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中华实验和临床感染病杂志(电子版) ›› 2023, Vol. 17 ›› Issue (06) : 400 -407. doi: 10.3877/cma.j.issn.1674-1358.2023.06.008

论著

187例单一屎肠球菌和粪肠球菌血流感染者临床特征及预后因素
李悦1, 马序竹2, 陈旭岩3, 丰雯诗1, 王逸群1,()   
  1. 1. 102218 北京,清华大学附属北京清华长庚医院 清华大学临床医学院普通内科
    2. 102218 北京,清华大学附属北京清华长庚医院 清华大学临床医学院感染性疾病科
    3. 102218 北京,清华大学附属北京清华长庚医院 清华大学临床医学院急诊科
  • 收稿日期:2023-08-04 出版日期:2023-12-15
  • 通信作者: 王逸群
  • 基金资助:
    北京市属医院科研培育计划项目(No. PX2020042); 清华大学自主科研计划(No. 2020Z99CFY034); 北京清华长庚医院研究基金资助(No. 12019C1005)

Clinical features and prognostic factors of 187 cases with single Enterococcus faecium or Enterococcus faecalis bloodstream infection

Yue Li1, Xuzhu Ma2, Xuyan Chen3, Wenshi Feng1, Yiqun Wang1,()   

  1. 1. Department of General Internal Medicine, Beijing Tsinghua University Affiliated Chang Gung Hospital, Tsinghua University Clinical School of Medicine, Beijing 102218, China
    2. Department of Infectious Diseases, Beijing Tsinghua University Affiliated Chang Gung Hospital, Tsinghua University Clinical School of Medicine, Beijing 102218, China
    3. Department of Emergency, Beijing Tsinghua University Affiliated Chang Gung Hospital, Tsinghua University Clinical School of Medicine, Beijing 102218, China
  • Received:2023-08-04 Published:2023-12-15
  • Corresponding author: Yiqun Wang
引用本文:

李悦, 马序竹, 陈旭岩, 丰雯诗, 王逸群. 187例单一屎肠球菌和粪肠球菌血流感染者临床特征及预后因素[J/OL]. 中华实验和临床感染病杂志(电子版), 2023, 17(06): 400-407.

Yue Li, Xuzhu Ma, Xuyan Chen, Wenshi Feng, Yiqun Wang. Clinical features and prognostic factors of 187 cases with single Enterococcus faecium or Enterococcus faecalis bloodstream infection[J/OL]. Chinese Journal of Experimental and Clinical Infectious Diseases(Electronic Edition), 2023, 17(06): 400-407.

目的

分析单一肠球菌血流感染(BSI)者的临床特征、耐药性及30 d内死亡危险因素。

方法

收集2018年1月至2023年2月清华大学附属北京清华长庚医院收治的187例单一屎肠球菌或粪肠球菌BSI患者的临床资料,入组患者分为屎肠球菌BSI组(133例)和粪肠球菌BSI组(54例),比较两组患者的临床特征和耐药性差异,应用多因素Logistic回归分析两类肠球菌BSI患者30 d内死亡的危险因素。

结果

单一肠球菌BSI患者中159例(85.03%)为医院获得性感染,原发感染灶以肝胆(91例、48.66%)、胃肠(39例、20.86%)及泌尿生殖系统(30例、16.04%)为主。与粪肠球菌BSI组患者比较,屎肠球菌BSI组患者既往90 d内住院比例(78.95% vs. 62.96%:χ2 = 5.143、P = 0.023)和降钙素原(PCT)水平[3.20(0.71,11.77)ng/ml vs. 1.14(0.35,8.56)ng/ml:Z =-2.124、P = 0.035]均显著升高,而原发感染灶为泌尿生殖系统来源比例及感染后继发呼吸衰竭占比低(12.03% vs. 25.93%:χ2 = 5.506、P = 0.027,28.57% vs. 46.30%:χ2 = 5.401、P = 0.020),差异均有统计学意义。两组患者30 d病死率差异无统计学意义(29.32% vs. 33.33%:χ2 = 0.291、P = 0.589)。屎肠球菌对青霉素、氨苄西林和左氧氟沙星耐药率均> 90%,显著高于粪肠球菌(91.73% vs. 12.96%:χ2 = 111.366、P < 0.001,90.98% vs. 11.11%:χ2 = 112.424、P < 0.001,92.48% vs. 38.89%:χ2 = 62.296、P < 0.001);其中分离耐万古霉素的屎肠球菌(VRE)5株(2.67%)。多因素Logistic回归分析显示:合并肿瘤(OR = 6.569、95%CI:1.625~26.556、P = 0.008)、白蛋白(ALB)< 30 g/L(OR = 5.173、95%CI:1.640~16.317、P = 0.005)及感染后继发心功能不全(OR = 10.361、95%CI:2.710~39.612、P = 0.001)均为屎肠球菌BSI患者30 d内死亡的独立危险因素,针对性用药为保护因素(OR = 0.106、95%CI:0.021~0.531、P = 0.006)。感染后继发呼吸衰竭(OR = 32.844、95%CI:1.946~554.441、P = 0.015)和肾功能不全(OR = 14.492、95%CI:1.422~147.683、P = 0.024)为粪肠球菌BSI患者30 d内死亡的独立危险因素。

结论

肠球菌BSI多为院内感染,以屎肠球菌为主,耐药率高,早期识别预后危险因素、积极抗感染治疗及加强脏器功能支持有助于改善患者预后。

Objective

To investigate the clinical features, drug resistance and risk factors for 30 d prognosis of enterococcal bloodstream infections (BSI).

Methods

Clinical data of 187 cases of single Enterococcus faecium or Enterococcus faecalis BSI from January 2018 to February 2023 were collected, and the differences of clinical features, drug resistance and prognosis between Enterococcus faecium (E. faecium) BSI group (133 cases) and Enterococcus faecalis (E. faecalis) BSI group (54 cases) were compared, respectively. Independent risk factors for E. faecalis and E. faecium BSI were identified by Logistic regression analysis.

Results

Nosocomial infection was predominant (159 cases, 85.03%) and the primary origin of infection were mainly hepatobiliary (91 cases, 48.66%), gastrointestinal (39 cases, 20.86%) and genitourinary duct (30 cases, 16.04%). Compared with E. faecalis BSI group, the proportion of within-90 d hospitalization (78.95% vs. 62.96%: χ2 = 5.143, P = 0.023) and procalcitonin (PCT) level [3.20 (0.71, 11.77) ng/ml vs. 1.14 (0.35, 8.56) ng/ml: Z =-2.124, P = 0.035] were higher in E. faecium BSI group, the proportion of genitourinary origin and respiratory failure which were secondary to BSI were lower (12.03% vs. 25.93%: χ2 = 5.506, P = 0.027; 28.57% vs. 46.30%: χ2 = 5.401, P = 0.020). There was no significant difference in 30 d mortality between the two groups (29.32% vs. 33.33%: χ2 = 0.291, P = 0.589). The resistance rates of penicillin, ampicillin and levofloxacin of E. faecium were significantly higher than those of E. faecalis (91.73% vs. 12.96%: χ2 = 111.366, 90.98% vs.11.11%: χ2 = 112.424, P < 0.001; 92.48% vs. 38.89%: χ2 = 62.296, P < 0.001). There were 5 cases (2.67%) of Vancomycin-resistant Enterococcus (VRE) strains. Multivariate analysis showed that tumors (OR = 6.569, 95%CI: 1.625-26.556, P = 0.008), albumin (ALB) < 30 g/L (OR = 5.173, 95%CI: 1.640-16.317, P = 0.005), secondary cardiac insufficiency after BSI (OR = 10.361, 95%CI: 2.710-39.612, P = 0.001) were all independent risk factors for death within 30-day of E. faecium BSI, sensitive medicine was the protective factor for death within 30 d of E. faecium BSI (OR = 0.106, 95%CI: 0.021-0.531, P = 0.006). Respiratory failure which were secondary to BSI (OR = 32.844, 95%CI: 1.946-554.441, P = 0.015) and renal insufficiency (OR = 14.492, 95%CI: 1.422-147.683, P = 0.024) were independent risk factors for death within 30d of E. faecalis BSI.

Conclusions

Enterococcal BSI is mostly nosocomial infection, mainly E. faecium, with a high drug resistance rate, early identification of risk factors for death, active anti-infection treatment and strengthening of organs support could improve the prognosis of patients.

表1 屎肠球菌BSI组与粪肠球菌BSI组患者的临床特征
临床特征 屎肠球菌BSI组(133例) 粪肠球菌BSI组(54例) 统计量 P
女性[例(%)] 47(35.33) 24(44.44) χ2 = 1.352a 0.245
年龄≥ 65岁[例(%)] 60(45.11) 20(37.04) χ2 = 1.023a 0.312
吸烟[例(%)] 27(20.30) 14(25.93) χ2 = 0.710a 0.399
饮酒[例(%)] 21(15.79) 11(20.37) χ2 = 0.568a 0.451
并发症[例(%)]        
糖尿病 27(20.30) 10(18.52) χ2 = 0.077a 0.782
肿瘤 69(51.88) 23(42.59) χ2 = 1.325a 0.250
器官移植 22(16.54) 3(5.56) χ2 = 3.110b 0.078
自身免疫性疾病 7(5.26) 0(0.00) χ2 = 1.673b 0.196
应用免疫抑制剂 27(20.30) 6(11.11) χ2 = 2.232a 0.135
入院至阳性时间[M(P25,P75),d] 10.00(4.00,20.50) 13.00(4.50,23.50) Z =-0.748 0.454
HABSI [例(%)] 115(86.47) 44(81.48) χ2 = 0.750a 0.387
入住ICU [例(%)] 64(48.12) 22(40.74) χ2 = 0.842a 0.359
近期住院史[例(%)] 105(78.95) 34(62.96) χ2 = 5.143a 0.023
抗菌药物暴露史[例(%)] 103(77.44) 40(74.07) χ2 = 0.337a 0.623
BSI前侵入性操作[例(%)]        
30 d内手术 96(72.18) 40(74.07) χ2 = 0.069a 0.792
机械通气 71(53.38) 25(46.30) χ2 = 0.772a 0.380
胃管 69(51.88) 25(46.30) χ2 = 0.479a 0.489
尿管 81(60.90) 31(57.41) χ2 = 0.195a 0.659
动静脉置管 97(72.93) 37(68.52) χ2 = 0.368a 0.544
原发感染灶[例(%)]        
不详 9(6.77) 9(16.67) χ2 = 4.327a 0.054
肝胆来源 71(53.38) 20(37.04) χ2 = 4.108a 0.053
胃肠道来源 30(22.56) 9(16.67) χ2 = 0.807a 0.431
泌尿生殖道来源 16(12.03) 14(25.93) χ2 = 5.506a 0.027
导管相关血流感染 7(5.26) 2(3.70) χ2 = 0.006b 0.941
针对性用药[例(%)] 102(76.69) 44(81.48) χ2 = 0.515a 0.473
BSI后继发脏器功能不全[例(%)]        
心功能不全 61(45.86) 22(40.74) χ2 = 0.408a 0.523
肝功能不全 75(56.39) 30(55.56) χ2 = 0.011a 0.917
肾功能不全 47(35.34) 21(38.89) χ2 = 0.209a 0.647
呼吸衰竭 38(28.57) 25(46.30) χ2 = 5.401a 0.020
实验室指标        
WBC [M(P25,P75),× 109/L] 11.07(6.82,16.12) 10.30(6.79,14.08) Z =-1.091 0.275
CRP [M(P25,P75),mg/L] 80.00(30.48,142.20) 115.83(46.35,169.25) Z =-2.009 0.055
PCT [M(P25,P75),ng/ml) 3.20(0.71,11.77) 1.14(0.35,8.56) Z =-2.124 0.034
ALB [M(P25,P75),g/L) 30.70(27.60,34.10) 31.20(28.88,34.65) Z =-0.868 0.386
BSI后30 d内死亡[例(%)] 39(29.32) 18(33.33) χ2 = 0.291a 0.589
耐药[例(%)]        
HLAR 56(42.11) 21(38.89) χ2 = 0.164a 0.685
青霉素 122(91.73) 7(12.96) χ2 = 111.366a < 0.001
氨苄西林 121(90.98) 6(11.11) χ2 = 112.424a < 0.001
左氧氟沙星 123(92.48) 21(38.89) χ2 = 62.296a < 0.001
万古霉素 5(3.76) 0(0.00) χ2 = 0.891a 0.345
利奈唑胺 1(0.75) 1(1.85) c 0.495
图1 屎肠球菌与粪肠球菌耐药性注:*P < 0.05
表2 屎肠球菌BSI存活组和死亡组患者的临床特征
表3 屎肠球菌BSI患者30 d死亡的多因素Logistic回归分析
表4 粪肠球菌BSI存活组和死亡组患者的临床特征
表5 粪肠球菌BSI患者30 d死亡的多因素Logistic回归分析
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