乙型肝炎相关性终末期肝病并发感染的临床特点、病原学特征以及影响因素分析

Clinical characteristics,pathogenic characteristics and influencing factors of hepatitis B-related end-stage liver disease complicated with infection

目的回顾分析乙型肝炎相关性终末期肝病(ESLD)并发感染的临床特点、病原学特征以及影响因素。方法选取2017年1月至2022年6月收治的82例乙型肝炎相关性ESLD患者,其中未并发感染34例,并发感染48例。应用单因素、多因素分析影响ESLD患者并发感染的因素,搜集感染发生部位、病原菌标本来源、培养结果等信息。结果单因素分析发现,并发感染组WBC、CRP、ALT、AST、TBil、Scr、INR、PCT及MELD评分分别为6.8(4.4,11.3)×10^(9)/L、35.8(17.3,43.8)mg/L、92(70,123)U/L、102(78,140)U/L、127.0(73.8,250.4)μmol/L、92.7(65.5,112.3)μmol/L、2.0(1.4,2.3)、6.2(2.0,9.0)ng/L及14(9,22)分,高于未并发感染组的3.7(3.0,5.3)×10^(9)/L、11.2(7.6,18.9)mg/L、57(18,88)U/L、54(24,79)U/L、37.3(17.9,80.2)μmol/L、74.2(44.8,97.0)μmol/L、0.9(0.7,1.2)、0.2(0.1,2.8)ng/L及7(5,11);并发感染组Alb、PTA为28.3(27.8,31.6)g/L及45.3(37.9,50.8)%,均低于未并发感染组的33.2(30.8,35.8)g/L及66.7(49.6,74.0)%,差异均有统计学意义(P<0.05)。单个、多个感染部位分别为37例(77.1%)、11例(22.9%),前者自高到低囊括SBP 18例(37.5%)、肺部感染13例(27.1%)、泌尿系感染4例(8.3%)及胆道感染2例(4.2%),后者自高到低囊括SBP合并肺部感染10例(20.8%)、SBP合并真菌感染1例(2.1%)。48例乙型肝炎相关性ESLD并发感染患者中共培养出16株(33.3%)病原菌,其中杆菌9株(56.2%)、球菌6株(37.5%)及真菌1株(6.2%)。杆菌自高到低为大肠埃希菌7株(43.7%)、肺炎克雷伯菌及产酸克雷伯菌各1株(6.2%);球菌自高到低为屎肠球菌5株(31.2%)及金黄色葡萄球菌1株(6.2%);真菌为白色念珠菌1株(6.2%)。大肠埃希菌对左氧氟沙星、环丙沙星等喹诺酮类耐药分别为4株、3株,对头孢呋辛耐药为5株,对头孢哌酮舒巴坦以及美罗培南、亚胺培南等碳青霉烯类药物均敏感。屎肠球菌对青霉素耐药为4株,对左氧氟沙星、环丙沙星等喹诺酮类药物耐药均为4株,对四环素、庆大霉素、链霉素耐药分别为1株、2株及3株。结论ESLD患者发生感染时可根据并发感染部位、既往抗生素用药史,结合病原菌流行谱及耐药检测分析,制定有效的抗感染方案。

Objective To investigate the clinical features,pathogenic features and influencing factors of hepatitis B-related end-stage liver disease(ESLD)complicated with infection.Methods A total of 82 patients with hepatitis B-related ESLD were selected between January 2017 and June 2022,including 51 males and 31 females with an age of 45(34,60)years.Among them,34 were not complicated with infection(non-complicated infection group),while 48 were complicated with infection(complicated infection group).The selected ESLD cases met the diagnostic requirements.Single-factor and multi-factor analyses were conducted to analyze the influencing factors of complicated infection in ESLD patients,and information such as infection location,pathogen specimen source,and culture results were collected.Results Univariate analysis indicated that the WBC,CRP,ALT,AST,TBil,Scr,INR,PCT and MELD scores in the complicated infection group were 6.8(4.4,11.3)×10^(9)/L,35.8(17.3,43.8)mg/L,92(70,123)U/L,102(78,140)U/L,127.0(73.8,250.4)μmol/l,92.7(65.5,112.3)μmol/l,2.0(1.4,2.3),6.2(2.0,9.0)ng/l and 14(9,22)points,which were significantly higher than those in the non-complicated infection group[3.7(3.0,5.3)×10^(9)/L,11.2(7.6,18.9)mg/L,57(18,88)U/L,54(24,79)U/L,37.3(17.9,80.2)μmol/l,74.2(44.8,97.0)μmol/l,0.9(0.7,1.2),0.2(0.1,2.8)and 7(5,11)points,P<0.05].Additionally,the Alb and PTA levels in the complicated infection group were 28.3(27.8,31.6)g/L and 45.3(37.9,50.8)%,which were significantly lower than those in the non-complicated infection group[33.2(30.8,35.8)g/L and 66.7(49.6,74.0)%,P<0.05].In the complicated infection group,37 cases(77.1%)had single infections and 11 cases(22.9%)had multiple infections.Among the patients with a single infection site,the most common infection was SBP in 18 cases(37.5%),followed by lung infection in 13 cases(27.1%),urinary tract infection in 4 cases(8.3%),and biliary tract infection in 2 cases(4.2%).For patients with multiple infection sites,the most common scenario was SBP combined with lung infection in 10 cases(20.8%),and SBP combined with fungal infection in 1 case(2.1%).A total of 16 pathogens(33.3%)were cultured among the 48 patients,including 9 strains of Bacillus(56.2%),6 strains of cocci(37.5%)and 1 strain of fungi(6.2%).The bacterial isolates consisted of 7 strains of Escherichia coli(43.7%),1 strain of Klebsiella pneumoniae(6.2%)and 1 strain of Klebsiella acidogenes(6.2%).Staphylococcal isolates comprised 5 strains of Enterococcus faecalis(31.2%)and 1 strain of Staphylococcus aureus(6.2%).Additionally,there was 1 strain of Candida albicans(6.2%)among the fungal isolates.The resistance rates of Escherichia coli to quinolones such as levofloxacin and ciprofloxacin were 57.1%(4/7)and 42.8%(3/7),respectively,while the resistance rate to cefuroxime was 71.4%(5/7).Escherichia coli exhibited sensitivity to carbapenems such as cefoperazone,sulbactam,meropenem and imipenem.The resistance rate of Enterococcus faecalis to penicillin,levofloxacin and ciprofloxacin were all 80.0%(4/5).Additionally,the resistance rate to tetracycline,gentamicin and streptomycin were 20.0%(1/5),40.0%(2/5)and 60.0%(2/5),respectively.Conclusion Effective antibiotic treatment plans should be developed for ESLD patients with infections based on the complicated infection site,past antibiotic use history,combined with the epidemic spectrum of pathogenic bacteria and the detection and analysis of drug resistance.This approach will help to prevent further aggravation of infection.