侵袭性肺曲霉菌病合并肺部感染的临床分析

Clinical analysis of invasive pulmonary aspergillosis combined with pulmonary infection

目的对侵袭性肺曲霉菌病(IPA)合并肺部感染的临床特征、危险因素及预后进行分析,旨在进一步提高临床医师对其认识及诊治水平。方法回顾性收集浙江大学附属第二医院2013.1-2021.10期间IPA住院患者的医疗电子病历资料,包括人口学信息、临床特征、生化指标、辅助检查、微生物数据以及预后指标等。患者分为IPA合并肺部感染和单纯性IPA两组,分析比较他们的临床特征、危险因素及预后情况。结果共筛选出156例IPA患者,年龄(67.12±12.89)岁,男性69.20%,其中IPA合并肺部感染和单纯性IPA分别为86例(55.13%)和70例(44.87%)。共分离出162株微生物,其中细菌、真菌、病毒占比分别是82.72%、7.41%和9.88%,其中混合有一种、两种以及3种及以上病原体占比分别50.00%、26.74%以及23.26%。多变量Logistics回归分析发现,机械通气(OR 4.89,95%CI 2.23~10.70)和既往中性粒细胞缺乏(OR 6.41,95%CI 1.33~30.93)为IPA合并肺部感染发生的独立危险因素。与单纯性IPA相比,IPA合并肺部感染患者更易发展成脓毒性休克(69.80%vs.32.90%,P<0.05),总住院天数、重症加强治疗病房(intensive care unit,ICU)住院天数以及机械通气天数均显著延长[分别为:16.00(8.00,36.5)vs.13.50(7.00,20.50),11.50(6.00,31.25)vs.8.50(1.75,11.00),12.00(6.75,25.25)vs.8.00(2.00,10.00),P<0.05],28 d病死率及住院病死率(分别为:55.80%vs.35.70%,64.00%vs.35.70%,P<0.05)也明显增高。结论IPA合并肺部感染在IPA中占比超过半数,主要为细菌,其次为真菌和病毒。IPA合并肺部感染发生的独立危险因素为机械通气及中性粒细胞缺乏,其预后较单纯性IPA更差,值得临床医师重视。

Objective To analyze the clinical features,risk factors and prognosis of IPA combined with lung infection,aiming to further improve clinicians'understanding and diagnosis and treatment of it.Methods Patients with IPA admitted to the Second Affi liated Hospital of Zhejiang University School of Medicine from January 2013 to October 2021 were retrospectively enrolled,and their clinical data was collected from the electronic medical record,including demographic information,clinical characteristics,biochemical indicators,auxiliary examination,microbial data and prognostic indicators.Patients were divided into two groups of IPA with pulmonary infection and IPA alone,and the clinical features,risk factors and prognosis of IPA patients with pulmonary infection were compared and analyzed in comparison with IPA patients alone.Results A total of 156 IPA patients were fi nally recruited,with an average age of(67.12±12.89)years old and a main male proportion of 69.20%.Among them,there were 86 cases(55.13%)with IPA with pulmonary infection and 70 cases(44.87%)with IPA alone.Half of the IPA patients with pulmonary infection were mixed with one pathogen.The main pathogen of mixed infection was bacteria(82.72%),whereas acinetobacter baumannii accounted for the most common pathogen(25.93%,42/162).Multivariate logistic regression analysis found that mechanical ventilation(OR 4.89,95%CI 2.23-10.70)and prior neutropenia(OR 6.41,95%CI 1.33-30.93)were independent risk factors for the occurrence of IPA with pulmonary infection.Compared with IPA alone,IPA patients with pulmonary infection were more likely to develop septic shock(69.80%vs.32.90%,P<0.05),and have longer lengthes of hospital stay[16.00(8.00,36.50)vs.13.50(7.00,20.50)]and ICU stay[11.50(6.00,31.25)vs.8.50(1.75,11.00)],and mechanical ventilation days[12.00(6.75,25.25)vs.8.00(2.00,10.00)],as well as a higher 28-day mortality(55.80%vs.35.70%)and in-hospital mortality(64.00%vs.35.70%).Conclusions IPA patients with pulmonary infection accounts for more than half of IPA patients.The main respiratory etiology of IPA with pulmonary infection is acinetobacter baumannii.The independent risk factors of IPA patients with pulmonary infection are mechanical ventilation and neutropenia.The prognosis of IPA patients with pulmonary infection is worse than patients with IPA alone,which is worthy for the attention of physicians.