严重创伤术后继发真菌感染情况耐药特征及影响因素分析

Analysis of Postoperative Fungal Infections Resistance Characteristics and Influencing Factors in Severe Trauma Patients

目的:探讨严重创伤术后继发真菌感染的感染情况、耐药特征及影响因素。方法:回顾性分析2017年4月至2024年3月空军军医大学第一附属医院急诊科收治的严重创伤患者516例,术后按照是否检出真菌感染分为感染组(n=145)和未感染组(n=371),统计感染组检出真菌菌种分布及耐药情况,收集两组临床资料,采用Logistic回归模型分析危险因素,经回归方程拟合的概率值绘制ROC曲线。结果:感染组145例中共检出真菌163株,占比最高为白念珠菌84株(51.53%),感染部位主要为呼吸道、泌尿道和手术部位。进行药敏试验的163株真菌对伊曲康唑的耐药情况最为严重(26株),对5-氟胞嘧啶和两性霉素B的耐药情况最轻(各1株)。单因素分析显示:创伤严重度评分(ISS评分)、入院序贯器官衰竭评分(SOFA)评分、有创通气及其时长、导尿管使用及其时长、中心静脉置管及其时长、连续性肾脏替代疗法(CRRT)、激素使用、抗生素使用≥7d、血糖水平、输血、ICU停留时长、入院时休克与严重创伤术后继发真菌感染有关(P<0.05)。多因素Logistic回归显示:ISS评分、SOFA评分、有创机械通气时长、导尿管使用及其时长、中心静脉置管使用、使用激素、输血、ICU停留时长是严重创伤术后继发真菌感染的重要影响因素(P<0.05)。ROC分析显示:ISS评分、入院SOFA评分、有创机械通气时长、导尿管使用、导尿管使用≥5d、中心静脉置管、激素使用、抗生素使用≥7d、输血、ICU停留时长的AUC分别为0.754、0.867、0.867、0.680、0.727、0.613、0.616、0.571、0.601、0.762,联合预测评估严重创伤术后继发真菌感染的AUC为0.992,95%CI为0.986~0.999,灵敏度为0.966,特异度为0.984;与Az=0.5相比,均有显著差异(P<0.05)。结论:白念珠菌为严重创伤术后继发真菌感染常见菌株。真菌对伊曲康唑敏感度较低,对5-氟胞嘧啶和两性霉素B敏感度较高。ISS评分、入院SOFA评分、有创机械通气时长、导尿管使用及其时长、中心静脉置管使用、使用激素、输血、ICU停留时长是严重创伤术后继发真菌感染重要影响因素。

Objective:To investigate the incidence of secondary fungal infections following surgery for severe trauma,their drug resistance characteristics,and influencing factors.Methods:A retrospective analysis was conducted on 516 severe trauma patients admitted to the Emergency Department of the First Affiliated Hospital of Air Force Medical University between April 2017 and March 2024.Patients were divided into an infection group(n=145)and a non-infection group(n=371)based on the presence of postoperative fungal infections.The fungal species distribution and drug resistance in the infection group were analyzed,and clinical data were collected for both groups.Logistic regression analysis was performed to identify risk factors,and ROC curves were plotted using the probabilities from the regression equation.Results:A total of 163 fungal strains were isolated from 145 patients in the infection group,with the highest proportion being Candida albicans(84 strains,51.53%).The main infection sites were the respiratory tract,urinary tract,and surgical sites.Among the 163 strains tested for drug sensitivity,the highest resistance was to itraconazole(26 strains),while the least resistance was observed for flucytosine and amphotericin B(1 strain each).Univariate analysis revealed that factors such as Injury Severity Score(ISS),Sequential Organ Failure Assessment(SOFA)score at admission,duration of invasive ventilation,use and duration of urinary catheters,use of central venous catheters,continuous renal replacement therapy(CRRT),use of corticosteroids,use of antibiotics for≥7 days,blood glucose levels,blood transfusions,ICU stay duration,and shock at admission were associated with postoperative fungal infections in severe trauma patients(P<0.05).Multivariate logistic regression showed that ISS score,SOFA score,duration of invasive mechanical ventilation,urinary catheter use and its duration,use of central venous catheters,use of corticosteroids,blood transfusion,and ICU stay duration were significant factors influencing postoperative fungal infections(P<0.05).ROC analysis indicated that the AUCs for ISS score,SOFA score,duration of invasive ventilation,urinary catheter use,urinary catheter use for≥5 days,central venous catheter use,corticosteroid use,antibiotic use for≥7 days,blood transfusion,and ICU stay duration were 0.754,0.867,0.867,0.680,0.727,0.613,0.616,0.571,0.601,and 0.762,respectively.The combined AUC for predicting postoperative fungal infections was 0.992,with a 95%confidence interval of 0.986~0.999,sensitivity of 0.966,and specificity of 0.984,which showed a significant difference compared to Az=0.5(P<0.05).Conclusion:Candida albicans is the most common fungal strain causing secondary infections following surgery for severe trauma.Fungi show lower sensitivity to itraconazole and higher sensitivity to flucytosine and amphotericin B.Important factors influencing postoperative fungal infections include ISS score,SOFA score at admission,duration of invasive ventilation,use and duration of urinary catheters,use of central venous catheters,use of corticosteroids,blood transfusions,and ICU stay duration.