急诊社区发生大肠埃希菌血流感染患者的临床特征及危险因素分析

Clinical characteristics and prognostic risk factors of patients with community-onset Escherichia coli bloodstream infection in emergency community

目的收集急诊社区发生大肠埃希菌(E.coli)血流感染患者的临床资料,分析影响患者病死率的危险因素。方法回顾性分析2016年1月1日至2021年12月31日复旦大学附属华山医院宝山院区收治的急诊社区获得性E.coli血流感染(CAECBSI)患者(CAECBSI组)和急诊社区发生医疗相关E.coli血流感染(HCAECBSI)患者(HCAECBSI组)的临床资料。比较两组患者性别、年龄、基础疾病、长期留置导尿管、留置血液透析管/腹膜透析管、原发感染部位、血培养阳性瓶数、入院时主要实验室检查结果、产超广谱β-内酰胺酶E.coli(ESBLEC)菌株检出情况、急诊手术、入院时全身炎症反应综合征(SIRS)评分和快速序贯器官衰竭评分(qSOFA)评分、休克、机械通气比例及机械通气时间、医院治疗时间和随访28 d病死率的差异。运用Logistic回归分析筛选出影响急诊社区发生E.coli血流感染患者预后的独立危险因素,并绘制受试者工作特征曲线(ROC曲线),分析各危险因素对患者预后的预测价值。结果共375例患者纳入本研究,CAECBSI组244例,28 d病死率3.69%(9例);HCABSI组131例,28 d病死率9.92%(13例)。几乎所有患者都存在至少1种基础疾病,超过70%的患者存在糖尿病,其余依次为高血压、慢性肾功能不全、脑卒中及心脏疾病等。在所有患者中女性比例超过50%,而在死亡患者中男性比例则高达63.64%。两组患者原发感染部位基本相同,排名前3位分别是泌尿系统感染、胆囊及胆道感染和肺部感染。与CAECBSI组比较,HCAECBSI组患者慢性肾功能不全比例(19.80%比9.80%)、长期留置导尿管比例(14.50%比0%)、留置血液透析管/腹膜透析管比例(9.92%比0%)、4瓶血培养阳性比例(33.59%比20.08%)、ESBLEC菌株检出率(51.91%比30.74%)、休克比例(20.61%比10.66%)、入院时白细胞计数〔WBC(×10^(9)/L):16.02±3.54比14.76±3.63〕、入院时血糖(mmol/L:13.71±5.36比10.37±5.18)、入院时血乳酸〔Lac(mmol/L):2.50(1.30)比1.85(0.90)〕、入院时SIRS评分(分:3.27±0.69比2.98±0.79)、入院时qSOFA评分(分:2.15±0.61比1.91±0.60)以及28 d病死率(9.92%比3.69%)均明显升高,而1瓶血培养阳性比例(9.92%比25.82%)、入院时血小板计数〔PLT(×10^(9)/L):178.66±66.53比216.36±67.72〕和入院时白蛋白〔ALB(g/L):33.53±5.09比37.55±4.69〕则明显下降(均P<0.05)。与死亡组比较,存活组患者年龄〔岁:67.0(19.5)比74.5(11.5)〕、高血压比例(24.36%比45.45%)、慢性肾功能不全比例(11.33%比40.91%)、脑卒中比例(6.23%比22.73%)、稳定期肿瘤比例(2.83%比13.64%)、长期留置导尿管比例(3.97%比22.73%)、留置血液透析管/腹膜透析管比例(2.83%比13.64%)、肺部感染比例(14.73%比45.45%)、入院时Lac〔mmol/L:2.10(1.10)比2.45(2.20)〕、入院时SIRS评分(分:3.05±0.76比3.55±0.67)、休克比例(12.18%比45.45%)、机械通气比例(2.55%比27.27%)和医院治疗时间(d:7.99±1.65比9.00±2.29)均明显降低(均P<0.05),而ESBLEC菌株检出率明显增高(63.64%比38.81%,P<0.05)。Logistic回归分析显示,年龄、慢性肾功能不全、肺部感染、入院时Lac、休克和ESBLEC菌株检出均为影响患者28 d预后的独立危险因素〔优势比(OR)和95%可信区间(95%CI)分别为0.936(0.895~0.980)、4.964(1.165~10.893)、3.738(1.257~11.120)、0.649(0.479~0.881)、3.979(1.264~11.406)和3.522(1.179~10.521),均P<0.05〕。ROC曲线分析显示,年龄对CAECBSI患者28 d预后的预测价值最高,ROC曲线下面积(AUC)=0.709,95%CI为0.636~0.783,P=0.01;当最佳截断值为66.50岁时,其敏感度和特异度为99.5%和47.9%。其次为入院时Lac(AUC=0.649),95%CI为0.531~0.767,P=0.019;当最佳截断值为2.35 mmol/L时,其敏感度和特异度为63.6%和63.5%。慢性肾功能不全、肺部感染、休克和ESBLEC菌株检出的AUC<0.5,均无预测价值。结论CAECBSI患者常伴有糖尿病、高血压、慢性肾功能不全等基础疾病,对ESBLEC耐药性日益严重,应加强院感防控与监测。高龄男性和入院时高乳酸血症的CAECBSI患者易发生死亡。

Objective To collect the clinical characteristics and prognosis risk factors of community-onset bloodstream infection(COBSI)caused by Escherichia coli(E.coli)in the department of emergency.Methods Patients with COBSI caused by E.coli admitted to Baoshan Hospital District of the Huashan Hospital Affiliated to Fudan University from January 1,2016 to December 31,2021 were retrospectively analyzed and divided into emergency community-acquired E.coli bloodstream infection(CAECBSI)group and emergency health care-associated E.coli bloodstream infection(HCAECBSI)group.The gender,age,basic disease,long-term indwelling catheters,indwelling hemodialysis tubes/abdominal dialysis tubes,primary infection site,number of positive bottles of blood culture,main laboratory examination results at admission,extended-spectrumβ-lactamase-producing E.coli(ESBLEC),emergency surgery,systemic inflammatory response syndrome(SIRS)and quick sequential organ failure assessment(qSOFA)score at admission,shock,mechanical ventilation proportion and time,hospital treatment time,and 28-day mortality were compared.Logistic regression analysis was used to identify risk factors for 28-day prognosis,the receiver operating characteristic curve(ROC curve)drawn to evaluate the predictive value of each risk factor on the prognosis.Results Totally 375 patients were included in the analysis.There were 244 cases in the CAECBSI group,and 28-day mortality was 3.69%(9 cases);131 cases in the HCAECBSI group,and 28-day mortality was 9.92%(13 cases).Almost all patients had at least one basic disease,and more than 70%of patients had diabetes,followed by hypertension,chronic renal insufficiency,stroke,and heart disease.Women accounted for 50%of all patients,while the proportion of men in dead patients was as high as 63.64%.The primary infection sites of the two groups were the same,and the 3 most were urinary system,gallbladder and biliary tract,and lung infection.Compared with the CAECBSI group,the patients in the HCAECBSI group had a significant increase in the rate of chronic renal insufficiency(19.80%vs.9.80%),long-term indwelling catheters(14.50%vs.0%),indwelling hemodialysis tubes/abdominal dialysis tubes(9.92%vs.0%),4 positive bottles of blood culture(33.59%vs.20.08%),ESBLEC strains(51.91%vs.30.74%),shock(20.61%vs.10.66%),white blood cell count(WBC)at admission(×10^(9)/L:16.02±3.54 vs.14.76±3.63),blood glucose at admission(mmol/L:13.71±5.36 vs.10.37±5.18),blood lactic acid(Lac)at admission[mmol/L:2.50(1.30)vs.1.85(0.90)],SIRS score at admission(3.27±0.69 vs.2.98±0.79),qSOFA score at admission(2.15±0.61 vs.1.91±0.60),and 28-day mortality(9.92%vs.3.69%),while the rate of 1 positive bottle of blood culture(9.92%vs.25.82%),platelet count(PLT)at admission(×10^(9)/L:178.66±66.53 vs.216.36±67.72)and the albumin(ALB)at admission(g/L:33.53±5.09 vs.37.55±4.69)significantly decreased(all P<0.05).Compared with the death group,the patients in the survival group showed significant decreases in the age[years old:67.0(19.5)vs.74.5(11.5)],hypertension(24.36%vs.45.45%),chronic renal insufficiency(11.33%vs.40.91%),stroke(6.23%vs.22.73%),stable tumors(2.83%vs.13.64%),long-term indwelling catheters(3.97%vs.22.73%),indwelling hemodialysis tubes/abdominal dialysis tubes(2.83%vs.13.64%),pulmonary infections(14.73%vs.45.45%),Lac at admission[mmol/L:2.10(1.10)vs.2.45(2.20)],SIRS score at admission(3.05±0.76 vs.3.55±0.67),shock(12.18%vs.45.45%),mechanical ventilation(2.55%vs.27.27%),and hospital treatment time(days:7.99±1.65 vs.9.00±2.29),while ESBLEC strains(63.64%vs.38.81%)showed a significant increase(all P<0.05).Logistic regression analysis showed that the age,blood Lac at admission were independent risk factors for 28-day prognosis[odds ratio(OR)and 95%confidence interval(95%CI)was 0.936(0.895-0.980),4.964(1.165-10.893),3.738(1.257-11.120),0.649(0.479-0.881),3.979(1.264-11.406)and 3.522(1.179-10.521),all P<0.05].ROC curve analysis showed that the age had the highest prognostic value for 28-day prognosis,and the area under ROC curve(AUC)was 0.709,95%CI was 0.636-0.783,P=0.01.When the optimal cut-off value was 66.50 years,the sensitivity and specificity were 99.5%and 47.9%,respectively;Followed by Lac at admission(AUC=0.649),95%CI was 0.531-0.767,P=0.019.When the optimal cut-off value was 2.35 mmol/L,the sensitivity and specificity were 63.6%and 63.5%,respectively.chronic renal insufficiency,pulmonary infections,shock,and ESBLEC strains showed no predictive value AUC<0.5.Conclusions The patients with emergency CAECBSI were often accompanied by basic diseases such as diabetes,hypertension,chronic renal insufficiency,etc.ESBLEC strains was becoming increasingly serious,and nosocomial prevention,control and surveillance should be strengthened.Elderly men and patients with high blood Lac at admission were prone to die due to emergency CAECBSI.