肺炎克雷伯菌肝脓肿的临床特点和预后影响因素分析

Clinical features and prognostic factors of Klebsiella pneumoniae liver abseces

目的探讨肺炎克雷伯菌肝脓肿(KPLA)的临床特点和预后影响因素,指导临床医生对KPLA早期诊断和有效的治疗。方法回顾性分析2019年1月至2021年12月在中国医科大学附属盛京医院住院并且血培养或脓液培养阳性的细菌性肝脓肿(PLA)患者。根据病原学结果分为肺炎克雷伯菌组(KP组)与非肺炎克雷伯菌组(nKP组)。比较两组之间临床特点、实验室检查、影像学检查、治疗和预后。采用多因素logistic回归分析预后的影响因素。结果235例病原学阳性细菌性肝脓肿患者中,KP组156例,nKP组79例。在基础疾病方面,KP组患者糖尿病的比例(51.9%)高于n KP组糖尿病的比例(32.9%),差异有统计学意义(χ^(2)=7.643,P=0.006),而nKP组患者较KP组多有胆道疾病的基础(χ^(2)=27.842,P=0.001)。发热和寒战是KP组和nKP组最常见的临床表现,胸腔积液和肺部感染均为两组最多见的并发症。与nKP组相比,KP组患者白细胞计数(WBC)、中性粒细胞淋巴细胞比值(NLR)、C反应蛋白(CRP)、降钙素原(PCT)、空腹血糖(FPG)、丙氨酸氨基转移酶(ALT)、血红蛋白(Hb)、白蛋白(ALB)均更高,差异均有统计学意义(Z值分别为-2.275,-2.478,-2.952,-2.905,-4.732,-2.243,-6.584,-3.051,P均<0.05)。细菌性肝脓肿患者影像学病灶均以单发(170/235,72.3%)、肝右叶(166/235,70.6%)为主。KP组和nKP组患者单纯脓汁培养的阳性率最高,分别是73.7%和67.1%,单纯血培养的阳性率较低,分别为12.2%和17.7%。KP组与nKP组患者治疗方法均以抗生素联合穿刺引流为主,比例分别为87.8%和82.3%。KP组和nKP组患者治疗方式和抗生素种类的选择差异无统计学意义(P>0.05)。KP组和nKP组患者临床转归有效率85.9%和81.0%,差异无统计学意义(P>0.05)。多因素logistic回归分析结果显示,低蛋白血症是KPLA患者预后不良的独立危险因素(P=0.016),超声或CT引导下脓肿穿刺引流术是KPLA患者预后较好的独立保护因素(P=0.001)。结论KPLA更易发生在有糖尿病基础疾病的人群中。临床表现缺乏特异性,应更早地完善细菌培养和影像学检查以明确诊断。低蛋白血症是KPLA预后不良的危险因素,尽早地行脓肿穿刺治疗为较好预后的保护因素。

Objective e To investigate the clinical features and prognostic factors of Klebsiella pneumoniae liver abscess(KPLA),and to provide a reference for early diagnosis and effective treatment.Methods A retrospective analysis was performed for the patients with liver abscess who were hospitalized and had positive blood culture or pus culture in Shengjing hospital of China Medical University,from January 2019 to December 2021.According to the results of etiology,these patients were divided into Klebsiella pneumoniae group(KP group)and non-Klebsiella pneumoniae group(nKP group).Clinical features,laboratory examination,radiological examination,treatment and prognosis were compared between the two groups.A multivariate logistic regression analysis was used to identify independent influencing factors for the prognosis.ResultsA total of 235 patients with liver abscess tested positive for pathogen were enrolled,with 156 patients in the KP group and 79 in the non-KP group.In terms of underlying diseases,the proportion of diabetes in the KP group(51.9%)was higher than that in the nKP group(32.9%),and the difference was statistically significant(χ^(2)=7.643,P=0.006).However,the proportion of biliary tract diseases in the nKP group was higher than that in the KP group(χ^(2)=27.842,P=0.001).Fever and chills were the most common clinical manifestations of hepatic abscess in KP and nKP groups,and pleural effusion and pulmonary infection were the most common complications.Compared with the nKP group,the white blood cell count(WBC),neutrophil/lymphocyte ratio(NLR),C-reactive protein(CRP),procalcitonin(PCT),fasting blood glucose(FPG),alanine aminotransferase(ALT),hemoglobin(Hb),and albumin(ALB)were higher in the KP group,and the differences were statistically significant(Z-values were-2.275,-2.478,-2.952,-2.905,-4.732,-2.243,-6.584,-3.051,respectively,P<0.05).The imaging lesions of PLA patients were mainly single(170/235,72.3%)and right lobe(166/235,70.6%).The patients in the KP group and nKP group had the highest positive rates of pus culture,73.7%and 67.1%,respectively,and the positive rates of blood culture were lower,12.2%and 17.7%,respectively.The treatment methods of patients in the KP group and nKP group were mainly antibiotics combined with puncture drainage,and the proportions were 87.8%and 82.3%respectively.There was no statistical significance in clinical outcome rate between KP group and nKP group(85.9%and 81.0%,P>0.05).The results of multivariate logistic regression analysis showed that hypoproteinemia was an independent risk factor for poor prognosis in KPLA patients(P=0.016),ultrasound or CT-guided abscess puncture drainage was an independent protective factor for better prognosis in KPLA patients(P=0.001).Conclusion sKPLA is more likely to occur in people with underlying diabetes.Clinical findings lack specificity,and cultures and imaging should be done earlier to confirm the diagnosis.Hypoproteinemia is a risk factor for a poor prognosis for KPLA,and early puncture drainage is a protective factor for a better prognosis.