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中华实验和临床感染病杂志(电子版) ›› 2023, Vol. 17 ›› Issue (06) : 408 -415. doi: 10.3877/cma.j.issn.1674-1358.2023.06.009

论著

老年糖尿病患者社区获得性肺炎病原分布及空腹血糖、糖化血红蛋白的预测价值
毛建1,†()   
  1. 1. 610017　成都市，成都市第二人民医院呼吸与危重症医学科
  • 收稿日期:2023-05-22 出版日期:2023-12-15
  • 通信作者: 毛建
  • 基金资助:
    2018年四川省医学科研青年创新课题(No. Q18052)

Pathogen distribution of community acquired pneumonia in elderly patients with diabetes and the predictive value of fasting blood glucose and glycosylated hemoglobin

Jian Mao1,†()   

  1. 1. Department of Respiratory and Critical Care Medicine, Chengdu Second People’s Hospital, Chengdu 610017, China
  • Received:2023-05-22 Published:2023-12-15
  • Corresponding author: Jian Mao
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引用本文：

毛建. 老年糖尿病患者社区获得性肺炎病原分布及空腹血糖、糖化血红蛋白的预测价值[J/OL]. 中华实验和临床感染病杂志(电子版), 2023, 17(06): 408-415.

Jian Mao. Pathogen distribution of community acquired pneumonia in elderly patients with diabetes and the predictive value of fasting blood glucose and glycosylated hemoglobin[J/OL]. Chinese Journal of Experimental and Clinical Infectious Diseases(Electronic Edition), 2023, 17(06): 408-415.

目的

分析老年糖尿病患者社区获得性肺炎（CAP）病原分布特点，并探讨空腹血糖（FBG）联合糖化血红蛋白（HbA1c）对其预测价值。

方法

系统抽样法选取2020年1月至2021年11月南充市第五人民医院收治的192例老年糖尿病出院患者开展队列研究，均接受随访。统计出院后3个月内患者CAP的发生率，分析病原分布特点。根据是否发生CAP将入组患者分为感染组（43例）和未感染组（149例），比较两组患者FBG和HbA1c水平；采用多因素Logistic回归分析探讨CAP危险因素，绘制受试者工作特征（ROC）曲线分析FBG变化率和HbA1c变化率对并发CAP的预测价值，并以曲线下面积（AUC）评价预测效能。

结果

老年糖尿病患者CAP发生率为22.40%（43/192）；并发CAP患者中细菌感染占比最高（79.07%、34/43），其次为肺炎支原体感染（4.76%、2/43）、病毒感染（4.65%、2/43）、真菌感染（4.65%、2/43）、细菌与真菌混合感染（4.65%、2/43），肺炎衣原体感染占比最低（2.33%、1/43）。痰标本培养后共分离55株病原菌，其中革兰阴性菌、革兰阳性菌、真菌占比分别为63.64%（35/43）、27.27%（15/43）和9.09%（5/43）。感染组患者出院后1个月、2个月、3个月FBG和HbA1c水平均显著高于出院时（FBG：t = 17.943、14.535、16.546，P均< 0.001；HbA1c：t = 16.976、16.735、16.734，P均< 0.001），且感染组患者出院后以上3个时间点FBG和HbA1c水平均显著高于未感染组（FBG：t = 15.435、46.522、17.865，P均< 0.001；HbA1c：t = 16.765、17.057、16.846，P均< 0.001）。感染组患者FBG变化率[（48.93 ± 7.61）%]和HbA1c变化率[（65.84 ± 7.97）%]均显著高于未感染组[FBG变化率：（20.04 ± 4.35）%，HbA1c变化率：（34.05 ± 5.11）%]，差异均有统计学意义（t = 11.026、15.884，P均< 0.001）。多因素Logistic回归分析显示，脑卒中后吞咽障碍（OR = 4.246、95%CI：1.486～4.264、P < 0.001）、并发胃食管反流（OR = 3.888、95%CI：1.175～3.946、P = 0.003）、出院3个月FBG变化率（≥ 47.58%）（OR = 4.246、95%CI：2.937～5.555、P = 0.015）和出院3个月HbA1c变化率（≥ 28.65%）（OR = 3.888、95%CI：2.689～5.088、P = 0.012）均为发生CAP的危险因素。ROC曲线分析显示，FBG变化率和HbA1c变化率预测老年糖尿病患者并发CAP的Cut-off值分别为47.58%和28.65%，灵敏度、特异度和AUC分别为51.16%、89.26%和0.779，60.47%、87.92%和0.741；二者联合预测老年糖尿病患者并发CAP的灵敏度、特异度和AUC分别为81.39%、88.59%和0.909，二者联合预测CAP的AUC显著高于FBG变化率或HbA1c变化率单指标预测，差异有统计学意义（Z = 2.201、P = 0.028，Z = 2.579、P = 0.010）。

结论

老年糖尿病患者CAP发生率高，常见革兰阴性菌感染，感染者FBG变化率和HbA1c变化率均较高，且二者联合对CAP发生预测价值较高。

关键词: 老年, 糖尿病, 社区获得性肺炎, 病原菌, 空腹血糖, 糖化血红蛋白
Objective

To investigate the characteristics of pathogen distribution of community acquired pneumonia (CAP) in elderly patients with diabetes, and to analyze the predictive value of fasting blood glucose (FBG) combined with glycosylated hemoglobin (HbA1c).

Methods

Total of 192 elderly patients with diabetes who were discharged from the Fifth People's Hospital of Nanchong from January 2020 to November 2021 were selected by systematic sampling method for cohort study, all of whom were followed up. The incidence of CAP of patients within 3 months after discharge and the distribution characteristics of pathogens were analyzed. All patients were divided into infected group (43 cases) and uninfected group (149 cases) based on whether complicated with CAP, and the levels of FBG and HbA1c between the two groups were compared, respectively. The risk factors of CAP were conducted by multivariate Logistic regression analysis. The predictive values of FBG change rate and HbA1c change rate for concurrent CAP were analyzed by the receiver operating characteristic (ROC) curve, and the predictive performances were evaluated by the area under the curve (AUC).

Results

The incidence rate of CAP was 22.40% (43/192). Among patients with CAP, bacterial infection accounted for the highest proportion (79.07%, 34/43), followed by Mycoplasma pneumoniae infection (4.76%, 2/43), viral infection (4.65%, 2/43), fungal infection (4.65%, 2/43) and bacterial and fungal mixed infection (4.65%, 2/43); Chlamydia pneumoniae infection accounted for the lowest proportion (2.33%, 1/43). After sputum culture, a total of 55 pathogenic bacteria were isolated, among which Gram-negative bacteria, Gram-positive bacteria and fungi accounted for 63.64% (35/43), 27.27% (15/43) and 9.09% (5/43), respectively. The levels of FBG and HbA1c at discharge of patients in infected group were significantly higher than those of 1 month, 2 months and 3 months after discharge (FBG: t = 17.943, 14.535, 16.546; all P < 0.001. HbA1c: t =16.976, 16.735, 16.734; all P < 0.001). And the levels of FBG and HbA1c of Infected patients were significantly higher at above three time points after discharge than those of uninfected patients (FBG: t = 15.435, 46.522, 17.865; all P < 0.001. HbA1c: t = 16.765, 17.057, 16.846; all P < 0.001). The FBG change rate [(48.93 ± 7.61)%] and HbA1c change rate [(65.84 ± 7.97)%] of patients in infected group were significantly higher than those of uninfected group [FBG: (20.04 ± 4.35)%, HbA1c: (34.05 ± 5.11)%], with significant differences (t = 11.026, 15.884; both P < 0.001). Multivariate Logistic regression analysis showed that post stroke dysphagia (OR = 4.246, 95%CI: 1.486-4.264, P < 0.001), concurrent gastroesophageal reflux (OR = 3.888, 95%CI: 1.175-3.946, P = 0.003), FBG change rate at 3 months after discharge (≥ 47.58%) (OR = 4.246, 95%CI: 2.937-5.555, P = 0.015) and HbA1c change rate at 3 months after discharge (≥ 28.65%) (OR = 3.888, 95%CI: 2.689-5.088, P = 0.012) were all influencing factors for CAP. ROC analysis showed that the cut-off values predicted by the change rates of FBG and HbA1c in elderly patients with diabetes complicated with CAP were 47.58% and 28.65%, respectively; and the sensitivity, specificity and AUC were 51.16%, 89.26% and 0.779, 60.47%, 87.92% and 0.741, respectively. The sensitivity, specificity and AUC predicted by the combination of the two indicators were 81.39%, 88.59% and 0.909, respectively, the AUC predicted by the combination of the two indicators were significantly higher than predicted by the change rates of FBG or HbA1c alone, with significant differences (Z = 2.201, P = 0.028; Z = 2.579, P = 0.010).

Conclusions

The incidence of CAP was high in elderly patients with diabetes mellitus, and the Gram-negative bacteria infection was common, the change rate of FBG and HbA1c in infected patients were high, and the combination of the two indicators had a high predictive value for CAP.

Key words: Elderly, Diabetes, Community acquired pneumonia, Pathogens, Fasting blood glucose, Hemoglobin A1c
表1 入组老年糖尿病患者所分离病原学分布
病原体 株（%）
革兰阴性菌 35（63.64）
肺炎克雷伯菌 12（34.29）
铜绿假单胞菌 8（22.86）
鲍曼不动杆菌 5（14.29）
大肠埃希菌 5（14.29）
流感嗜血杆菌 4（11.43）
变形杆菌 1（2.86）
革兰阳性菌 15（27.27）
黄色葡萄球菌 8（53.34）
表皮葡萄球菌 3（20.00）
肺炎链球菌 2（13.33）
粪肠球菌 2（13.33）
真菌 5（9.09）
白色假丝酵母菌 2（40.00）
光滑假丝酵母菌 2（40.00）
曲霉菌属 1（20.00）
表2 感染组和未感染组老年糖尿病患者一般资料
指标 感染组（43例） 未感染组（149例） 统计量 P值
性别[例（%）]     χ2 = 0.066a 0.797
男 23（53.49） 83（55.70）    
女 20（46.51） 66（44.30）
年龄（ ± s，岁） 73.05 ± 9.88 72.36 ± 9.27 t = 0.742 0.285
病程（ ± s，年） 9.15 ± 1.52 8.98 ± 1.44 t = 1.604 0.198
脑卒中后吞咽障碍[例（%）]     χ2 = 28.372b < 0.001
是 13（30.23） 5（3.36）    
否 30（69.77） 144（96.64）
并发胃食管反流[例（%）]     χ2 = 30.935a < 0.001
是 18（41.86） 11（7.38）    
否 25（58.14） 138（92.62）
出院时FBG（ ± s，mmol/L） 6.15 ± 1.08 6.20 ± 1.11 t = 0.262 0.794
出院时HbA1c（ ± s，%） 5.28 ± 0.76 5.33 ± 0.82 t = 0.358 0.721
出院3个月FBG变化率（ ± s，%） 48.93 ± 7.61 20.04 ± 4.35 t = 11.026 < 0.001
出院3个月HbA1c变化率（ ± s，%） 65.84 ± 7.97 34.05 ± 5.11 t = 15.884 < 0.001
血糖控制未达标[例（%）]     χ2 = 5.580a 0.018
是 19（44.19） 38（25.50）    
否 24（55.81） 111（74.50）
表3 感染组和未感染组老年糖尿病患者出院时与出院后FBG水平（ ± s，mmol/L）
组别 例数 出院时 出院后1个月 出院后2个月 出院后3个月
感染组          
出院后1个月内感染 10 5.91 ± 0.96 7.14 ± 1.12 — —
出院后2个月内感染 13 5.76 ± 1.13 7.65 ± 1.43 8.42 ± 1.65 —
出院后3个月内感染 20 5.89 ± 1.05 7.38 ± 1.22 8.34 ± 1.86 9.53 ± 1.92
未感染组 149 5.81 ± 1.07 5.93 ± 1.08 6.01 ± 1.12 6.06 ± 1.24
统计量   F = 0.070 F = 19.635 F = 47.487 t = 7.865
P值   0.976 < 0.001 < 0.001 < 0.001
表4 感染组和未感染组老年糖尿病患者出院时与出院后HbA1c水平（ ± s，%）
组别 例数 出院时 出院后1个月 出院后2个月 出院后3个月
感染组 43        
出院后1个月内感染 10 6.25 ± 0.76 7.54 ± 0.84 — —
出院后2个月内感染 13 6.13 ± 0.84 7.36 ± 0.89 8.01 ± 1.14 —
出院后3个月内感染 20 6.17 ± 0.81 7.31 ± 0.92 7.63 ± 1.06 8.49 ± 1.27
未感染组 149 6.22 ± 0.79 6.31 ± 0.85 6.37 ± 0.74 6.26 ± 0.88
统计量   F = 0.077 F = 17.358 F = 41.588 t = 7.611
P值   0.972 < 0.001 < 0.001 < 0.001
表5 老年糖尿病患者并发CAP的多因素Logistic回归分析
影响因素 β值 S.E.值 Wald χ2值 OR值 95%CI P值
脑卒中后吞咽障碍 0.923 0.269 11.773 4.246 1.486～4.264 < 0.001
并发胃食管反流 0.667 0.309 6.161 3.888 1.175～3.946 0.003
出院3个月FBG变化率（≥ 47.58%） 1.446 0.668 4.686 4.246 2.937～5.555 0.015
出院3个月HbA1c变化率（≥ 28.65%） 1.358 0.612 4.924 3.888 2.689～5.088 0.012
图1 FBG变化率和HbA1c变化率以及二者联合预测老年糖尿病患者并发CAP的ROC曲线
表6 FBG变化率和HbA1c变化率以及二者联合对老年糖尿病患者并发CAP的预测效能
指标 Cut-off值（%） 敏感性（%） 特异性（%） AUC 95%CI
FBG变化率 47.58 51.16 89.26 0.779 0.681～0.859
HbA1c变化率 28.65 60.47 87.92 0.741 0.637～0.828
联合检测 — 81.39 88.59 0.909 0.828～0.957
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