重症医学科侵袭性肺曲霉病临床特征分析

Analysis of clinical features of invasive pulmonary aspergillosis in intensive care unit

目的回顾性分析重症医学科(intensive care unit,ICU)侵袭性肺曲霉病(invasive pulmonary aspergillosis,IPA)的临床特征以提高临床诊治水平。方法收集2017年3月—2022年3月中国科学技术大学附属第一医院(安徽省立医院)ICU内诊断为IPA的患者81例,并选取同期同病区肺部感染且痰培养曲霉阴性的非IPA患者81例。比较两组的宿主因素、疾病严重程度(急性生理学和慢性健康评估Ⅱ评分)、基础疾病、临床症状和体征、相关实验室检查,应用单因素分析和多因素条件Logistic回归分析,找出ICU内IPA患者的危险因素。同时,分析IPA组患者的曲霉类型及两组患者入ICU后28天转归。结果81例IPA患者中确诊4例,临床诊断77例,烟曲霉、黄曲霉为感染的主要病原体。IPA组与非IPA组均可出现发热、咳嗽咳痰、呼吸困难和肺湿啰音等症状和体征。IPA组患者降钙素原水平高于非IPA组,差异有统计学意义(P=0.016)。IPA组患者的血清半乳甘露聚糖抗原检测(galactomannan antigen test,GM试验)阳性率高于非IPA组,差异有统计学意义(P=0.000)。IPA组肺部影像学空洞的发生率较非IPA组高,差异有统计学意义(P=0.022)。单因素分析显示中心静脉置管、感染性休克、行完全肠外营养、合并慢性阻塞性肺疾病、免疫抑制是IPA的危险因素(P<0.05);进一步多因素条件Logistic回归分析显示行完全肠外营养、合并慢性阻塞性肺疾病、免疫抑制是IPA的独立危险因素(P<0.05)。IPA组患者28天病死率较非IPA组升高(55.6%比34.6%,P=0.007)。结论IPA患者无特异性的临床症状和体征,常见病原体为烟曲霉、黄曲霉。血清GM试验、肺部影像学有空洞表现有助于IPA诊断,如果既往有慢性阻塞性肺疾病、免疫抑制病史,以及行完全肠外营养的患者,在ICU住院期间需要高度警惕IPA可能。

Objective To retrospectively analyze the clinical features of invasive pulmonary aspergillosis(IPA)in intensive care unit(ICU),so as to improve the level of clinical diagnosis and treatment.Methods A total of 81 patients diagnosed as IPA from March,2017 to March,2022 in the ICU of The First Affiliated Hospital of USTC,Division of Life Sciences and Medicine,University of Science and Technology of China were selected as infection group.A total of 81 non-IPA patients with pulmonary infection and Aspergillus negative sputum culture were selected as the control group.The host factors,Acute Physiology and Chronic Health AssessmentⅡscore at admission,underlying diseases,clinical symptoms and signs,relevant laboratory test results,and lung CT findings were compared between the two groups.Univariate analysis and multivariate conditional logistic regression analysis were used to identify the risk factors for the occurrence of pulmonary aspergillosis in IPA patients in ICU.At the same time,the types of aspergillus in the IPA group and the outcomes of the two groups at 28 days after ICU admission were analyzed.Results Of the 81 IPA patients,4 were proven diagnosed and 77 were putative diagnosed.IPA patients were mainly infected with Aspergillus fumigatus and Aspergillus flavus.Symptoms and signs such as fever,cough and expectoration,dyspnea and pulmonary rales occurred in both groups.The level of procalcitonin in IPA group was higher than that in non-IPA group,and the difference was statistically significant(P=0.016).The positive rate of serum galactomannan antigen test(GM test)in the IPA group was higher than that in the non-IPA group,and the differences was statistically significant(P=0.000).The incidence of pulmonary imaging cavities in IPA group was higher than that in non-IPA group,and the difference was statistically significant(P=0.022).Univariate analysis showed that central venous catheterization,septic shock,complete parenteral nutrition,chronic obstructive pulmonary disease,and immunosuppression were risk factors for IPA(P<0.05);Multivariate conditional logistic regression analysis showed that complete parenteral nutrition,chronic obstructive pulmonary disease,and immunosuppression were independent risk factors for IPA(P<0.05).The 28-day fatality rate in IPA group was higher than that in non-IPA group(55.6%vs.34.6%,P=0.007).Conclusions IPA patients have no specific clinical symptoms and signs,and are mainly infected with Aspergillus fumigatus and Aspergillus flavus;GM test has guiding significance for the diagnosis of IPA.Serum GM test and pulmonary imaging have cavity findings that are helpful for the diagnosis of IPA.Patients with a history of chronic obstructive pulmonary disease,immunosuppression,or complete parenteral nutrition need to be on high alert for the possibility of IPA during ICU stay.