重症监护老年患者感染多重耐药菌的危险因素分析

Risk factors for infections by multidrug-resistant organisms in elderly patients admitted to the intensive care unit

目的:通过对重症监护医学信息数据库(MIMIC)老年患者进行回顾性研究,探讨ICU老年患者发生多重耐药菌(MRDO)感染的危险因素。方法:使用结构化查询语言提取MIMIC-Ⅳv2.0数据库中老年患者的基本信息、疾病严重性评分、实验室检查、使用药物、医疗操作、终点事件信息。根据患者是否感染多重耐药菌,分为非多重耐药菌感染组(non-MDRO)和多重耐药菌感染组(MDRO)。根据变量类型进行单因素分析,对于单因素分析有意义的变量进行Logistic回归,计算多重耐药菌感染的优势比及95%可信区间。使用Kaplan-Meier法计算生存率并绘制生存曲线,采用Log-Rank检验对患者28 d生存率进行分析。结果:共纳入患者31237例,其中非多重耐药菌感染组26032例,多重耐药菌感染组5205例,多重耐药菌感染率16.7%。培养标本种类中尿液培养出多重耐药菌数量最多,病原微生物中肠杆菌属占比最高。多因素Logistic回归结果显示:年龄(P=0.006)、男性(P<0.001)、冠脉疾病(P<0.001)、脑部疾病(P=0.042)、血红蛋白(P<0.001)、白蛋白(P<0.001)、有创机械通气(P<0.001)是多重耐药菌感染的保护因素;糖尿病(P<0.001)、慢性阻塞性肺疾病(COPD)(P<0.001)、慢性肾病(P<0.001)、白细胞(P=0.001)、简化急性生理Ⅱ评分(SAPSⅡ)(P<0.001)、曾经使用抗生素(P<0.001)、使用质子泵抑制剂(P<0.001)、糖皮质激素(P<0.001)、免疫抑制剂(P<0.001)、镇静药物(P<0.001)、肾脏替代治疗(P=0.015)是多重耐药菌感染的危险因素。non-MDRO组28 d死亡率为16.3%,MDRO组28 d死亡率为19.1%,两组比较差异有统计学意义(P<0.001)。结论:多重耐药菌感染患者死亡率较非感染患者高,曾经使用抗生素、使用质子泵抑制剂、糖皮质激素、免疫抑制剂、镇静药物、肾脏替代治疗是多重耐药菌感染的危险因素。

Objective To identify risk factors for infections by multidrug-resistant organisms(MDRO)in elderly patients admitted to the intensive care unit(ICU)based on an retrospective analysis of data from the Medical Information Mart for Intensive Care-Ⅳv2.0(MIMIC-Ⅳv2.0).Methods Structured query language was used to extract basic information,disease severity scores,laboratory test results,medications,medical procedures,and outcome events of elderly patients from MIMIC-Ⅳv2.0.Patients were divided into a non-MDRO group and an MDRO group based on whether they had MDRO infections.Univariate analysis was performed according to the type of variables.For significant variables identified from univariate analysis,logistic regression was used to calculate the odds ratio and the 95%confidence interval for MDRO infections.The Kaplan-Meier method was used to draw survival curves.The log-rank test was used to analyze the 28-day survival rate.Results A total of 31237 cases were enrolled,including 26032 with non-MDRO infections and 5205 with MDRO infections.The MDRO infection rate was 16.7%.MDRO were most frequently found in urine cultures,and the most common bacteria belonged to the genus Enterobacter.Multivariate logistic regression analysis showed that age(P=0.006),being male(P<0.001),coronary artery disease(P<0.001),brain disease(P=0.042),hemoglobin(P<0.001),albumin(P<0.001),and mechanical ventilation(P<0.001)were protective factors against MDRO infections.Diabetes(P<0.001),COPD(P<0.001),chronic kidney disease(P<0.001),white blood cell(P=0.001),SAPSⅡ(P<0.001),previous use of antibiotics(P<0.001),use of proton pump inhibitors(P<0.001),glucocorticoids(P<0.001),immunosuppressants(P<0.001)and sedatives(P<0.001),and continuous renal replacement therapy(CRRT)(P=0.015)were risk factors for MDRO infections.The 28-day mortality rates of the non-MDRO and MDRO groups were 16.3%and 19.1%,respectively.The log-rank test showed that the difference between two groups was statistically significant(P<0.001).Conclusions The mortality rate among patients with MDRO infections is higher than among those with non-MDRO infections.Previous use of antibiotics,use of proton pump inhibitors,glucocorticoids,immunosuppressants and sedatives,mechanical ventilation,and CRRT are risk factors for MDRO infections.