Care Unit(EICU)of a tertiary hospital in Xi'an from Jan.2013 to Dec.2021 were retrospectively selected.The patients were divided into IFD group and non-IFD group according to the presence or absence of IFD.Clinical data of the two groups were compared.The location characteristics,etiological characteristics,combined bacterial infection,drug resistance of detected fungi,clinical manifestations of IFD,treatment methods and high risk factors of IFD were analyzed.Results There were 346 cases in the IFD group,253 males and 93 females aged 19-63 years,mean 48.3 years.While 686 cases in the non-IFD group,including 549 males and 137 females aged 19-58 years,mean 47.8 years.Statistically significant differences were found in injury severity score(ISS),sequential organ failure score(SOFA),shock,invasive mechanical ventilation treatment,invasive mechanical ventilation duration,blood transfusion,hormone use,antibiotic use time≥7 d,central venous catheterization,continuous renal replacement therapy treatment,and EICU length of stay between the two groups(all P<0.05).The most common sites of severe trauma with IFD were the respiratory tract(40.7%)and urinary tract(30.5%);the most common fungus was Candida albicans(53.3%);the most common bacterium was staphylococcus aureus(42.8%);Candida resistance was more common in clinical practice;the main clinical manifestations of fungal infections were fever,leukocytosis,and positive G and GM tests.The treatment methods for post-traumatic IFD included antifungal drugs,removal or replacement of internal catheters,surgical debridement,etc.Logistic multivariate analysis showed that there were significant differences between IFD group and non-IFD group in five indicators,respectively SOFA score(OR=3.193,95%CI:1.233-6.561),central venous catheterization(OR=4.123,95%CI:1.154-5.583),antibiotic use≥7 d(OR=4.171,95%CI:1.423-11.091,duration of mechanical ventilation(OR=1.862,95%CI:1.264-2.882),and length of ICU stay(OR=1.324,95%CI:1.052-2.011).Conclusion The higher SOFA score,central venous catheterization,use of antibiotics≥7 d,longer duration of mechanical ventilation,and longer length of ICU stay are the high risk factors for developing IFD in trauma patients.