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中华实验和临床感染病杂志(电子版)

中华实验和临床感染病杂志(电子版) ›› 2023, Vol. 17 ›› Issue (04) : 230 -237. doi: 10.3877/cma.j.issn.1674-1358.2023.04.003

论著

181例心脏外科患者发生血流感染危险因素分析
武元星, 任建伟, 朱光发†()   
  1. 100029　北京，首都医科大学附属北京安贞医院呼吸与危重症医学科
  • 收稿日期:2023-03-23 出版日期:2023-08-15
  • 通信作者: 朱光发
  • 基金资助:
    国家自然科学基金(No. 81970067)

Risk factors of patients with bloodstream infection in cardiac surgery

Yuanxing Wu, Jianwei Ren, Guangfa Zhu†()   

  1. Department of Respiratory and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
  • Received:2023-03-23 Published:2023-08-15
  • Corresponding author: Guangfa Zhu
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引用本文：

武元星, 任建伟, 朱光发. 181例心脏外科患者发生血流感染危险因素分析[J]. 中华实验和临床感染病杂志(电子版), 2023, 17(04): 230-237.

Yuanxing Wu, Jianwei Ren, Guangfa Zhu. Risk factors of patients with bloodstream infection in cardiac surgery[J]. Chinese Journal of Experimental and Clinical Infectious Diseases(Electronic Edition), 2023, 17(04): 230-237.

目的

探讨心脏外科患者发生血流感染的危险因素，观察多菌种血流感染与单一阴性菌血流感染的临床特征，为预防心脏外科患者血流感染发生和治疗提供依据。

方法

选取2018年1月至2021年10月首都医科大学附属北京安贞医院心脏外科收治的血流感染者资料，总结病原体检出及分布；选取同时期心脏外科非感染者，与感染组患者根据年龄、性别进行1︰1配比，分析血流感染组（包括革兰阴性菌和阳性菌的混合感染与单一阴性菌感染）与非血流感染组患者临床资料，计量资料比较采用t检验或非参数检验，计数资料比较采用χ2检验，将可能影响血流感染的指标进行多因素Logistic回归，分析血流感染及混合血流感染发生的危险因素。

结果

同时期共收治心脏外科患者55 908例，发生血流感染者181例，感染率为0.3%（181/55 908）。血流感染组与非血流感染组间体外循环（CPB）时间（Z = 5.031、P = 0.001）和手术时间（Z = 3.830、P = 0.001）、是否接受体外膜肺氧合（ECMO）（χ2 = 11.569、P = 0.001）、主动脉内球囊反搏术（IABP）（χ2 = 30.685、P = 0.001）和连续性肾脏替代治疗（CRRT）（χ2 = 24.761、P = 0.001）支持、感染发生前使用碳青霉烯类（χ2 = 11.661、P = 0.001）、喹诺酮类（χ2 = 4.096、P = 0.043）、万古霉素（χ2 = 4.096、P = 0.043）以及联合使用抗菌药物（χ2 = 13.286、P = 0.001）差异均有统计学意义；多因素Logistic回归分析发现，CPB时间（OR = 5.031、95%CI：1.843~6.798、P < 0.001）和手术时间（OR = 1.228、95%CI：1.056~1.427、P = 0.008）、接受ECMO（OR = 4.180、95%CI：1.863~9.377、P = 0.001）、IABP（OR = 4.017、95%CI：1.572~10.267、P = 0.004）和CRRT（OR = 8.586，95%CI：2.494~29.560、P = 0.001）操作、血流感染发生前使用碳青霉烯类（OR = 15.742、95%CI：5.699~43.478、P < 0.001）、喹诺酮类（OR = 2.272、95%CI：1.057~4.886、P = 0.030）、万古霉素（OR = 4.297，95%CI：1.199~15.400、P = 0.025）以及联合使用抗菌药物（OR = 4.520、95%CI：2.154~9.484、P = 0.001）均为术后血流感染发生的危险因素。感染组较非感染组患者总住院时间显著延长，差异有统计学意义（Z = 8.033、P = 0.001）；感染组患者住院期间死亡52例（28.7%），非感染组死亡17例（9.3%），两组病死率差异有统计学意义（χ2 = 21.935、P = 0.001）。血流感染组中37例（20.4%）患者为单一革兰阴性杆菌感染，28例（15.5%）患者为单一革兰阳性球菌感染，116例（64.1%）患者为革兰阴性杆菌和革兰阳性球菌混合感染；共检出革兰阴性杆菌234株，以鲍曼不动杆菌（64株、27.3%）和肺炎克雷伯菌（56株、23.9%）最常见；共检出革兰阳性球菌145株，以表皮葡萄球菌（69株、47.6%）最常见。单因素分析结果显示，混合感染组与单一阴性菌感染组患者CPB时间（t = －4.010、P = 0.001）和手术时间（t =－8.532、P = 0.001）、接触3种（χ2 = 11.723、P = 0.001）及3种以上（χ2 = 4.618、P = 0.032）侵入性血管内装置治疗、感染发生前使用碳青霉烯类（χ2 = 11.661、P = 0.001）、万古霉素（χ2 = 4.096、P = 0.043）、利奈唑胺（χ2 = 15.174、P = 0.001）、多黏菌素（χ2 = 6.353、P = 0.012）以及联合使用抗菌药物（χ2 = 13.286、P = 0.001）差异均有统计学意义。多因素Logistic回归分析结果显示，CPB时间（OR = 4.851、95%CI：1.190~1.313、P = 0.015）和手术时间（OR = 14.764、95%CI：1.363~17.264、P = 0.014）、接触3种（OR = 1.257、95%CI：1.046~1.510、P = 0.015）及3种以上（OR = 1.006、95%CI：1.001~1.012、P = 0.032）侵入性血管内装置、混合感染发生前使用碳青霉烯类（OR = 4.765、95%CI：1.770~12.828、P = 0.002）、万古霉素（OR = 7.750、95%CI：1.277~4.203、P = 0.026）、利奈唑胺（OR = 3.925、95%CI：1.665~9.254、P = 0.002）、多黏菌素（OR = 1.987、95%CI：1.985~3.451、P = 0.020）以及联合使用抗菌药物（OR = 1.466、95%CI：1.012~1.976、P = 0.012）均为发生混合血流感染的危险因素，且发生混合血流感染后住院时间显著延长，差异有统计学意义（Z =－1.576、P = 0.001）。

结论

心脏外科发生血流感染以及混合血流感染者多与侵入性血管内装置植入和抗菌药物使用有关，并可导致患者住院时间延长及病死率增加，严重影响患者预后。需关注手术操作及抗菌药物的合理使用，以期降低心脏外科血流感染的发生。

关键词: 血流感染, 血管内装置植入, 病原学, 危险因素, 预后
Objective

To investigate the risk factors of the occurrence of bloodstream infection, and to analyze the difference of clinical characteristics between multi-bacterial bloodstream infection and single negative bacteria, to provide evidence for the prevention and treatment of bloodstream infection in cardiac surgery.

Methods

Medical records of patients with bloodstream infection in Department of Cardiac surgery, Beijing Anzhen Hospital, Capital Medical University from January 2018 to October 2021 were selected to summarize the detection and distribution of pathogens. Non-infection patients were selected with 1︰1 according to the age and gender of patients in infection group during the same period. The clinical data of the bloodstream infection group (including the multi-bacterial infection and single infection of Gram-negative bacteria and Gram-positive bacteria) and the non-infection group were analyzed, respectively. The measurement data were analyzed by t test or non-parametric test, and the counting data was analyzed by χ2 test. The indicators that may affect bloodstream infection were analyzed by multivariate Logistic regression, the risk factors of bloodstream infection and mixed bloodstream infection were analyzed.

Results

During the same period, a total of 55 908 cardiac surgery patients were admitted, and 181 cases with bloodstream infection, with an infection rate of 0.3% (181/55 908). The results showed that CPB time (Z = 5.031, P = 0.001) and operation time (Z = 3.830, P = 0.001), usage of ECMO (χ2 = 11.569, P = 0.001), IABP (χ2 = 30.685, P = 0.001) and CRRT (χ2 = 24.761, P = 0.001), exposure to carbapenems (χ2 = 11.661, P = 0.001), quinolones (χ2 = 4.096, P = 0.043), vancomycin (χ2 = 4.096, P = 0.043) and combined antibiotics (χ2 = 13.286, P = 0.001) before infection were statistically different between infection group and non-infection group. Multivariate Logistic regression analysis showed that CPB time (OR = 5.031, 95%CI: 1.843-6.798, P < 0.001) and operation time (OR = 1.228, 95%CI: 1.056-1.427, P = 0.008), usage of ECMO (OR = 4.180, 95%CI: 1.863-9.377, P = 0.001), IABP (OR = 4.017, 95%CI: 1.572-10.267, P = 0.004), CRRT (OR = 8.586, 95%CI: 2.494-29.560, P = 0.001), exposure to carbapenems (OR = 15.742, 95%CI: 5.699-43.478, P < 0.001), quinolones (OR = 2.272, 95%CI: 1.057-4.886, P = 0.030) and vancomycin (OR = 4.297, 95%CI: 1.199-15.400, P = 0.025) and combined use of antibiotics (OR = 4.520, 95%CI: 2.154-9.484, P = 0.001) before infection were all risk factors of postoperative bloodstream infection, with statistically significant differences. The total hospital duration of patients in infection group was significantly longer than that of non-infection group, with significant difference (Z = 8.033, P = 0.001). There were 52 deaths (28.7%) in infection group and 17 deaths (9.3%) in non-infecteion group, the mortality rate of the two groups was significantly different (χ2 = 21.935, P = 0.001). Among bloodstream infection group, 37 patients (20.4%) were infected with single Gram-negative bacilli, 28 patients (15.5%) were infected with single Gram-positive cocci, 116 patients (64.1%) were infected with Gram-negative bacilli and Gram-positive cocci. Total of 234 Gram-negative bacillus strains were detected, Acinetobacter baumannii (64 strains, 27.3%) and Klebsiella pneumoniae (56 strains, 23.9%) were the most common pathogens. Total of 145 strains of Gram-positive cocci were detected, among which Staphylococcus epidermidis (69 strains, 47.6%) was the most common. The results showed that CPB time (t =-4.010, P = 0.001) and operation time (t =-8.532, P = 0.001), exposure to 3 kinds of invasive endovascular devices (χ2 = 11.723, P = 0.001) and more than 3 kinds of invasive endovascular devices (χ2 = 4.618, P = 0.032), exposure to carbapenems (χ2 = 11.661, P = 0.001), vancomycin (χ2 = 4.096, P = 0.043), linezolid (χ2 = 15.174, P = 0.001), polycolistin (χ2 = 6.353, P = 0.012) and combined antibiotics (χ2 = 13.286, P = 0.001) before infection were significantly different between multi-bacterial bloodstream infection and single negative bacteria group. Multivariate Logistic regression analysis showed that CPB time (OR = 4.851, 95%CI: 1.190-1.313, P = 0.015) and operation time (OR = 14.764, 95%CI: 1.363-17.264, P = 0.014), exposure to 3 (OR = 1.257, 95%CI: 1.046-1.510, P = 0.015) or more than 3 (OR = 1.006, 95%CI: 1.001-1.012, P = 0.032) invasive endovascular devices, usage of carbapenems (OR = 4.765, 95%CI: 1.770-12.828, P = 0.002), vancomycin (OR = 7.750, 95%CI: 1.277-4.203, P = 0.026), linezolid (OR = 3.925, 95%CI: 1.665-9.254, P = 0.002), polycolistin (OR = 1.987, 95%CI: 1.985-3.451, P = 0.020) and combined use of antibiotics (OR = 1.466, 95%CI: 1.012-1.976, P = 0.012) before infection were the risk factors of postoperative multi-bacterial bloodstream infection, and the differences were statistically significant. The length of hospital duration was significantly prolonged after multi-bacterial bloodstream infection, with significant difference (Z =-1.576, P = 0.001).

Conclusions

Bloodstream infection and mixed bloodstream infection of patients with cardiac surgery are mostly associated with invasive intravascular device implantation and antibiotic exposure, and can lead to prolonged hospitalization and increased mortality, which seriously affect the prognosis of patients. Therefore, it is necessary to pay attention to the surgical operation and the rational use of antibiotics to reduce the occurrence of blood flow infection in cardiac surgery.

Key words: Bloodstream infection, Implantation of intravascular devices, Etiology, Risk factors, Prognosis
表1 血流感染者病原学检出和分布
细菌种类 株数（%）
革兰阴性杆菌  
鲍曼不动杆菌 64（27.3）
肺炎克雷伯菌 56（23.9）
铜绿假单胞菌 52（22.2）
阴沟肠杆菌 36（15.4）
黏质沙雷菌 14（6.0）
大肠埃希菌 12（5.1）
革兰阳性球菌  
表皮葡萄球菌 69（47.6）
头状葡萄球菌 18（12.4）
溶血葡萄球菌 14（9.7）
人葡萄球菌 14（9.7）
金黄色葡萄球菌 13（9.0）
粪肠球菌 12（8.3）
屎肠球菌 3（2.6）
腐生葡萄球菌 1（0.8）
沃氏葡萄球菌 1（0.8）
表2 血流感染组与非感染组患者临床特征
指标 感染组（181例） 非感染组（181例） 统计量 P值
接受CPB [例（%）] 116（75.8） 117（67.5） χ2 = 1.811 0.178a
CPB [M（P25，P75），min] 207.0（150.3，270.3） 175.0（146.0，244.0） Z = 5.031 0.001
手术时间[M（P25，P75），h] 8.0（5.0，10.5） 5.0（3.2，8.3） Z = 3.830 0.001
接受ECMO [例（%）] 16（10.4） 2（13.5） χ2 = 11.569 0.001a
接受IABP [例（%）] 39（25.5） 5（16.2） χ2 = 30.685 0.001a
接受CRRT [例（%）] 30（19.6） 3（13.5） χ2 = 24.761 0.001a
抗菌药物应用[例（%）]        
碳青霉烯类 48（31.4） 12（54.0） χ2 = 26.868 0.001a
头孢菌素类 109（71.2） 102（70.3） χ2 = 0.738 0.387a
β-内酰胺类 77（50.3） 53（43.2） χ2 = 2.210 0.322a
喹诺酮类 11（7.2） 4（13.5） χ2 = 7.703 0.006a
万古霉素 92（60.1） 13（45.9） χ2 = 90.488 0.001a
多黏菌素 2（1.3） 0（0.0） χ2 = 2.013 0.156b
联合使用 89（58.1） 34（32.4） χ2 = 41.124 0.001a
表3 血流感染发生相关危险因素的多因素Logistic回归分析
危险因素 β值 S.E.值 Wald χ2值 OR值 95%CI P值
CPB时间 7.519 0.648 5.946 4.851 1.190~181.113 < 0.05
手术时间 2.916 1.285 4.392 14.764 1.363~17.264 < 0.05
接受ECMO 1.278 4.068 4.116 3.539 1.843~6.798 < 0.001
接受IABP 2.692 2.186 3.912 1.228 1.056~1.427 0.008
接受CRRT 1.432 0.154 4.321 8.586 2.494~29.560 0.001
碳青霉烯类使用 1.581 0.142 2.167 15.742 5.699~43.478 < 0.001
喹诺酮类使用 0.443 0.648 5.946 2.272 1.057~4.886 0.030
万古霉素使用 1.339 8.217 0.079 4.297 1.199~15.400 0.025
抗菌药物联合使用 7.542 5.128 1.345 4.520 2.154~9.484 0.001
表4 混合感染组和单一感染组患者临床特征
影响因素 混合感染组（116例） 单一感染组（37例） 统计量 P值
CPB（ ± s，min） 187.62 ± 62.14 208.51 ± 64.46 t =－4.010 0.001
手术时间（ ± s，h） 6.17 ± 2.00 7.56 ± 2.14 t =－8.532 0.001
IABP [例（%）] 33（28.4） 6（16.2） χ2 = 2.210 0.137a
ECMO [例（%）] 11（9.5） 5（13.5） χ2 = 0.487 0.485b
CRRT [例（%）] 25（21.6） 5（13.5） χ2 = 1.150 0.284a
同时或先后接触侵入性血管内装置治疗[例（%）]        
2种 28（24.1） 6（16.2） χ2 = 1.019 0.313a
3种 44（37.9） 3（8.1） χ2 = 11.723 0.001a
3种以上 19（16.4） 1（2.7） χ2 = 4.618 0.032b
抗菌药物应用[例（%）]        
碳青霉烯类 28（24.1） 20（54.1） χ2 = 11.661 0.001a
头孢菌素类 83（71.6） 26（70.3） χ2 = 0.022 0.881a
β-内酰胺类 61（52.6） 16（43.2） χ2 = 0.980 0.322a
喹诺酮类 6（5.2） 5（13.5） χ2 = 2.925 0.087b
万古霉素 75（64.7） 17（45.9） χ2 = 4.096 0.043a
利奈唑胺 50（43.1） 3（8.1） χ2 = 15.174 0.001a
替加环素 6（5.2） 3（8.1） χ2 = 0.437 0.509b
多黏菌素 2（1.7） 0（0.0） — 0.012c
替考拉宁 7（6.0） 6（16.2） χ2 = 3.740 0.053b
联合使用 77（66.4） 12（32.4） χ2 = 13.286 0.001a
表5 发生混合菌血流感染危险因素的多因素Logistic回归分析
危险因素 β值 S.E.值 Wald χ2值 OR值 95%CI P值
CPB时间 1.346 0.285 2.438 4.851 1.190~1.313 0.015
手术时间 2.907 5.218 2.230 14.764 1.363~17.264 0.014
同时或先后接触侵入性血管内装置治疗            
3种 0.731 1.285 3.790 1.257 1.046~1.510 0.015
3种以上 1.597 0.324 5.640 1.006 1.001~1.012 0.032
碳青霉烯类 1.106 0.753 4.392 4.765 1.770~12.828 0.002
万古霉素 3.498 0.504 3.214 7.750 1.277~4.203 0.026
利奈唑胺 3.289 0.612 3.798 3.925 1.665~9.254 0.002
多黏菌素 2.352 1.287 7.890 1.987 1.985~3.451 0.020
抗菌药物联合 4.507 1.246 1.906 1.466 1.012~1.976 0.012
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