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中华实验和临床感染病杂志(电子版) ›› 2020, Vol. 14 ›› Issue (03) : 198 -205. doi: 10.3877/cma.j.issn.1674-1358.2020.03.004

所属专题: 文献

论著

医院获得性肺炎克雷伯菌血流感染临床特征及预后影响因素
沈自燕1, 林少清1, 杜兴冉2, 赵水娣3, 冯旰珠1,()   
  1. 1. 210011 南京市,南京医科大学第二附属医院呼吸科
    2. 210011 南京市,南京医科大学第二附属医院感染科
    3. 210011 南京市,南京医科大学第二附属医院检验科
  • 收稿日期:2019-10-31 出版日期:2020-06-15
  • 通信作者: 冯旰珠
  • 基金资助:
    国家自然科学基金资助项目(No. 81670013)

Clinical characteristics and prognostic risk factors of hospital acquired Klebsiella pneumoniae bloodstream infection

Ziyan Shen1, Shaoqing Lin1, Xingran Du2, Shuidi Zhao3, Ganzhu Feng1,()   

  1. 1. Department of Respiration Medicine, the Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China
    2. Department of Infectious Diseases, the Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China
    3. Department of Clinical Laboratory, the Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China
  • Received:2019-10-31 Published:2020-06-15
  • Corresponding author: Ganzhu Feng
  • About author:
    Corresponding author: Feng Ganzhu, Email:
引用本文:

沈自燕, 林少清, 杜兴冉, 赵水娣, 冯旰珠. 医院获得性肺炎克雷伯菌血流感染临床特征及预后影响因素[J/OL]. 中华实验和临床感染病杂志(电子版), 2020, 14(03): 198-205.

Ziyan Shen, Shaoqing Lin, Xingran Du, Shuidi Zhao, Ganzhu Feng. Clinical characteristics and prognostic risk factors of hospital acquired Klebsiella pneumoniae bloodstream infection[J/OL]. Chinese Journal of Experimental and Clinical Infectious Diseases(Electronic Edition), 2020, 14(03): 198-205.

目的

探讨医院获得性肺炎克雷伯菌血流感染(nKP BSI)的临床特征及预后影响因素,为治疗nKP BSI提供依据。

方法

对2014年5月至2019年4月南京医科大学第二附属医院收治的nKP BSI住院患者临床资料(年龄、性别、住院科室、合并疾病、感染原发灶、有创治疗措施、临床最终结局及药敏试验结果等)进行回顾性分析。采用Logistic回归分析影响患者28 d预后的独立危险因素。

结果

90例nKP BSI患者中以男性居多(64/90、71.1%),年龄中位数为67.5(56.75,82.25)岁,来自本院16个诊疗单元,最常见于ICU(16/90、17.8%),其次为消化内科(12/90、13.3%)和肾内科(11/90、12.2%)。入组nKP BSI患者并发症中最常见为肺部感染(52/90、57.8%)。患者常见原发感染灶为下呼吸道感染(33/90、36.7%)、胆道感染(17/90、18.9%)和导管相关性感染(12/90、13.3%)。患者侵入性诊疗操作以尿管插入(38/90、42.2%)为主,其次为中心静脉置管(35/90、38.9%)。入组患者共分离90株分离株,其中碳青霉烯类耐药肺炎克雷伯菌(CRKP)17例(18.9%),CRKP患者28 d病死率高达52.9%(9/17)。90例nKP BSI患者28 d病死率为31.1%(28/90)。多因素Logistic回归分析显示Pitt菌血症评分(PBS)≥ 3分(OR = 5.614、95%CI:1.298~24.577、P = 0.021),Charlson并发症指数(CCI)≥ 6分(OR = 6.862、95%CI:1.480~31.824、P = 0.014)及呼吸衰竭(OR = 18.534、95%CI:1.557~220.628、P = 0.021)均为影响nKp BSI患者28 d预后的独立危险因素。

结论

nKp BSI多发于老年男性,下呼吸道及胆道感染为其常见的原发疾病,尿管插入与中心静脉置管为该病发生的重要医源性因素;该病患者PBS≥ 3分、CCI≥ 6分及合并呼吸衰竭为影响预后的重要危险因素,此类患者应予高度重视。

Objective

To investigate the clinical characteristics and prognostic risk factors of nosocomial Klebsiella pneumonia bloodstream infection (nKP BSI) and provide evidence for clinical treatment of nKP BSI.

Methods

The clinical data including age, gender, inpatient department, complicated diseases, primary infection, invasive treatment, clinical outcome and result of drug sensitivity analysis of hospitalized patients with nKP BSI admitted to the Second Affiliated Hospital of Nanjing Medical University from May 2014 to April 2019 were analyzed, retrospectively. Logistic regression analysis was used to analyze independent risk factors for 28-day prognosis of patients.

Results

The majority of patients with nKP BSI were male (64/90, 71.1%), with a median age of 67.5 (56.75, 82.25) years old. The 90 patients were from 16 clinical departments of the hospital, mostly in ICU (16/90, 17.8%), followed by gastroenterology (12/90, 13.3%) and nephrology (11/90, 12.2%). nKP BSI was often complicated with multiple diseases, and the most common of which was pulmonary infection (52/90, 57.8%). The most common primary infection site was the respiratory tract (33/90, 36.7%), followed by biliary tract (17/90, 18.9%) and catheter-related (12/90, 13.3%). The most common invasive treatment during hospitalization was urinary catheter (38/90, 42.2%), followed by central venous catheter (35/90, 38.9%). Among the 90 isolates, 17 strains were carbapenem resistant Klebsiella pneumoniae (CRKP) and the 28-day mortality rate was 52.9% (9/17). The 28-day mortality rate of nKp BSI was 31.1% (28/90). Multivariate Logistic regression analysis showed that Pitt bacteriaemia score (PBS) ≥ 3 (OR = 5.614, 95%CI: 1.298-24.577, P = 0.021), Charlson comorbidity index (CCI) ≥ 6 (OR = 6.862, 95%CI: 1.480-31.824, P = 0.014) and respiratory failure (OR = 18.534, 95%CI: 1.557-220.628, P = 0.021) were all independent risk factors for 28-day prognosis of patients with nKP BSI.

Conclusions

nKP BSI occurs mainly in elderly male patients. Lower respiratory tract and biliary tract infections were common primary diseases. Urinary catheter and central venous catheterization were important iatrogenic factors for nKP BSI. PBS ≥ 3, CCI ≥ 6 and respiratory failure were important risk factors of prognosis. High attention should be paid to such patients.

表1 90例患者的一般资料、科室分布和血流感染原发灶
表2 90例患者Pitt菌血症评分
表3 90例nKP BSI患者临床特征
表4 CRKP组和CSKP组患者的临床特征
影响因素 CRKP(17例) CSKP(73例) 统计量 P
男性[例(%)] 15(88.2) 49(67.1) 0.136
年龄[M(P25,P75),岁] 83(75.5,85.5) 65(54.5,76.0) Z =-2.697 0.005
合并疾病[例(%)] ? ? ? ?
? 糖尿病 5(29.4) 23(31.5) χ2 = 0.028 1.000
? 高血压 10(58.8) 23(31.5) χ2 = 4.431 0.035
? 脑梗死 9(52.9) 23(31.5) χ2 = 0.028 1.000
? 冠状动脉粥样硬化性心脏病 9(52.9) 14(19.2) 0.011
? 慢性阻塞性肺病 0(0) 5(6.8) 0.579
? 肾功能不全 6(35.3) 15(20.5) 0.213
? 慢性肝功能不全 1(5.9) 4(5.5) 1.000
? 恶性肿瘤 2(11.8) 25(34.2) χ2 = 3.319 0.068
1个月内侵入性诊疗操作[例(%)] ? ? ? ?
? 中心静脉置管 13(76.5) 20(27.4) χ2 = 14.299 < 0.001
? 外周静脉置管 5(29.4) 28(38.4) χ2 = 0.475 0.584
? 有创机械辅助通气 12(70.6) 16(21.9) χ2 = 15.240 < 0.001
? 胃管 13(76.5) 11(15.1) χ2 = 26.584 < 0.001
? 尿管 13(76.5) 21(28.8) χ2 = 13.349 < 0.001
? 其他导管(引流管) 4(23.5) 21(28.8) 0.771
? 手术 4(23.5) 22(30.1) 0.769
? 血液透析 2(11.8) 11(15.1) 1.000
3个月内使用抗菌药物[例(%)] 11(64.7) 36(49.3) χ2 = 1.309 0.253
3个月内使用免疫抑制剂[例(%)] 0(0.0) 8(11.0) 0.344
合理的经验性抗菌药物治疗[例(%)] 5(29.4) 58(79.5) χ2 = 16.442 < 0.001
BSI前住院时间[M(P25,P75),d] 28.0(10.5,54.0) 8.0(3.0,20.5) Z =-2.289 0.022
住院时间[M(P25,P75),d] 29.0(18.0,57.0) 18.0(12.0,30.0) Z =-2.539 0.009
入住ICU [例(%)] 7(41.2) 13(17.8) χ2 = 4.357 0.052
28 d死亡[例(%)] 9(52.9) 19(26.0) χ2 = 4.660 0.031
表5 影响nKP BSI患者28 d预后的单因素分析
影响因素 死亡组(28例) 生存组(62例) χ2 P
性别(男) 22(78.6) 42(67.7) 1.101 0.294
年龄> 60岁 23(82.1) 38(61.3) 3.840 0.050
PBS≥ 3分 20(71.4) 15(24.2) 18.109 < 0.001
CCI≥ 6分 15(53.6) 16(25.8) 6.585 0.010
住院时间> 30 d 9(32.1) 18(29.0) 0.089 0.766
入住ICU史 11(39.3) 9(14.5) 0.009
合并疾病 ? ? ? ?
? 肺部感染 21(75.0) 31(50.0) 4.492 0.026
? 胆道系统感染 7(25.0) 12(19.4) 0.369 0.544
? 肝脓肿 0(0.0) 5(8.1) 0.319
? 泌尿系统感染 0(0.0) 2(3.2) 1.000
? 感染性休克 10(35.7) 3(4.8) < 0.001
? 低蛋白血症 10(35.7) 20(32.3) 0.104 0.747
? 呼吸衰竭 10(35.7) 2(3.2) < 0.001
侵入性诊疗操作 ? ? ? ?
? 中心静脉置管 13(46.4) 22(35.5) 0.972 0.324
? 外周静脉置管 13(46.4) 19(30.6) 2.097 0.148
? 有创机械辅助通气 9(32.1) 15(24.2) 0.623 0.430
? 胃管 7(25.0) 9(14.5) 0.246
? 尿管 15(53.6) 23(37.1) 2.146 0.143
? 其他导管(引流管) 6(21.4) 22(35.5) 1.778 0.182
? 穿刺 0(0.0) 9(14.5) 0.052
? 手术 9(32.1) 23(37.1) 0.207 0.813
? 血液透析 7(25.0) 6(9.7) 0.101
血流感染原发灶 ? ? ? ?
? 呼吸道 11(39.3) 20(32.3) 0.422 0.516
? 导管 3(10.7) 6(9.7) 0.023 1.000
? 泌尿系统 3(10.7) 2(3.2) 0.172
? 胆道 4(14.3) 14(22.6) 0.829 0.411
? 腹腔 2(7.1) 7(11.3) 0.715
? 原发 2(7.1) 9(14.5) 0.492
? 其他 3(10.7) 4(6.5) 0.489 0.673
其他相关因素 ? ? ? ?
? 免疫抑制剂 6(21.4) 8(12.9) 0.352
? 胃肠外营养 5(17.9) 16(25.8) 0.681 0.409
? 合理经验性抗菌药物治疗 16(57.1) 48(77.4) 3.860 0.049
? 拔除深静脉置管 1(3.6) 14(22.6) 5.018 0.031
? 拔除尿管 0(0.0) 2(3.2) 1.000
? MDR 16(57.1) 24(38.7) 2.654 0.103
? CRKP 9(32.1) 8(12.9) 4.660 0.031
表6 影响nKP BSI患者28 d预后的多因素Logistic回归分析
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