特发性炎性肌病住院患者合并肺部感染的临床及病原学特征与危险因素研究

Clinical and pathogenic characteristics and risk factors of pulmonary infection in hospitalized patients with idiopathic inflammatory myopathies

目的探讨特发性炎性肌病(idiopathic inflammatory myopathies,IIM)住院患者合并肺部感染的临床及病原学分布特征与危险因素,为临床诊治提供参考。方法回顾性分析2010年1月至2020年1月10年间福建省立医院风湿免疫科收治住院的371例IIM患者的临床资料,根据是否合并肺部感染分为感染组(233例)和非感染组(138例),观察IIM患者肺部感染的临床特征,肺部感染病原学分布情况,探讨影响IIM患者发生肺部感染的危险因素。结果感染组患者中检出100株病原菌,其中多见真菌感染,共计43株,革兰氏阴性杆菌32株,革兰氏阳性菌16株,结核及非结核分枝杆菌9株。两组患者的性别构成差异无统计学意义(P>0.05)。在整体年龄上,感染组要大于非感染组[(59.8±13.9)岁比(52.4±15.8)岁,t=4.692,P<0.001],在年龄构成上,感染组中≥60岁患者达53.6%(125/233),多于非感染组的31.9%(44/138)。感染组合并间质性肺疾病(interstitial lung disease,ILD)患者61.8%(144/233)比非感染组(27.54%,38/138)高(χ2=40.720,P<0.001)。对比两组间免疫抑制剂的使用情况,发现感染组联合使用环磷酰胺、吗替麦考酚酸酯多于非感染组,组间差异有统计学意义(P<0.05)。两组患者的实验室检查指标比较,感染组白细胞计数、纤维蛋白原、D-二聚体、红细胞沉降率、C反应蛋白高于非感染组,感染组淋巴细胞计数、白蛋白低于非感染组,P均<0.05。多因素Logistic回归分析结果发现,吸烟者(OR=2.476,95%CI:1.130~5.426)、年龄≥60岁(OR=2.164,95%CI:1.301~3.598)、合并ILD(OR=4.048,95%CI:2.416~6.781)、淋巴细胞计数≤1.2×109/L(OR=2.411,95%CI:1.437~4.045)、白蛋白≤30g/L(OR=2.720,95%CI:1.472~5.028)、C反应蛋白升高(OR=0.988,95%CI:0.981~0.995)、纤维蛋白原升高(OR=0.728,95%CI:0.598~0.887)、球蛋白降低(OR=1.043,95%CI:1.003~1.085)是IIM发生肺部感染的独立危险因素(P<0.05)。结论IIM合并肺部感染的主要病原菌包括念珠菌和革兰氏阴性杆菌,对于高龄有吸烟者且合并ILD的IIM患者,当临床发现淋巴细胞计数、白蛋白、球蛋白降低,C反应蛋白、纤维蛋白原升高时需警惕继发肺部感染的可能,而在筛查肺部感染病原菌时,应关注机会致病菌的筛查,尽早确认肺部感染病因并启动适当的抗感染治疗有助于改善患者预后。

Objective To explore the clinical and pathogenic distribution characteristics and risk factors of pulmonary infection in hospitalized patients with idiopathic inflammatory myopathies(IIM),and provide reference for clinical diagnosis and treatment.Method The clinical data of 371 patients with IIM admitted to the Department of Rheumatology and Immunology of Fujian Provincial Hospital from January 2010 to January 2020 were retrospectively analyzed.The patients were divided into the infected group(n=233)and the non-infected group(n=138).The clinical characteristics and the pathogenetic distribution were observed to explore the risk factors affecting the occurrence of pulmonary infections in patients with IIM.Result In the infection group,100 strains of pathogenic bacteria were detected,among which fungal infections were the most common,with a total of 43 strains,32 strains of gram-negative bacilli,16 strains of gram-positive bacteria,and 9 strains of tuberculosis and nontuberculous mycobacteria.There was no significant difference in the gender composition between the two groups(P>0.05).In terms of the overall age,the infected group was larger than the non-infected group[(59.8±13.9)years VS(52.4±15.8)years,t=4.692,P<0.001].In terms of the age distribution,patients aged 60 and above accounted for 53.6%(125/233)in the infection group,which was higher than the 31.9%(44/138)in the non-infection group.The proportion of patients with interstitial lung disease(ILD)in the infected group was 61.8%(144/233),significantly higher than the non-infected group's 27.54%(38/138,χ²=40.720,P<0.001).When comparing the usage of immunosuppressive agents between the two groups,the infection group had a higher combined usage of cyclophosphamide and mycophenolate mofetil than the non-infection group(P<0.05).The white blood cell count,fibrinogen,D-dimer,erythrocyte sedimentation rate and C-reactive protein in the infected group were higher than those in the non-infected group,and the lymphocyte count,albumin in the infected group were lower than those in the non-infected group.(P<0.05).The results of multivariate logistic regression analysis showed that smokers(OR=2.476,95%CI:1.130—5.426),age≥60 years(OR=2.164,95%CI:1.301—3.598),pulmonary infection comorbid with ILD(OR=4.048,95%CI:2.416—6.781),lymphocyte count≤1.2×109/L(OR=2.411,95%CI:1.437—4.045),albumin≤30g/L(OR=2.720,95%CI:1.472—5.028),elevated C-reactive protein(OR=0.988,95%CI:0.981—0.995),elevated fibrinogen(OR=0.728,95%CI:0.598—0.887)and decreased globulin(OR=1.043,95%CI:1.003—1.085)were independent risk factors for the development of pulmonary infection in IIM(P<0.05).Conclusion The primarypathogens of IIM comorbid with pulmonary infection include Candida and gram-negative bacilli.For elderly infected patients with IIM who have a history of smoking and ILD,it is necessary to be alert to the possibility of secondary pulmonary infection when observing reduced lymphocyte count,albumin and globulin,as well as elevated C-reactive protein and fibrinogen.In screening pulmonary infectious pathogens,priority should be given to opportunistic agents.Early identification of the cause of pulmonary infection and initiation of appropriate anti-infective therapy can help improve patients'outcomes.