肿瘤患者念珠菌血症病原学特点和死亡危险因素分析

Analysis of etiological characteristics and death risk factors of candidemia in tumor patients

目的分析肿瘤患者念珠菌血症病原学特点和预后危险因素,为改善患者预后提供参考。方法收集2013年1月—2022年12月复旦大学附属肿瘤医院所有念珠菌血症肿瘤患者临床资料,根据患者预后分为死亡组和生存组。比较死亡组和生存组疾病谱、临床分离株微生物学数据和相关实验室指标检验结果的差异。采用Logistic回归分析评估念珠菌血症肿瘤患者死亡的危险因素,采用受试者工作特征(ROC)曲线评估危险因素判断患者预后的效能。结果共纳入67例念珠菌血症肿瘤患者,以胰腺癌(25.4%)、结直肠癌(16.4%)、食管癌(16.4%)患者为主;死亡26例(38.8%)。共分离出念珠菌68株,以白念珠菌(44.1%)、近平滑念珠菌(20.6%)、光滑念珠菌(11.8%)为主;98.4%的念珠菌为两性霉素B野生型,90.9%为伊曲康唑野生型。原发肿瘤远隔转移、合并3种及以上基础疾病、血液透析、气管切开、机械通气、合并细菌血流感染、中心静脉导管相关真菌感染是患者预后的影响因素(P<0.05);原发肿瘤远隔转移(P=0.003)和机械通气(P=0.019)是患者死亡的独立危险因素。有43例患者送检(1,3)-β-D-葡聚糖(BDG),阳性率为48.8%。死亡组和生存组C反应蛋白(CRP)、降钙素原(PCT)、血小板(PLT)计数、纤维蛋白原(Fib)、D-二聚体(DD)、纤维蛋白原降解产物(FDP)差异有统计学意义(P<0.05)。PLT计数预测念珠菌血症肿瘤患者死亡的ROC曲线下面积为0.751,高于其他指标;DD预测念珠菌血症肿瘤患者死亡的敏感性(88.0%)高于其他指标;PCT预测念珠菌血症肿瘤患者死亡的特异性(77.3%)高于其他指标。结论念珠菌血症肿瘤患者预后差,病原菌以白念珠菌为主,且主要为两性霉素B野生型菌株。原发肿瘤远隔转移和机械通气与患者死亡密切相关。BDG和血培养联合送检有助于早期诊断;CRP、PCT、PLT计数、Fib、DD、FDP水平可一定程度预测患者预后;PCT和DD可用于预测患者生存情况。

Objective To analyze the etiological characteristics and prognosis risk factors of pathogenic bacteria in tumor patients with candidemia,so as to provide a reference for improving the prognosis of patients.Methods All the patients with candidemia in Fudan University Cancer Hospital from January 2013 to December 2022 were enrolled and classified into death group and survival group according to their prognosis.The differences of disease spectrum,microbiological data of clinical isolates and laboratory determination results were compared between death group and survival group.Logistic regression analysis was used to evaluate the risk factors of death in tumor patients with candidemia.Receiver operating characteristics(ROC)curves were used to assess the effectiveness of risk factors in determining patient prognosis.Results A total of 67 tumor patients with candidemia were enrolled,mainly pancreatic cancer(25.4%),colorectal cancer(16.4%)and esophageal cancer(16.4%).Totally,26 cases(38.8%)died.Totally,68 isolates of Candida were isolated,mainly Candida albicans(44.1%),Candida parapsilosis(20.6%)and Candida glabrata(11.8%).The 98.4%of Candida isolates were amphotericin B wild type,and 90.9%were itraconazole wild type.Distant metastasis of primary tumor,three or more underlying diseases,hemodialysis,tracheotomy,mechanical ventilation,bacterial bloodstream infection and central venous catheter-related fungal infection were the prognostic factors(P<0.05).Distant metastasis of primary tumor(P=0.003)and mechanical ventilation(P=0.019)were independent risk factors for death.Totally,43 patients were determined for(1,3)-beta-D-glucan(BDG),with a positive rate of 48.8%.There was statistical significance in serum C-reactive protein(CRP),procalcitonin(PCT),platelet(PLT)count,plasma fibrinogen(Fib),D-dimer(DD)and fibrinogen degradation product(FDP)between death and survival groups(P<0.05).The area under curve of PLT count for predicting death of tumor patients with candidemia was 0.751,which was higher than other indexes.DD(88.0%)was more sensitive to predict death in tumor patients with candidemia than other indexes,and PCT(77.3%)was more specific to predict death in tumor patients with candidemia than other indexes.Conclusions The prognosis of tumor patients with candidemia is poor,and the pathogenic bacteria are Candida albicans,mainly amphotericin B wild type isolates.Distant metastasis of primary tumor and mechanical ventilation are related to patient death.The combination of BDG and blood culture is helpful for early diagnosis.Serum CRP,PCT,PLT count,Fib,DD and FDP levels can predict the prognosis of patients to a certain extent.PCT and DD can be used to predict patient survival.