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泛耐药鲍曼不动杆菌菌血症危险因素及临床结局

隆云 郭清华 刘大为 张小江 宋连燕 何怀武

隆云, 郭清华, 刘大为, 张小江, 宋连燕, 何怀武. 泛耐药鲍曼不动杆菌菌血症危险因素及临床结局[J]. 协和医学杂志, 2015, 6(4): 260-266. doi: 10.3969/j.issn.1674-9081.2015.04.005
引用本文: 隆云, 郭清华, 刘大为, 张小江, 宋连燕, 何怀武. 泛耐药鲍曼不动杆菌菌血症危险因素及临床结局[J]. 协和医学杂志, 2015, 6(4): 260-266. doi: 10.3969/j.issn.1674-9081.2015.04.005
Yun LONG, Qing-hua GUO, Da-wei LIU, Xiao-jiang ZHANG, Lian-yan SONG, Huai-wu HE. Risk Factors and Clinical Outcomes of Pan-drug Resistant Acinetobacter baumannii Bacteremia[J]. Medical Journal of Peking Union Medical College Hospital, 2015, 6(4): 260-266. doi: 10.3969/j.issn.1674-9081.2015.04.005
Citation: Yun LONG, Qing-hua GUO, Da-wei LIU, Xiao-jiang ZHANG, Lian-yan SONG, Huai-wu HE. Risk Factors and Clinical Outcomes of Pan-drug Resistant Acinetobacter baumannii Bacteremia[J]. Medical Journal of Peking Union Medical College Hospital, 2015, 6(4): 260-266. doi: 10.3969/j.issn.1674-9081.2015.04.005

泛耐药鲍曼不动杆菌菌血症危险因素及临床结局

doi: 10.3969/j.issn.1674-9081.2015.04.005
详细信息
    通讯作者:

    刘大为 电话:010-69157091, E-mail:dwliu@medmail.com.cn

  • 中图分类号: R378;R969.3

Risk Factors and Clinical Outcomes of Pan-drug Resistant Acinetobacter baumannii Bacteremia

More Information
  • 摘要:   目的  比较泛耐药鲍曼不动杆菌(pan-drug resistant Acinetobacter baumannii, PDRAB)菌血症与非泛耐药鲍曼不动杆菌(non-pan-drug resistant Acinetobacter baumannii, NPDRAB)菌血症的临床资料, 探讨PDRAB菌血症的危险因素及其临床结局。  方法  本研究为回顾性队列研究, 纳入对象为2010年1月1日至2012年12月31日就诊于北京协和医院的鲍曼不动杆菌菌血症患者, 采用统一的标准表格收集患者的临床资料和检验结果, 以鲍曼不动杆菌血培养标本采集14 d内发生院内死亡为主要临床结局。  结果  共纳入52例鲍曼不动杆菌菌血症患者, 平均年龄(54±20)岁, 其中男性30例(57.7%); 平均急性生理与慢性健康状况Ⅱ(acute physiology and chronic health evaluation Ⅱ, APACHE Ⅱ)评分(21±9)分, 平均序贯器官衰竭评估(sepsis-related organ failure assessment, SOFA)评分(10±5)分; 鲍曼不动杆菌菌血症发生前, 患者中位住院时间为12 d(7~20 d); 仅6例患者对碳青霉烯类药物敏感。33例患者感染NPDRAB, 19例感染PDRAB。在感染鲍曼不动杆菌前, PDRAB患者与NPDRAB患者比较, 接受机械通气概率更大(94.7%比63.6%, P=0.031), 住院时间更长(中位住院时间17 d比10 d, P=0.025)。鲍曼不动杆菌菌血症患者14 d死亡率为67.3%(35/52)。多因素分析提示, 脓毒性急性肾损伤(OR 7.9, 95% CI 1.113~55.448, P=0.039)、不适当抗菌药物治疗(OR 9.4, 95% CI 1.020~87.334, P=0.048)和降钙素原水平(OR 1.3, 95% CI 1.332~1.088, P=0.005)是鲍曼不动杆菌菌血症患者14 d死亡的独立危险因素。  结论  鲍曼不动杆菌具有多重耐药性, 甚至对目前所有全身用抗菌药物均不敏感, 感染患者死亡率较高。菌血症发生前接受机械通气和住院时间是PDRAB菌血症的危险因素, 但PDRAB感染本身不能作为判断患者预后不良的指标。不适当抗菌药物治疗、脓毒性急性肾损伤和降钙素原水平是鲍曼不动杆菌菌血症患者14 d死亡的独立危险因素。
  • 表  1  PDRAB与NPDRAB感染患者人口统计学和临床特征比较

    特征 NPDRAB PDRAB P
    例数[n(%)] 33(63.5) 19(36.5)
    年龄(x±s, 岁) 56±21 47±20 0.102
    男性[n(%)] 22(66.7) 8(42.1) 0.084
    报告时间(x±s, d) 10±6 13±11 0.345
    APACHE Ⅱ评分(x±s,分) 21±10 20±9 0.419
    SOFA评分(x±s,分) 10±6 10±5 0.877
    全身基础疾病[n(%)]
        高血压 7(21.2) 4(21.1) 1.000
        糖尿病 9(27.3) 4(21.1) 0.868
        慢性阻塞性肺疾病 3(9.1) 2(10.5) 1.000
        实体肿瘤 10(30.3) 7(36.8) 0.628
        脑血管意外 7(21.2) 3(15.8) 0.910
        自身免疫性疾病 12(36.4) 11(57.8) 0.132
        贫血 27(81.8) 17(89.5) 0.736
    甾体类药物使用[n(%)] 17(51.5) 13(68.4) 0.235
    既往抗生素使用[n(%)] 24(72.7) 14(73.7) 0.940
    ≥2类抗生素[n(%)] 16(50.0) 10(52.6) 0.856
    三代头孢菌素[n(%)] 10(31.3) 5(26.3) 0.708
    碳青霉烯类[n(%)] 21(65.6) 13(68.4) 0.838
    三代头孢菌素+碳青霉烯类
        [n(%)]
    3(9.4) 3(15.8) 0.812
    β-内酰胺酶抑制剂[n(%)] 13(40.6) 4(21.4) 0.152
    米诺环素/四环素[n(%)] 1(3.1) 2(10.0) 0.672
    ICU收住时间>7 d [n(%)] 26(78.8) 12(63.2) 0.221
    肺炎[n(%)] 26(78.8) 16(84.2) 0.910
    菌血症发生前住院时间
        [M(Q1~Q3),d]
    10(6~17) 17(9~63) 0.025
    真菌感染[n(%)] 9(27.3) 10(52.6) 0.067
    机械通气[n(%)] 21(63.6) 18(94.7) 0.031
    病毒感染[n(%)] 2(6.1) 3(15.8) 0.511
    PDRAB:泛耐药鲍曼不动杆菌;NPDRAB:非泛耐药鲍曼不动杆菌;APACHE Ⅱ:急性生理与慢性健康状况Ⅱ;SOFA:序贯器官衰竭评估;ICU:重症监护病房
    下载: 导出CSV

    表  2  PDRAB和NPDRAB感染患者临床结局比较

    组别 例数
    [n(%)]
    阳性报警时间
    [M(Q1~Q3),h]
    脓毒性AKI
    [n(%)]
    脓毒性休克
    [n(%)]
    导管相关感染
    [n(%)]
    PCT水平
    [M(Q1~Q3),ng/ml]
    不适当抗菌药物
    治疗[n(%)]
    14 d死亡
    [n(%)]
    NPDRAB 33(63.5) 9(6~12) 15(45.4) 17(48.6) 23(69.7) 4.23(1.79~10.25) 21(63.6) 20(60.6)
    PDRAB 19(36.5) 10(8~10) 12(63.1) 11(57.9) 16(84.2) 4.57(1.06~10.00) 19(100) 15(78.9)
    P 0.345 0.219 0.513 0.406 0.947 0.008 0.175
    PDRAB、NPDRAB:同表 1;AKI:急性肾损伤;PCT:降钙素原
    下载: 导出CSV

    表  3  鲍曼不动杆菌菌血症14 d死亡的危险因素单因素分析

    危险因素 存活组 非存活组 P
    例数[n(%)] 17(32.7) 35(67.3)
    年龄(x±s, 岁) 57.7±20.6 50.3±18.8 0.249
    男性[n(%)] 10(58.8) 20(57.1) 0.908
    菌血症发生前住院时间
        [M(Q1~Q3), d]
    11(7.5~21.5) 14(6.0~20.0) 0.747
    APACHE Ⅱ评分
        (x±s, 分)
    16.8±7.4 22.6±9.6 0.028
    SOFA评分(x±s, 分) 6.8±4.4 11.2±5.0 0.004
    甾体类药物使用
        [n(%)]
    9(52.9) 21(60.0) 0.629
    高血压[n(%)] 6(35.3) 5(14.3) 0.168
    糖尿病[n(%)] 5(29.4) 8(22.9) 0.864
    慢性阻塞性肺疾病
        [n(%)]
    3(17.6) 2(5.7) 0.386
    实体肿瘤[n(%)] 6(35.3) 11(31.4) 0.780
    脑血管意外[n(%)] 5(29.4) 5(14.3) 0.356
    自身免疫性疾病
        [n(%)]
    5(29.4) 18(51.4) 0.134
    贫血[n(%)] 14(82.4) 30(85.7) 1.000
    既往抗生素使用史
        [n(%)]
    12(70.6) 26(74.3) 1.000
    ICU收住时间>7 d
        [n(%)]
    15(88.2) 23(65.7) 0.166
    机械通气[n(%)] 15(88.2) 34(97.1) 0.246
    脓毒性AKI [n(%)] 4(23.5) 23(65.7) 0.004
    肺炎[n(%)] 13(76.5) 29(82.9) 0.863
    导管相关感染[n(%)] 13(76.5) 26(74.3) 1.000
    真菌感染[n(%)] 3(17.6) 16(45.7) 0.049
    病毒感染[n(%)] 0(0.0) 5(14.3) 0.255
    痰培养[n(%)]
        阳性 13(76.5) 32(91.4) 0.294
        存在PDR细菌 6(35.3) 12(34.3) 0.943
        存在XDR细菌 13(76.5) 29(82.9) 0.863
    血培养[n(%)]
        存在PDR细菌 4(23.5) 15(42.9) 0.175
        存在XDR细菌 15(88.2) 33(94.3) 0.831
    PCT水平[M(Q1~Q3),
        ng/ml]
    2.6(0.77~3.82) 10(4.63~26.48) <0.001
    脓毒性休克[n(%)] 6(35.6) 28(80.0) 0.001
    不适当抗菌药物治疗
        [n(%)]
    10(58.8) 30(85.7) 0.031
    药物联用[n(%)] 9(52.9) 15(42.9) 0.494
    碳青霉烯类[n(%)] 9(52.9) 12(34.3) 0.198
    磺胺甲恶唑[n(%)] 16(94.1) 28(80.0) 0.361
    抗球菌治疗[n(%)] 12(70.6) 23(65.7) 0.725
    抗真菌治疗[n(%)] 14(82.4) 26(74.3) 0.767
    抗病毒治疗[n(%)] 16(94.1) 33(94.3) 1.000
    APACHE Ⅱ、SOFA、ICU:同表 1;AKI、PCT:同表 2;PDR:泛耐药; XDR:广泛耐药
    下载: 导出CSV
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  • 收稿日期:  2015-04-26
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