耐碳青霉烯类革兰阴性菌肺炎的发生及死亡风险因素分析
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摘要
目的探讨影响耐碳青霉烯类革兰阴性菌(CR-GNB)肺炎发生及其死亡的风险因素,为临床经验性诊治和预防提供参考。方法回顾性分析2016年1月至12月226例革兰阴性菌肺炎住院患者,根据药敏结果分为碳青霉烯类耐药组114例和非耐药组112例,根据预后将耐药组分为存活组88例和死亡组26例。采取单因素及多因素分析,确定引起CR-GNB肺炎发生及死亡的独立危险因素。结果单因素分析显示,入住ICU、近期手术、长期卧床、发热、意识障碍、90天内使用碳青霉烯类抗生素、呼吸衰竭、休克、感染前有创操作、感染病原菌(ABA、SMA)、院内获得,在耐药组的比例明显高于非耐药组;入住ICU、冠心病、糖尿病、肾功能不全、呼吸衰竭、休克、留置导尿、深静脉置管、机械通气,在死亡组的比例明显高于存活组。多因素分析显示,之前90天内应用碳青霉烯类抗生素以及机械通气、鲍曼不动杆菌感染、院内获得的患者发生CR-GNB肺炎的风险增加。休克、深静脉置管、糖尿病、冠心病的CR-GNB肺炎患者死亡风险增加。结论之前90天内应用碳青霉烯类抗生素以及机械通气、鲍曼不动杆菌感染、院内获得是发生CR-GNB肺炎的独立危险因素;休克、深静脉置管、糖尿病、冠心病是其死亡的独立危险因素。
Objective To explore the risk factors and its related prognostic factors of the pneumonia caused by Carbapenem-resistant gram-negative bacteria(CR-GNB).Methods We retrospectively analyzed the clinical materials of patients diagnosed by gram-negative bacteria pneumonia in 2016. According to the sputum or bronchoalveolar lavage fluid(BALF) culture results, patients were divided into CR-GNB group(n=114) and nCR-GNB group(n=112). We further divided CR-GNB group into survived(n=88) and died(n=26) in terms of patients' 30 day prognosis.We conducted the statistical analysis using univariate analysis and multivariate analysis to identify independent risk factors for CR-GNB and associated mortability in pneumonia patients. Results Univariate analysis revealed that eleven factors were associated with the pneumoniae caused by CR-GNB, including ICU stay, recent history of surgery, bed-ridden, fever, conscious disturbance, carbapenem antibiotics application in past 90 days, respiratory failure, shock, invasive manipulation, ABA and SMA infection, hospital acquired. ICU stay, coronary heart disease, diabetes mellitus, renal failure, respiratory failure, shock, retention catheterization, deep vein catheterization and mechanical ventilation were associated with the mortality of CR-GNB pneumonia. Multivariate analysis showed that Carbapenem antibiotics application in past 90 days, mechanical ventilation, ABA infection and hospital acquired is independent risk factor of CR-GNB. Furthermore, shock, deep vein catheterization, diabetes mellitus and coronary heart diseases were independently associated with mortality of CR-GNB pneumonia. Conclusion Carbapenem antibiotics application in past 90 days, mechanical ventilation, ABA infection and hospital acquired is independent risk factor of CR-GNB. Furthermore, shock, deep vein catheterization, diabetes mellitus and coronary heart diseases were independently associated with mortality of CR-GNB pneumonia.
Objective To explore the risk factors and its related prognostic factors of the pneumonia caused by Carbapenem-resistant gram-negative bacteria(CR-GNB).Methods We retrospectively analyzed the clinical materials of patients diagnosed by gram-negative bacteria pneumonia in 2016. According to the sputum or bronchoalveolar lavage fluid(BALF) culture results, patients were divided into CR-GNB group(n=114) and nCR-GNB group(n=112). We further divided CR-GNB group into survived(n=88) and died(n=26) in terms of patients' 30 day prognosis.We conducted the statistical analysis using univariate analysis and multivariate analysis to identify independent risk factors for CR-GNB and associated mortability in pneumonia patients. Results Univariate analysis revealed that eleven factors were associated with the pneumoniae caused by CR-GNB, including ICU stay, recent history of surgery, bed-ridden, fever, conscious disturbance, carbapenem antibiotics application in past 90 days, respiratory failure, shock, invasive manipulation, ABA and SMA infection, hospital acquired. ICU stay, coronary heart disease, diabetes mellitus, renal failure, respiratory failure, shock, retention catheterization, deep vein catheterization and mechanical ventilation were associated with the mortality of CR-GNB pneumonia. Multivariate analysis showed that Carbapenem antibiotics application in past 90 days, mechanical ventilation, ABA infection and hospital acquired is independent risk factor of CR-GNB. Furthermore, shock, deep vein catheterization, diabetes mellitus and coronary heart diseases were independently associated with mortality of CR-GNB pneumonia. Conclusion Carbapenem antibiotics application in past 90 days, mechanical ventilation, ABA infection and hospital acquired is independent risk factor of CR-GNB. Furthermore, shock, deep vein catheterization, diabetes mellitus and coronary heart diseases were independently associated with mortality of CR-GNB pneumonia.
引文
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[2] Farida H,Gasem MH,Suryanto A,et al.Viruses and gram-negative bacilli dominate the etiology of community-acquired pneumonia in Indonesia,a cohort study[J].IJID,2015,38:101-107.
[3] Cantón R,Akóva M,Carmeli Y,et al.Rapid evolution and spread of carbapenemases among Enterobacteriaceae in Europe[J].Clin Microbiol Infect,2012,18(5):413-431.
[4] van Duin D,Doi Y.The global epidemiology of carbapenemase-producing Enterobacteriaceae[J].Virulence,2017,8(4):460-469.
[5] de Maio Carrilho CM,de Oliveira LM,Gaudereto J,et al.A prospective study of treatment of carbapenem-resistant Enterobacteriaceae infections and risk factors associated with outcome[J].BMC Infect Dis,2016,16(1):629.
[6] Tuon FF,Graf ME,Merlini A,et al.Risk factors for mortality in patients with ventilator-associated pneumonia caused by carbapenem-resistant Enterobacteriaceae[J].Braz J Infect Dis,2017,21(1):1-6.
[7] 杭欣,张波.耐碳青霉烯肺炎克雷伯菌易感因素分析[J].山西医科大学学报,2016,47(5):450-454.
[8] 蒋凤丽,董亚琳,刘东,等.ICU耐碳青霉烯类抗菌药物鲍曼不动杆菌肺部感染危险因素分析[J].中国药房,2015,26(29):4077-4079.
[9] Fu Q,Ye H,Liu S.Risk factors for extensive drug-resistance and mortality in geriatric inpatients with bacteremia caused by Acinetobacter baumannii[J].Am J Infect Control,2015,43(8):857-860.
[10] 中华医学会呼吸病学分会.中国成人社区获得性肺炎诊断和治疗指南(2016年版)[J].中华结核和呼吸杂志,2016,39(4):1-27.
[11] 葛均波,徐永建.内科学[M].8 版.北京:人民卫生出版社,2013:42.
[12] 刘震,刘启蒙,赵丽,等.急诊成人重症社区获得性肺炎的病原学调查及分析[J].中国呼吸与危重监护杂志,2015,14(1):42-47.
[13] Cockerill FWM,Bush K,Dudley M,et al.Clinical Laboratory Standards Institute.Performance standards for antimicrobial suscetibility testing:twentieth informational supplement[S].M100-S20.Wayne.PA:CLSI,2010.
[14] 胡付品.2014年CHINET中国细菌耐药性监测[J].中国感染与化疗杂志,2015,(5):401-410.
[15] 叶相如,胡必杰,周春妹,等.耐碳青霉烯类肺炎克雷伯菌感染与定植患者预后相关因素分析[J].中华医院感染学杂志,2015,25(11):2489-2491.
[16] 吕群,阮肇扬,王建军,等.耐碳青霉烯类铜绿假单胞菌感染患者的临床特点与预后分析[J].中华医院感染学杂志,2015,25(24):5570,5571.
[17] 赖国祥.机械通气并发症及其防治[J].中国医师进修杂志.2009,32:29-31.