严重烧伤病人血流感染的流行病学特点及死亡危险因素分析
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摘要
目的探讨严重烧伤病人血液感染(bloodstream infections,BSI)的特点,评价BSI对严重烧伤病人90天死亡率的影响。方法收集2011-2016年某院烧伤科收治的87例严重烧伤病人的临床资料,包括病人的人口统计学、疾病严重程度、主要治疗方案以及结局和微生物学数据等。通过单变量和多变量逻辑回归分析评估BSI特征与90天死亡率之间的关联。结果在87例重度和特重度烧伤病人中,有59例发生BSI,发生率为67. 8%。与无BSI组相比,BSI组病人的烧伤总面积(total burn surface area,TBSA)和危重疾病评分(APACHEⅡ、SOFA和ABSI)均显著提高,差异有统计学意义(Z=9. 264、4. 430、4. 705,P <0. 05),并且行气管切开术、置入中心静脉导管、接受机械通气和60天、90天死亡人数均显著增多,差异有统计学意义(χ~2=11. 836、8. 842、14. 016、5. 884、8. 203,P <0. 05)。在分离获得的162株病原菌中,革兰氏阴性菌占75. 3%,革兰氏阳性菌占12. 3%,真菌占12. 3%。最常见的5种微生物为鲍曼不动杆菌、肺炎克雷伯菌、念珠菌、铜绿假单胞菌和嗜麦芽窄食单胞菌。多变量分析结果显示,导管相关BSI(调整OR=5. 8,95%CI=1. 5～25. 3,P=0. 017)和混合BSI(调整OR=6. 0,95%CI=1. 4～27. 8,P=0. 015)与90天死亡风险升高呈独立相关。结论 BSI在严重烧伤病人中具有较高的发生率。革兰氏阴性菌和真菌是主要原因。导管相关BSI和混合BSI与90天死亡风险升高相关。
Objective To determine the epidemiological characteristics of bloodstream infections(BSI) and to evaluate the impact of BSI on 90-day mortality in severe burn patients. Methods The clinical data of 87 patients with severe burns admitted to the ICU ward of our hospital from 2011 to 2016 were collected,including the patient's demography,disease severity,major treatment plans,outcome and microbiological data. Univariate and multivariate logistic regression analyses were used to evaluate the association between BSI and 90-day mortality. Results Of the 87 patients with severe burns,59 had BSI,with an incidence of 67. 8%. Compared with the no acquired BSI group,the TBSA,and critical disease score(APACHE Ⅱ,SOFA and ABSI) in the BSI group were significantly increased(Z = 9. 264,4. 430,4. 705,P < 0. 05),and the line of tracheotomy,central venous catheter placement,receiving mechanical ventilation and the 60-day and 90-day mortality were significantly increased(χ~2= 11. 836,8. 842,14. 016,5. 884,8. 203,P < 0. 05). Of the 162 pathogens,75. 3% were gram-negative bacteria,12. 3% were gram-positive bacteria,and 12. 3% were Fungus. The five most common organisms were Acinetobacter baumannii, Klebsiella pneumoniae, Candida, Pseudomonas aeruginosa, and Stenotrophomonas maltophilia. Multivariate analysis showed that catheter-related BSI(adjusted OR = 5. 8,95% CI = 1. 5 ～ 25. 3,P = 0. 017) and mixed BSI(adjusted OR =6. 0,95% CI = 1. 4 ～ 27. 8,P = 0. 015) were independently associated with an increased risk of 90-day mortality. Conclusion A strikingly high rate of BSI is observed in severe burn patients. Gram-negative organisms and fungi are the leading causes. Catheter related BSI and mixed BSI are associated with increased risk of 90-day mortality.
Objective To determine the epidemiological characteristics of bloodstream infections(BSI) and to evaluate the impact of BSI on 90-day mortality in severe burn patients. Methods The clinical data of 87 patients with severe burns admitted to the ICU ward of our hospital from 2011 to 2016 were collected,including the patient's demography,disease severity,major treatment plans,outcome and microbiological data. Univariate and multivariate logistic regression analyses were used to evaluate the association between BSI and 90-day mortality. Results Of the 87 patients with severe burns,59 had BSI,with an incidence of 67. 8%. Compared with the no acquired BSI group,the TBSA,and critical disease score(APACHE Ⅱ,SOFA and ABSI) in the BSI group were significantly increased(Z = 9. 264,4. 430,4. 705,P < 0. 05),and the line of tracheotomy,central venous catheter placement,receiving mechanical ventilation and the 60-day and 90-day mortality were significantly increased(χ~2= 11. 836,8. 842,14. 016,5. 884,8. 203,P < 0. 05). Of the 162 pathogens,75. 3% were gram-negative bacteria,12. 3% were gram-positive bacteria,and 12. 3% were Fungus. The five most common organisms were Acinetobacter baumannii, Klebsiella pneumoniae, Candida, Pseudomonas aeruginosa, and Stenotrophomonas maltophilia. Multivariate analysis showed that catheter-related BSI(adjusted OR = 5. 8,95% CI = 1. 5 ～ 25. 3,P = 0. 017) and mixed BSI(adjusted OR =6. 0,95% CI = 1. 4 ～ 27. 8,P = 0. 015) were independently associated with an increased risk of 90-day mortality. Conclusion A strikingly high rate of BSI is observed in severe burn patients. Gram-negative organisms and fungi are the leading causes. Catheter related BSI and mixed BSI are associated with increased risk of 90-day mortality.
引文
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[11] BOUZA E, BURILLO A, MUNOZ P, et al. Mixed bloodstream infections involving bacteria and Candida spp[J]. J Antimicrob Chemother,2013,68(8):1881-1888.
[12]应颖秋.念珠菌感染预防用药能否降低ICU患者死亡率和继发感染率[J].临床药物治疗杂志,2017,15(12):76-76.
[13] MASHALY ES, ELMAHDY RH. Vancomycin heteroresistance in coagulase negative Staphylococcus blood stream infections from patients of intensive care units in Mansoura University Hospitals,Egypt[J]. Ann Clin Microbiol Antimicrob,2017,16(1):63.
[14] SETHI S,ZAMAN K,JAIN N. Mycoplasma genitalium infections:current treatment options and resistance issues[J]. Infect Drug Resist,2017,10(9):283-292.
[15]杨春,王蕾蕾,丁玉莲.烧伤患者中心静脉引起的血液感染危险因素分析及莫匹罗星的运用价值[J].重庆医学,2016,45(33):4698-4700.
[16] TANG C,LI J,SHOU B,et al. Epidemiology and Outcomes of Bloodstream Infections in 177 Severe Burn Patients from an Industrial Disaster:A Multicenter Retrospective Study[J]. Clin Microbiol Infect,2017,24(2):1-7.
[17] AFONSO E,BLOT K,BLOT S. Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units:a systematic review and meta-analysis of randomised crossover trials[J]. Euro Surveill,2016,21(46):30400.
[18]张慧,李夏卉,叶艳胜,等.乙醇封管对导管相关性血流感染预防效果的Meta分析[J].中华医院感染学杂志,2017,27(18):4159-4162.
[2] RENAU ESCRIG AI,SALAVERT M,VIVO C,et al. Candidemia in major burns patients[J]. Mycoses,2016,59(6):391-398.
[3]龚雅利,杨子晨,殷素鹏,等. 162例严重烧伤血流感染患者病原学特征分析[J].中华烧伤杂志,2016,32(9):529-535.
[4] SHUPP JW,PAVLOVICH AR,JENG JC,et al. Epidemiology of bloodstream infections in burn-injured patients:a review of the National Burn Repository[J]. J Burn Care Res,2010,31(4):521-528.
[5] PATEL BM, PARATZ JD, MALLET A, et al. Characteristics of bloodstream infections in burn patients:An 11-year retrospective study[J]. Burns,2012,38(5):685-690.
[6]马晓媛,肖雅,陈涛,等.解剖学评分联合生理学评分对严重创伤患者并发多器官功能障碍综合征的预测价值[J].中华烧伤杂志,2016,32(2):105-108.
[7]王长远,曹涛,孙长怡,等.降钙素原评估老年脓毒性休克患者预后的价值[J].中华实用诊断与治疗杂志,2016,30(1):46-48.
[8] PILANCI O,ERGIN S,SIREKBASAN S,et al. Serum Neopterin and Procalcitonin Levels in Relationship with Pediatric Burn Wound Infections[J]. Acta Microbiol Immunol Hung,2016,63(1):47-56.
[9] SOUSA D,CENICEROS A,GALEIRAS R,et al. Microbiology in burns patients with blood stream infections:trends over time and during the course of hospitalization[J]. Infect Dis,2017,50(4):1-8.
[10] DOLGACHEV VA,CIOTTI SM,EISMA R,et al. Nanoemulsion Therapy for Burn Wounds Is Effective as a Topical Antimicrobial Against Gram-Negative and Gram-Positive Bacteria[J]. J Burn Care Res,2016,37(2):104-114.
[11] BOUZA E, BURILLO A, MUNOZ P, et al. Mixed bloodstream infections involving bacteria and Candida spp[J]. J Antimicrob Chemother,2013,68(8):1881-1888.
[12]应颖秋.念珠菌感染预防用药能否降低ICU患者死亡率和继发感染率[J].临床药物治疗杂志,2017,15(12):76-76.
[13] MASHALY ES, ELMAHDY RH. Vancomycin heteroresistance in coagulase negative Staphylococcus blood stream infections from patients of intensive care units in Mansoura University Hospitals,Egypt[J]. Ann Clin Microbiol Antimicrob,2017,16(1):63.
[14] SETHI S,ZAMAN K,JAIN N. Mycoplasma genitalium infections:current treatment options and resistance issues[J]. Infect Drug Resist,2017,10(9):283-292.
[15]杨春,王蕾蕾,丁玉莲.烧伤患者中心静脉引起的血液感染危险因素分析及莫匹罗星的运用价值[J].重庆医学,2016,45(33):4698-4700.
[16] TANG C,LI J,SHOU B,et al. Epidemiology and Outcomes of Bloodstream Infections in 177 Severe Burn Patients from an Industrial Disaster:A Multicenter Retrospective Study[J]. Clin Microbiol Infect,2017,24(2):1-7.
[17] AFONSO E,BLOT K,BLOT S. Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units:a systematic review and meta-analysis of randomised crossover trials[J]. Euro Surveill,2016,21(46):30400.
[18]张慧,李夏卉,叶艳胜,等.乙醇封管对导管相关性血流感染预防效果的Meta分析[J].中华医院感染学杂志,2017,27(18):4159-4162.