念珠菌血症患者的临床特征及预后分析和构建预测模型

To analyze the clinical characteristics and prognosis of patients with candidemia and construct a predictive model

目的了解念珠菌血症患者的临床特征和菌种分布,探讨影响其预后的危险因素及构建预测模型。方法回顾性收集2017年1月1日至2022年12月31日香港大学深圳医院血培养念珠菌属阳性病例,描述其临床特征、菌种分布、基础疾病、治疗及30 d预后相关危险因素,采用t检验和χ^(2)检验进行预后单因素分析,采用logistic回归分析预后因素及构建念珠菌血症预后的预测模型。结果观察期间,共有60例病例入选,其中男性35例(58.33%),女25例(41.67%);平均年龄为(56.65±24.02)岁,35例(63.52%)是老年患者(61~100)岁;念珠菌血症的平均发生率为1.6例/10000人次住院患者;医院获得性感染病例42例(65.22%);45例(75.00%)发病前30 d曾使用广谱抗生素;25例(41.67%)发病前30 d接受手术治疗;38例(63.33%)留置中心静脉置管和31例(51.67%)留置导尿管;白念珠菌为主要致病菌株,其次为热带念珠菌;54例曾接受至少1次的系统抗真菌治疗,启动抗真菌治疗的平均时间为发病后(1.68±2.84)d;首选的抗真菌药物为米卡芬净(38例)。其中,生存29例(48.33%),平均年龄为(52.90±26.66)岁,死亡31例(51.67%),平均年龄为(60.00±21.11)岁;单因素分析显示高血压、意识障碍、淋巴细胞绝对值减少、血小板计数降低与患者死亡相关,48 h内移除中心静脉置管和足量的系统抗真菌药与患者生存相关;多因素分析结果显示高血压(OR=18.02,P=0.025)、意识障碍(OR=22.07,P=0.059)、淋巴细胞绝对值减少(OR=3.79,P=0.294)和血小板计数降低(OR=8.47,P=0.073)是念珠菌血症死亡的独立危险因素,而48 h内移除中心静脉置管(OR=0.46,P=0.346)和足量的系统抗真菌药物治疗(OR=0.17,P=0.400)则为保护性因素。结论念珠菌血症患者具有高龄、基础疾病多、病死率高等临床特点;致病菌株以白念珠菌为主;高血压、意识障碍、淋巴细胞绝对值减少和血小板计数降低是死亡独立危险因素。48 h内移除中心静脉置管和足量的系统抗真菌药物治疗是预后的保护性因素;预测模型有助于临床判断念珠菌血症患者的预后。

Objective To investigate the clinical characteristics and Candida species distribution of patients with candidemia,and to explore the risk factors for prognosis and construct a predictive model.Methods The candidemia cases from January 1,2017 to December 31,2022 were retrospectively analyzed,and their clinical features,microbiology,underlying diseases,treatment and 30 days outcomes were described by chart review.The univariate and multivariate logistic regression analyses were identified and were used to construct a predictive model.Results During the observation period,a total of 60 cases were enrolled,including 35 males(58.33%)and 25 females(41.67%).The mean age was(56.65±24.02)years,and 35 cases(63.52%)were elderly(61-100 years).The mean incidence of candidemia was 1.6 cases per 10000 inpatients.42 cases(65.22%)were hospital acquired infection.45 cases(75.00%)had been given broad-spectrum antibiotics 30 days before onset of the candidemia.25 cases(41.67%)underwent surgery 30 days before onset.38 cases(63.33%)had indwelling central venous catheters and 31 cases(51.67%)had indwelling urinary catheters.Candida albicans was predominantly,followed by Candida tropical.54 patients received at least one dose of antifungal drug,and the mean time of initiation of antifungal therapy was(1.68±2.84)days after onset.Micafungin was the primary antifungal agent.Among the enrolled cases,29 cases(48.33%)survived with mean age of(52.90±26.66)years,and 31 cases(51.67%)died with mean age of(60.00±21.11)years.Univariate analysis revealed that hypertension,unconsciousness,lymphopenia and thrombocytopenia were associated with death.On the other hand,removal of central venous catheter within 48 hours and early use of adequate antifungal agent were associated with survival.Multivariate analysis showed that hypertension(OR=18.02,P=0.025),unconsciousness(OR=22.07,P=0.059),lymphopenia(OR=3.79,P=0.294),and thrombocytopenia(OR=8.47,P=0.073)were independent risk factors for death of candidemia.However,removal of central venous catheter within 48 hours(OR=0.46,P=0.346)and early use of adequate antifungal agent(OR=0.17,P=0.400)were protective factors.Conclusion The case fatality rate of candidemia has remained high.Candida albicans is the predominant pathogen.Hypertension,unconsciousness,lymphopenia and thrombocytopenia are independent risk factors for death,while removal of central venous catheter within 48 hours and early use of adequate antifungal agent are protective factors.This predictive model may help doctors in managing candidemia patients.