革兰阳性菌血流感染患者预后的影响因素分析
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摘要
目的探讨革兰阳性菌血流感染患者28d预后的影响因素。方法以2016年1月-2017年10月中山大学孙逸仙纪念医院革兰阳性菌血流感染患者为研究对象,回顾性分析患者临床及微生物学资料,分析其病原菌分布和临床特点,采用Cox比例风险回归分析革兰阳性菌血流感染患者28d预后的影响因素。结果研究共纳入革兰阳性菌血流感染患者276例,培养出280株革兰阳性菌。其中,凝固酶阴性葡萄球菌155株占55.36%,金黄色葡萄球菌47株占16.79%。将患者按诊断血流感染后28d的结局分为28d死亡组与28d生存组,28d死亡组患者的APACHEⅡ评分、Pitt评分、感染中毒性休克型和不适当初始抗菌药物比例高于28d生存组患者(17.125vs.11.292,3.425vs.1.699,80.000%vs.25.847%,65.000%vs.41.525%,P均<0.05)。在校正性别、年龄因素后,多因素Cox比例风险回归分析提示不适当初始抗菌药物(校正RR:3.281,95%CI:1.701～6.331,P<0.05)、感染中毒性休克型(校正RR 7.380,95%CI 3.123-17.443,P<0.05)或APACHEⅡ评分(校正RR:1.065,95%CI:1.016～1.116,P<0.05)是革兰阳性菌血流感染患者28d死亡独立危险因素。结论不适当初始抗菌药物是革兰阳性菌血流感染患者28d死亡独立危险因素。
OBJECTIVE To explore the influencing factors for 28-day prognosis of the patients with gram-positive bacteria bloodstream infection.METHODS The patients with gram-positive bacteria bloodstream infection who were treated in Sun Yat-Sen Memorial Hospital,Sun Yat-Sen University from Jan 2016 to Oct 2017 were recruited as the study objects,the clinical and microbiological data of the patients were retrospectively analyzed,the distribution of pathogens and clinical characteristics were observed,and the influencing factors for the 28-day prognosis of the patients with gram-positive bacteria bloodstream infection were analyzed by using Cox proportional hazard regression model.RESULTS A total of 280 strains of gram-positive bacteria were isolated from 276 patients with gram-positive bacteria bloodstream infection,155(55.36%)of which were coagulase-negative Staphylococcus,and 47(16.79%)were Staphylococcus aureus.The patients diagnosed with bloodstream infection were divided into the 28-day death group and the 28-day survival group according to the 28-day outcomes.The APACHEⅡ score and Pitt score of the 28-day death group were significantly higher than those of the 28-day survival group,the proportions of the patients who had septic shock and were treated with inappropriate initial antibiotics were higher in the 28-day death group than in the 28-day survival group(17.125 vs.11.292,3.425 vs.1.699,80.000% vs.25.847%,65.000% vs.41.525%,all P<0.05).After the gender and age were adjusted,the multivariate Cox proportional hazard regression analysis indicated the inappropriate initial antibiotics therapy(adjusted RR:3.281,95%CI:1.701-6.331,P<0.05),septic shock(adjusted RR 7.380,95%CI 3.123-17.443,P<0.05)and APACHEⅡscore(adjusted RR:1.065,95%CI:1.016-1.116,P<0.05)were the independent risk factors for the 28-day death of the patients with gram-positive bacteria bloodstream infection.CONCLUSION The inappropriate initial antibiotics therapy is the independent risk factor for the 28-day death of the patients with gram-positive bacteria bloodstream infection.
OBJECTIVE To explore the influencing factors for 28-day prognosis of the patients with gram-positive bacteria bloodstream infection.METHODS The patients with gram-positive bacteria bloodstream infection who were treated in Sun Yat-Sen Memorial Hospital,Sun Yat-Sen University from Jan 2016 to Oct 2017 were recruited as the study objects,the clinical and microbiological data of the patients were retrospectively analyzed,the distribution of pathogens and clinical characteristics were observed,and the influencing factors for the 28-day prognosis of the patients with gram-positive bacteria bloodstream infection were analyzed by using Cox proportional hazard regression model.RESULTS A total of 280 strains of gram-positive bacteria were isolated from 276 patients with gram-positive bacteria bloodstream infection,155(55.36%)of which were coagulase-negative Staphylococcus,and 47(16.79%)were Staphylococcus aureus.The patients diagnosed with bloodstream infection were divided into the 28-day death group and the 28-day survival group according to the 28-day outcomes.The APACHEⅡ score and Pitt score of the 28-day death group were significantly higher than those of the 28-day survival group,the proportions of the patients who had septic shock and were treated with inappropriate initial antibiotics were higher in the 28-day death group than in the 28-day survival group(17.125 vs.11.292,3.425 vs.1.699,80.000% vs.25.847%,65.000% vs.41.525%,all P<0.05).After the gender and age were adjusted,the multivariate Cox proportional hazard regression analysis indicated the inappropriate initial antibiotics therapy(adjusted RR:3.281,95%CI:1.701-6.331,P<0.05),septic shock(adjusted RR 7.380,95%CI 3.123-17.443,P<0.05)and APACHEⅡscore(adjusted RR:1.065,95%CI:1.016-1.116,P<0.05)were the independent risk factors for the 28-day death of the patients with gram-positive bacteria bloodstream infection.CONCLUSION The inappropriate initial antibiotics therapy is the independent risk factor for the 28-day death of the patients with gram-positive bacteria bloodstream infection.
引文
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[15] Yanai M,Ogasawara M,Hayashi Y,et al.Impact of interventions by an antimicrobial stewardship program team on appropriate antimicrobial therapy in patients with bacteremic urinary tract infection[J].J Infect Chemother,2018,24(3):206-211.
[16] Picot-Gueraud R,Batailler P,Caspar Y,et al.Bacteremia caused by multidrug-resistant bacteria in a French university hospital center:3years of collection[J].Am J Infect Control,2015,43(9):960-964.
[17] Yang CJ,Chung YC,Chen TC,et al.The impact of inappropriate antibiotics on bacteremia patients in a community hospital in Taiwan:an emphasis on the impact of referral information for cases from a hospital affiliated nursing home[J].BMC Infect Dis,2013,13:500.
[18] Chuang YC,Cheng A,Sun HY,et al.Microbiological and clinical characteristics of Acinetobacter baumannii bacteremia:implications of sequence type for prognosis[J].J Infect,2018,pii:S0163-4453(18)30288-3.
[2] Paulsen J,Mehl A,Askim A,et al.Epidemiology and outcome of Staphylococcus aureus bloodstream infection and sepsis in a Norwegian county 1996-2011:an observational study[J].BMC Infect Dis,2015,15:116.
[3] Kaasch AJ,Barlow G,Edgeworth JD,et al.Staphylococcus aureus bloodstream infection:apooled analysis of five prospective,observational studies[J].J Infect,2014,68(3):242-251.
[4] Greenhouse I,Babushkin F,Finn T,et al.Long-term outcomes of inappropriate antibiotic therapy for upper urinary tract infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae:a retrospective cohort study[J].Diagn Microbiol Infect Dis,2017,89(3):222-229.
[5] Gudiol C,Ayats J,Camoez M,et al.Increase in bloodstream infection due to vancomycin-susceptible Enterococcus faeciumin cancer patients:risk factors,molecular epidemiology and outcomes[J].PLoS One,2013,8(9):e74734.
[6] CDC/NHSN surveillance definitions for specific types of infections[S].CDC,2017.
[7] Bloodstream infection event(central line-associated bloodstream infection and non-central line-associated bloodstream infection)[S].CDC,2015.
[8] American Thoracic Society,Infectious Diseases Society of America.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia[J].Am J Respir Crit Care Med,2005,171(4):388-416.
[9] Seymour CW,Liu VX,Iwashyna TJ,et al.Assessment of clinical criteria for sepsis:for the Third International Consensus Definitions for Sepsis and Septic Shock(Sepsis-3)[J].JAMA,2016,315(8):762-774.
[10] Chen HC,Lin WL,Lin CC,et al.Outcome of inadequate empirical antibiotic therapy in emergency department patients with community-onset bloodstream infections[J].J Antimicrob Chemother,2013,68(4):947-953.
[11] Honda H,Higuchi N,Shintani K,et al.Inadequate empiric antimicrobial therapy and mortality in geriatric patients with bloodstream infection:a target for antimicrobial stewardship[J].J Infect Chemother,2018,24(10):807-811.
[12]黄鲜,王雪,王平,等.严重脓毒症/脓毒性休克患者预后的影响因素研究[J].实用心脑肺血管病杂志,2017,25(12):26-29.
[13]Valles J,Rello J,Ochagavia A,et al.Community-acquired bloodstream infection in critically ill adult patients:impact of shock and inappropriate antibiotic therapy on survival[J].Chest,2003,123(5):1615-1624.
[14] Kang CI,Kim SH,Park WB,et al.Bloodstream infections caused by antibiotic-resistant gram-negative bacilli:risk factors for mortality and impact of inappropriate initial antimicrobial therapy on outcome[J].Antimicrob Agents Chemother,2005,49(2):760-766.
[15] Yanai M,Ogasawara M,Hayashi Y,et al.Impact of interventions by an antimicrobial stewardship program team on appropriate antimicrobial therapy in patients with bacteremic urinary tract infection[J].J Infect Chemother,2018,24(3):206-211.
[16] Picot-Gueraud R,Batailler P,Caspar Y,et al.Bacteremia caused by multidrug-resistant bacteria in a French university hospital center:3years of collection[J].Am J Infect Control,2015,43(9):960-964.
[17] Yang CJ,Chung YC,Chen TC,et al.The impact of inappropriate antibiotics on bacteremia patients in a community hospital in Taiwan:an emphasis on the impact of referral information for cases from a hospital affiliated nursing home[J].BMC Infect Dis,2013,13:500.
[18] Chuang YC,Cheng A,Sun HY,et al.Microbiological and clinical characteristics of Acinetobacter baumannii bacteremia:implications of sequence type for prognosis[J].J Infect,2018,pii:S0163-4453(18)30288-3.