血清可溶性髓系细胞触发受体1、降钙素原水平及急性生理学与慢性健康状况评分系统Ⅱ评分对血流感染患者预后的预测价值研究
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摘要
背景血流感染(BSI)发病率及病死率均较高,但其缺乏特异性临床表现,是目前危重症领域的重点和难点,寻找预测BSI患者预后的有效指标对合理制定治疗策略及降低患者病死率具有重要意义。目的探讨血清可溶性髓系细胞触发受体1(sTREM-1)、降钙素原(PCT)水平及急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分对BSI患者预后的预测价值。方法选取2017年1月—2018年6月西南医科大学附属医院收治的BSI患者142例作为观察组,另选取同期体检健康者100例作为对照组。比较对照组和观察组受试者实验室检查指标〔包括血清sTREM-1、PCT、超敏C反应蛋白(hs-CRP)水平及血肌酐(Scr)、血乳酸(LAC)水平〕及APACHEⅡ评分。根据入院后30 d内预后将BSI患者分为存活组108例、死亡组34例,比较存活组和死亡组患者一般资料、实验室检查指标及APACHEⅡ评分。BSI患者预后影响因素分析采用多因素Logistic回归分析;绘制受试者工作特征(ROC)曲线评价血清sTREM-1、PCT水平及APACHEⅡ评分对BSI患者预后的预测价值。结果 (1)观察组患者血清sTREM-1、PCT、hs-CRP水平及Scr水平、LAC水平、APACHEⅡ评分高于对照组(P<0.05)。(2)存活组和死亡组患者性别、年龄、血清hs-CRP水平比较,差异无统计学意义(P>0.05);死亡组患者血清sTREM-1、PCT水平及Scr水平、LAC水平、APACHEⅡ评分高于存活组(P<0.05)。(3)多因素Logistic回归分析结果显示,血清sTREM-1〔OR=1.164,95%CI(1.068,1.269)〕、PCT〔OR=1.383,95%CI(1.191,1.605)〕水平及APACHEⅡ评分〔OR=1.929,95%CI(1.261,2.952)〕是BSI患者预后的独立影响因素(P<0.05)。(4)受试者工作特征(ROC)曲线显示,血清sTREM-1水平预测BSI患者预后的曲线下面积(AUC)为0.898〔95%CI(0.836,0.943)〕,血清PCT水平为0.863〔95%CI(0.796,0.915)〕,APACHEⅡ评分为0.812〔95%CI(0.768,0.873)〕。结论血清sTREM-1、PCT水平及APACHEⅡ评分是BSI患者预后的独立影响因素,且三者对BSI患者预后均具有一定预测价值。
Background Both morbidity and mortality of bloodstream infection(BSI)are relatively high,but it is lack of specific clinical manifestations,which is one of key and difficult points in critical illness area,thus actively detecting effective prognostic indicators of BSI is of great significance for developing rational treatment strategies and reducing the mortality.Objective To investigate the predictive value of serum levels of sTREM-1 and PCT,and APACHEⅡ score on the prognosis inpatients with BSI. Methods Participants were recruited in the Affiliated Hospital of Southwest Medical University from January 2017 to June 2018,including 142 patients with BSI(served as observation group)and 100 healthy physical examinees(served as control group). Laboratory examination results(including serum levels of sTREM-1,PCT and hs-CRP,Scr,LAC)and APACHE Ⅱ score were compared between control group and observation group. According to the prognosis within 30 days after admission,patients in BSI group were divided into survival subgroup(n=108)and death subgroup(n=34),then general information,laboratory examination results and APACHE Ⅱ score were compared between the two subgroups. Multivariate Logistic regression analysis was used to analyze the influencing factors of prognosis in patients with BSI,and ROC curve was drawn to evaluate the prognostic value of sTREM-1,PCT and APACHE Ⅱ score in patients with BSI. Results(1)Serum levels of sTREM-1,PCT and hs-CRP,Scr,LAC and APACHE Ⅱ score in observation group were statistically significantly higher than those in control group(P<0.05).(2)No statistically significant difference of gender,age or serum hs-CRP level was found between survival subgroup and death subgroup(P>0.05),while serum levels of sTREM-1 and PCT,Scr,LAC and APACHE Ⅱ score in death subgroup were statistically significantly higher than those in survival subgroup(P<0.05).(3)Multivariate Logistic regression analysis results showed that,serum levels of sTREM-1[OR=1.164,95%CI(1.068,1.269)] and PCT[OR=1.383,95%CI(1.191,1.605)],and APACHE Ⅱ score[OR=1.929,95%CI(1.261,2.952)]were independent influencing factors of prognosis in patients with BSI(P<0.05).(4)ROC curve analysis revealed that,AUC of serum levels of sTREM-1 and PCT,and APACHEⅡ score was 0.898[95%CI(0.836,0.943)],0.863[95%CI(0.796,0.915)],0.812[95%CI(0.768,0.873)]in predicting the prognosis in patients with BSI,respectively. Conclusion Serum levels of sTREM-1 and PCT,and APACHE Ⅱ score are independent influencing factors of prognosis in patients with BSI,and all of them have significant prognostic value in patients with BSI.
Background Both morbidity and mortality of bloodstream infection(BSI)are relatively high,but it is lack of specific clinical manifestations,which is one of key and difficult points in critical illness area,thus actively detecting effective prognostic indicators of BSI is of great significance for developing rational treatment strategies and reducing the mortality.Objective To investigate the predictive value of serum levels of sTREM-1 and PCT,and APACHEⅡ score on the prognosis inpatients with BSI. Methods Participants were recruited in the Affiliated Hospital of Southwest Medical University from January 2017 to June 2018,including 142 patients with BSI(served as observation group)and 100 healthy physical examinees(served as control group). Laboratory examination results(including serum levels of sTREM-1,PCT and hs-CRP,Scr,LAC)and APACHE Ⅱ score were compared between control group and observation group. According to the prognosis within 30 days after admission,patients in BSI group were divided into survival subgroup(n=108)and death subgroup(n=34),then general information,laboratory examination results and APACHE Ⅱ score were compared between the two subgroups. Multivariate Logistic regression analysis was used to analyze the influencing factors of prognosis in patients with BSI,and ROC curve was drawn to evaluate the prognostic value of sTREM-1,PCT and APACHE Ⅱ score in patients with BSI. Results(1)Serum levels of sTREM-1,PCT and hs-CRP,Scr,LAC and APACHE Ⅱ score in observation group were statistically significantly higher than those in control group(P<0.05).(2)No statistically significant difference of gender,age or serum hs-CRP level was found between survival subgroup and death subgroup(P>0.05),while serum levels of sTREM-1 and PCT,Scr,LAC and APACHE Ⅱ score in death subgroup were statistically significantly higher than those in survival subgroup(P<0.05).(3)Multivariate Logistic regression analysis results showed that,serum levels of sTREM-1[OR=1.164,95%CI(1.068,1.269)] and PCT[OR=1.383,95%CI(1.191,1.605)],and APACHE Ⅱ score[OR=1.929,95%CI(1.261,2.952)]were independent influencing factors of prognosis in patients with BSI(P<0.05).(4)ROC curve analysis revealed that,AUC of serum levels of sTREM-1 and PCT,and APACHEⅡ score was 0.898[95%CI(0.836,0.943)],0.863[95%CI(0.796,0.915)],0.812[95%CI(0.768,0.873)]in predicting the prognosis in patients with BSI,respectively. Conclusion Serum levels of sTREM-1 and PCT,and APACHE Ⅱ score are independent influencing factors of prognosis in patients with BSI,and all of them have significant prognostic value in patients with BSI.
引文
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[3]中华人民共和国卫生部.医院感染诊断标准(试行)[J].中华医学杂志,2001,81(5):314-320.DOI:10.3760/j:issn:0376-2491.2001.05.027.
[4]PARAJULI B D,SHRESTHA G S,PRADHAN B,et al.Comparison of acute physiology and chronic health evaluationⅡand acute physiology and chronic health evaluationⅣto predict intensive care unit mortality[J].Indian J Crit Care Med,2015,19(2):87-91.DOI:10.4103/0972-5229.151016.
[5]HOEBOER S H,ALBERTS E,VAN DEN HUL I,et al.Old and new biomarkers for predicting high and low risk microbial infection in critically ill patients with new onset fever:a case for procalcitonin[J].J Infect,2012,64(5):484-493.DOI:10.1016/j.jinf.2012.01.002.
[6]杨祖耀,詹思延,王波,等.中国血流感染住院病死率的系统评价和meta分析[J].北京大学学报(医学版),2010,42(3):304-307.DOI:10.3969/j.issn.1671-167X.2010.03.013.
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[8]FAUCI A S,MORENS D M.The perpetual challenge of infectious diseases[J].N Engl J Med,2012,366(5):454-461.DOI:10.1056/nejmra1108296.
[9]张哲英.可溶性髓样细胞触发受体-1在脓毒症中的研究进展[J].中国急救医学,2013,33(10):951-954.DOI:10.3969/j.issn.1002-1949.2013.10.024.
[10]鄢洁,李多,傅玉琼,等.可溶性髓系细胞触发受体-1及降钙素原对社区获得性肺炎及肺结核的鉴别诊断价值[J].实用心脑肺血管病杂志,2015,23(9):87-89.DOI:10.3969/j.issn.1008-5971.2015.09.028.
[11]DIMOPOULOU I,PELEKANOU A,MAVROU I,et al.Early serum levels of soluble triggering receptor expressed on myeloid cells-1 in septic patients:correlation with monocyte gene expression[J].J Crit Care,2012,27(3):294-300.DOI:10.1016/j.jcrc.2011.06.013.
[12]JEONG S J,SONG Y G,KIM C O,et al.Measurement of plasma s TREM-1 in patients with severe sepsis receiving early goal-directed therapy and evaluation of its usefulness[J].Shock,2012,37(6):574-578.DOI:10.1097/SHK.0b013e318250da40.
[13]DEMISSEI B G,CLELAND J G,O'CONNOR C M,et al.Procalcitonin-based indication of bacterial infection identifies high risk acute heart failure patients[J].Int J Cardiol,2016,204:164-171.DOI:10.1016/j.ijcard.2015.11.141.
[14]BARTOLETTI M,ANTONELLI M,BRUNO BLASI F A,et al.Procalcitonin-guided antibiotic therapy:an expert consensus[J].Clin Chem Lab Med,2018,56(8):1223-1229.DOI:10.1515/cclm-2018-0259.
[15]王绍鸣,张才明.细菌性血流感染致脓毒症患者血清PCT、CRP及内毒素水平变化及临床意义[J].解放军医药杂志,2018,30(1):53-55,63.DOI:10.3969/j.issn.2095-140X.2018.01.014.
[16]龙云铸,李丹,傅京力,等.急性生理学与慢性健康状况评分系统Ⅱ评分和心肌损伤标志物与感染性休克患者预后的关系研究[J].实用心脑肺血管病杂志,2018,26(6):31-34.DOI:10.3969/j.issn.1008-5971.2018.06.008.
[17]袁晓宇,袁菊萍,王艳,等.D-二聚体、急诊脓毒症病死率评分及急性生理学与慢性健康状况评价系统Ⅱ评分对急诊脓毒症患者预后的预测价值[J].实用心脑肺血管病杂志,2016,24(5):96-99.DOI:10.3969/j.issn.1008-5971.2016.05.026.
[18]罗运山,刘易林,邓霞梅,等.可溶性髓样细胞触发性受体1、降钙素原、C-反应蛋白在脓毒症中的临床价值[J].实用医学杂志,2016,32(17):2861-2863.DOI:10.3969/j.issn.1006-5725.2016.17.023.
[19]王自财,张小莉,黄循斌,等.脓毒症患儿血浆可溶性髓系细胞触发受体1、降钙素原和C反应蛋白水平变化的研究[J].海南医学,2013,24(11):1625-1628.DOI:10.3969/j.issn.1003-6350.2013.11.0678.
[20]JEDYNAK M,SIEMIATKOWSKI A,MROCZKO B,et al.Soluble TREM-1 serum level can early predict mortality of patients with sepsis,severe sepsis and septic shock[J].Arch Immunol Ther Exp(Warsz),2018,66(4):299-306.DOI:10.1007/s00005-017-0499-x.
[21]刘兆玮,苗菲菲,张红,等.血中炎性指标水平、急性生理和慢性健康评分Ⅱ与血流感染严重程度的相关性分析[J].中国感染与化疗杂志,2018,18(5):477-481.DOI:10.16718/j.1009-7708.2018.05.006.
[22]马焕先,史宪杰,梁雨荣,等.乳酸清除率及BNP的动态变化与脓毒血症患者预后的临床分析[J].中华医院感染学杂志,2016,26(23):5398-5400.DOI:10.11816/cn.ni.2016-161610.
[2]国家卫生计生委合理用药专家委员会.2017年全国细菌耐药监测报告[EB/OL].(2018-11-30)[2019-01-20].http://www.chinets.com/Data/AntibioticDrugFast.
[3]中华人民共和国卫生部.医院感染诊断标准(试行)[J].中华医学杂志,2001,81(5):314-320.DOI:10.3760/j:issn:0376-2491.2001.05.027.
[4]PARAJULI B D,SHRESTHA G S,PRADHAN B,et al.Comparison of acute physiology and chronic health evaluationⅡand acute physiology and chronic health evaluationⅣto predict intensive care unit mortality[J].Indian J Crit Care Med,2015,19(2):87-91.DOI:10.4103/0972-5229.151016.
[5]HOEBOER S H,ALBERTS E,VAN DEN HUL I,et al.Old and new biomarkers for predicting high and low risk microbial infection in critically ill patients with new onset fever:a case for procalcitonin[J].J Infect,2012,64(5):484-493.DOI:10.1016/j.jinf.2012.01.002.
[6]杨祖耀,詹思延,王波,等.中国血流感染住院病死率的系统评价和meta分析[J].北京大学学报(医学版),2010,42(3):304-307.DOI:10.3969/j.issn.1671-167X.2010.03.013.
[7]BOUCHON A,DIETRICH J,COLONNA M,et al.Cutting edge:inflammatory responses can be triggered by TREM-1,a novel receptor expressed on neutrophils and monocytes[J].J Immunol,2000,164(10):4991-4995.
[8]FAUCI A S,MORENS D M.The perpetual challenge of infectious diseases[J].N Engl J Med,2012,366(5):454-461.DOI:10.1056/nejmra1108296.
[9]张哲英.可溶性髓样细胞触发受体-1在脓毒症中的研究进展[J].中国急救医学,2013,33(10):951-954.DOI:10.3969/j.issn.1002-1949.2013.10.024.
[10]鄢洁,李多,傅玉琼,等.可溶性髓系细胞触发受体-1及降钙素原对社区获得性肺炎及肺结核的鉴别诊断价值[J].实用心脑肺血管病杂志,2015,23(9):87-89.DOI:10.3969/j.issn.1008-5971.2015.09.028.
[11]DIMOPOULOU I,PELEKANOU A,MAVROU I,et al.Early serum levels of soluble triggering receptor expressed on myeloid cells-1 in septic patients:correlation with monocyte gene expression[J].J Crit Care,2012,27(3):294-300.DOI:10.1016/j.jcrc.2011.06.013.
[12]JEONG S J,SONG Y G,KIM C O,et al.Measurement of plasma s TREM-1 in patients with severe sepsis receiving early goal-directed therapy and evaluation of its usefulness[J].Shock,2012,37(6):574-578.DOI:10.1097/SHK.0b013e318250da40.
[13]DEMISSEI B G,CLELAND J G,O'CONNOR C M,et al.Procalcitonin-based indication of bacterial infection identifies high risk acute heart failure patients[J].Int J Cardiol,2016,204:164-171.DOI:10.1016/j.ijcard.2015.11.141.
[14]BARTOLETTI M,ANTONELLI M,BRUNO BLASI F A,et al.Procalcitonin-guided antibiotic therapy:an expert consensus[J].Clin Chem Lab Med,2018,56(8):1223-1229.DOI:10.1515/cclm-2018-0259.
[15]王绍鸣,张才明.细菌性血流感染致脓毒症患者血清PCT、CRP及内毒素水平变化及临床意义[J].解放军医药杂志,2018,30(1):53-55,63.DOI:10.3969/j.issn.2095-140X.2018.01.014.
[16]龙云铸,李丹,傅京力,等.急性生理学与慢性健康状况评分系统Ⅱ评分和心肌损伤标志物与感染性休克患者预后的关系研究[J].实用心脑肺血管病杂志,2018,26(6):31-34.DOI:10.3969/j.issn.1008-5971.2018.06.008.
[17]袁晓宇,袁菊萍,王艳,等.D-二聚体、急诊脓毒症病死率评分及急性生理学与慢性健康状况评价系统Ⅱ评分对急诊脓毒症患者预后的预测价值[J].实用心脑肺血管病杂志,2016,24(5):96-99.DOI:10.3969/j.issn.1008-5971.2016.05.026.
[18]罗运山,刘易林,邓霞梅,等.可溶性髓样细胞触发性受体1、降钙素原、C-反应蛋白在脓毒症中的临床价值[J].实用医学杂志,2016,32(17):2861-2863.DOI:10.3969/j.issn.1006-5725.2016.17.023.
[19]王自财,张小莉,黄循斌,等.脓毒症患儿血浆可溶性髓系细胞触发受体1、降钙素原和C反应蛋白水平变化的研究[J].海南医学,2013,24(11):1625-1628.DOI:10.3969/j.issn.1003-6350.2013.11.0678.
[20]JEDYNAK M,SIEMIATKOWSKI A,MROCZKO B,et al.Soluble TREM-1 serum level can early predict mortality of patients with sepsis,severe sepsis and septic shock[J].Arch Immunol Ther Exp(Warsz),2018,66(4):299-306.DOI:10.1007/s00005-017-0499-x.
[21]刘兆玮,苗菲菲,张红,等.血中炎性指标水平、急性生理和慢性健康评分Ⅱ与血流感染严重程度的相关性分析[J].中国感染与化疗杂志,2018,18(5):477-481.DOI:10.16718/j.1009-7708.2018.05.006.
[22]马焕先,史宪杰,梁雨荣,等.乳酸清除率及BNP的动态变化与脓毒血症患者预后的临床分析[J].中华医院感染学杂志,2016,26(23):5398-5400.DOI:10.11816/cn.ni.2016-161610.