肝硬化患者感染状况、危险因素分析与细菌耐药性、耐药基因研究
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摘要
每年全球死于肝硬化的人数超过50万,是继心脏病、中风、胸科疾病和癌症之后第五致死疾病。而且不像其他主要致死因素,肝病发病率还在不断的上升而不是下降,但是没有有效手段去控制局面,肝病专家面临前所未有的挑战。肝硬化是肝病的免疫力低下阶段,感染是肝硬化患者最重要的并发症之一,肝硬化住院患者的感染率高达25%-30%,感染导致30%-50%的肝硬化患者死亡。而且最近几十年除了对自发性细菌性腹膜炎的早期认识和治疗有很多研究,自发性腹膜炎的存活率取得提高,其他感染存活率几乎没有进展,肝硬化患者一旦感染死亡率升高四倍。很多国家和地区对本地区肝硬化住院患者感染状况进行调查,包括肝硬化患者感染的独立危险因素、感染分布、致病菌分布及耐药状况等,各地的数据并不一致。国内还没有系统进行肝硬化患者感染状况、细菌谱及耐药基因等调查的系统资料,而这些资料能为临床医生提供参考,加强肝硬化患者感染的管理,提高肝硬化患者的生存率。
研究目的
1.调查肝硬化住院患者的感染率,评估感染的危险因素。
2.分析肝硬化住院患者血液感染主要致病菌谱及耐药状况,并与2001-2004年资料比较,发现变化规律。
3.研究肝硬化住院患者血液感染的产超广谱β内酰胺酶大肠埃希菌耐药基因型、感染危险因素及愈后相关因素。
研究内容和方法
1.采用横断面研究,连续收集420例肝硬化住院患者,查阅患者相关临床资料、实验室及影像学检查资料,采用单因素分析、逻辑回归分析等方法分析患者感染相关因素和独立危险因素。
2.采用全自动微生物培养和鉴定技术,我们对2009年至2011年连续三年共1017株分离菌进行分布和药敏情况进行分析,并与本实验室2001-2004年的资料进行动态比较。
3.采用病例对照研究、多重PCR、PCR.测序及比对等,对2011年123株肝硬化血液感染的大肠埃希菌超广谱β内酰胺酶基因型进行分析；使用单因素分析、多因素分析和逻辑回归分析比较产超广谱β内酰胺酶和不产酶组的可能危险因素及独立危险因素。
研究结果
1.通过调查统计肝硬化住院患者感染率20%,最常见感染是自发性细菌性腹膜炎(32%),其他依次为呼吸道感染(18%)、血液感染(14%)和泌尿系感染(11%),怀疑感染没有微生物证据的占25%。单因素分析显示低白蛋白血症、胃肠道出血、入住重症监护病房和进行内窥镜治疗可能与感染相关；逻辑回归分析显示胃肠道出血和低白蛋白血症是肝硬化住院患者感染独立危险因素。
2.共检出30个属,88个种1017株菌(同一患者不记重复菌株),其中需氧菌1014株,占99.7%；真菌3株,占0.3%；革兰氏阴性菌591株,占58.1%；革兰氏阳性菌423株,占41.6%；排在前五位的细菌是：大肠埃希菌(308株)凝固酶阴性葡萄球菌(245株),克雷伯菌属(102株),链球菌(78株),金黄色葡萄球菌(36株)。与2001年—2004年血培养结果相比,革兰氏阴性菌的比例降低(58.1%vs.71.5%,P=0.0469)；大肠埃希菌产ESBLs比率明显升高(50.4%vs.18.0%,P<0.0001)。
3.连续收集123株大肠埃希菌,共有62株菌产超广谱β内酰胺酶；均为CTX-M型超广谱β内酰胺酶,CTX-M-1群31株,CTX-M-9群37株,其中有6株菌同时产两群CTX-M型,测序比对出CTX-M-3、CTX-M-15、CTX-M-14等八种基因型。与未产酶大肠埃希菌血液感染组相比,产超广谱β内酰胺酶大肠埃希菌感染组预防使用抗生素特别是β内酰胺酶类抗生素更多(P＝0.0018和P=0.0036),院内感染比例更高(P=0.0014),导致的死亡更多(P=0.0152)；单因素分析发现死亡组感染性休克(10/21vs.6/102,P<0.0001)、肝性脑病(12/21vs.21/102,P=0.0006)和肾功能受损(P=0.0078)等比例高于存活组；逻辑回归分析发现,预用抗生素和预用头孢类抗生素均为产ESBLs大肠埃希菌血液感染肝硬化住院患者的独立危险因素(OR=4.184,95%CI=1.697-10.32和OR=4.365,95%CI=1.611-11.83)；院内感染也是产ESBLs的独立危险因素(OR=5.333,95%CI=1.850-15.37)。对于患者的愈后经逻辑回归分析：院内感染(OR=9.128,95%CI=1.850-15.37)、感染性休克(OR=14.55,95%CI=4.428-14.78).肝性脑病(OR=5.143,95%CI=1.913-13.82)和肾功能受损(OR=4.136,95%CI=1.374-12.46)都是影响愈后的独立危险因素。
结论
1.本研究发现：胃肠道出血和低白蛋白血症导致肝硬化住院患者感染独立危险因素。
2.与以前监测结果相比,肝硬化住院患者血液感染的细菌仍然以革兰氏阴性菌为主,但是比例下降；大肠埃希菌产超广谱β内酰胺酶比例显著升高。
3.肝硬化住院患者血液感染大肠埃希菌产超广谱β内酰胺酶主要基因型为CTX-M型；慎重预用抗生素,加强对重症肝病患者的管理。
BACKGROUND
There were500,000individuals in the world die each year from liver cirrhoses and the numbers are increasing steadily. Liver cirrhosis is now the fifth most common cause of death after heart disease, stroke, chest disease and cancer. However, unlike other major causes of mortality, liver cirrhosis rates are increasing rather than declining. For hepatologists worldwide, there have never been more challenges faced. Cirrhosis is considered an immunocompromised state that leads to a variety of infections, which then account for an approximate30%-50%mortality. Bacterial infections occer in32%to34%of admitted patients with cirrhosis. Apart from early recognition and better treatment of spontaneous bacterial peritonitis (SBP) leading to better survival, there has been little improvement in overall survival rates in recent decades:infections still account for a4-fold increase in mortality among patients with cirrhosis. There are many data about the infections risk factors, independent risk facters, distrabution of pathogens, antibiotics resistence spectrum of patients with cirrhosis in different countries and parts worldwide. But the data were not same. But there were no data on distribution fo infections, pathogen and bacterial resistence spectrum of bloodstream infection, and E. coli bacterimia in patients with cirrhosis in China. These data are necessary to help docters prevention, early diagnosis, and proper management of these infections to improve survival.
AIM
1. To investigate the infection rate in hospitalized patients with liver cirrhosis and to assess the risk facors of infections.
2. To analyze the spectrum of bacteria and bacterial resistence in hospitalized patients with liver cirrhosis. To find changes by comparing the data from2001to2004.
3. To identify the risk factors for bloodstream infections caused by extended-spectrum beta-lactamase(ESBLs)-producing Escherichia coli in hospitalized patients with liver cirrhosis and the associated clinical outcomes of bacteremia..
METHODS
1. The prospective study was performed to assess the risk of bacterial infection in420hospitalized patients with liver cirrhosis. The data collected included age, gender, etiology of liver disease, reason for admission, admission site, origin of admission, endoscopic sclerotherapy or banding, variables of the Child-Pugh score (serum bilirubin and albumin, prothrombin time, degree of ascites, and encephalopathy), timing of bacterial infection after hospitalization, duration of hospitalization, and discharge status (alive vs dead). Univariate Analysis and logistic regression were used to analyse the risk fachors and independent risk factors of infections.
2. Auto bacterial culture system and identification system were performed to analyze the spectrum of1017bacteria and the antibiotic resistence. The changes of spectrum of bacteria and bacterial resistence were found by comparing with the data of2001to2004.
3.62ESBLs-producing E coli were genotyped by multi-PCR, PCR, sequancing and blast. Case control research was performed. Risk facters and independent risk factors were analyzed by univariate analysis, multivariate analysis, and logistic regression between research group and control group.
RESULTS
1. Twenty-eight (20%) patients developed an infection during their hospitalization. of Spontaneous bacterial peritonitis (32%) were the most common infections. Univariate analysis showed that patients who developed an infection were more likely to have a low serum albumin level, gastrointestinal bleeding, to stay in the intensive care unit, and to undergo therapeutic endoscopy. Logistic regression identified gastrointestinal bleeding (OR=4.3,95%CI=1.7-10.9) and a low serum albumin (OR=1.3,95%CI=1.03-1.22) as the only two variables independently associated with the development of an infection..
2.30genera,88species and1017strains were obtained from the blood cultures in patients with liver cirrhosis, including1014-strain aerobic isolates (99.7%),0anaerobic isolates (0.0%) and3fungi (0.3%). The most common pathogens were Escherichia coli(308strains), coagulase-negative Staphylococcus(245strains), and Klebsiella spp.(102strains), streptotococcus spp.(78strains), and staphylococcus aus(36strains). Compared with the data of2001-2004, there was a big decrease of the rate of gram-negtive bacteria(P=0.0469). ESBLs-producing rate in E coli had an markable increase (P<0.0001)
3. A total of123non-duplicate clinical isolates of E coli were consecutively collected from liver cirrhosis patients with bloodstream infection.62clinical isolates were detected to produce CTX-M type ESBLs. there were31CTX-M-1group and37CTX-M-9group, including6stains habouring both CTX-M-1and CTX-M-9group. Eight CTX-M genotypes were confirmed by sequencing of the PCR products, including CTX-M-3, CTX-M-14, CTX-M-15, CTX-M-24, CTX-M-28, CTX-M-31, CTX-M-65and CTX-M-79. Previous antibiotic treatment, previous beta-lactamase antibiotic treatment,and nosco were the independent risk factor for bacteremia due to ESBLs-producing E coli (OR=4.184,95%CI=1.697-10.3, OR=4.365,95%CI=1.611-11.83, and OR=5.333,95%CI=1.850-15.37, respectively). nosocomial infection, septic shock, encephalopathy, and renal impired t reatment were the independent risk factors for higher mortality rate (OR=9.128,95%CI=1.850-15.37, OR=14.55,95%CI=4.428-14.78, OR=5.143,95%CI=1.913-13.82, and OR=4.136,95%CI=1.374-12.46, respectively).
CONCLUSIONS:
1. Our present study indicates that patients with liver cirrhosis who are admitted for gastrointestinal bleeding and low serum albumin level have a higher risk of developing a infection during their hospitalization than other cirrhotic patients.
2. The most common pathogens isolated from blood cultures in patients with liver cirrhosis were gram-negtive bacteria. But the rate of ESBLs-producing E coli was higher than the data of2001-2004.
3. The dominant genotype of ESBLs produced by E coli isolated from bloodstream infection in patients with liver cirrhosis were CTX-M. Quick detection and early appropriate antibiotic treatment and prevention are urgently needed for ESBLs-producing E coli bacterimia in patients with cirrhosis.
研究目的
1.调查肝硬化住院患者的感染率,评估感染的危险因素。
2.分析肝硬化住院患者血液感染主要致病菌谱及耐药状况,并与2001-2004年资料比较,发现变化规律。
3.研究肝硬化住院患者血液感染的产超广谱β内酰胺酶大肠埃希菌耐药基因型、感染危险因素及愈后相关因素。
研究内容和方法
1.采用横断面研究,连续收集420例肝硬化住院患者,查阅患者相关临床资料、实验室及影像学检查资料,采用单因素分析、逻辑回归分析等方法分析患者感染相关因素和独立危险因素。
2.采用全自动微生物培养和鉴定技术,我们对2009年至2011年连续三年共1017株分离菌进行分布和药敏情况进行分析,并与本实验室2001-2004年的资料进行动态比较。
3.采用病例对照研究、多重PCR、PCR.测序及比对等,对2011年123株肝硬化血液感染的大肠埃希菌超广谱β内酰胺酶基因型进行分析；使用单因素分析、多因素分析和逻辑回归分析比较产超广谱β内酰胺酶和不产酶组的可能危险因素及独立危险因素。
研究结果
1.通过调查统计肝硬化住院患者感染率20%,最常见感染是自发性细菌性腹膜炎(32%),其他依次为呼吸道感染(18%)、血液感染(14%)和泌尿系感染(11%),怀疑感染没有微生物证据的占25%。单因素分析显示低白蛋白血症、胃肠道出血、入住重症监护病房和进行内窥镜治疗可能与感染相关；逻辑回归分析显示胃肠道出血和低白蛋白血症是肝硬化住院患者感染独立危险因素。
2.共检出30个属,88个种1017株菌(同一患者不记重复菌株),其中需氧菌1014株,占99.7%；真菌3株,占0.3%；革兰氏阴性菌591株,占58.1%；革兰氏阳性菌423株,占41.6%；排在前五位的细菌是：大肠埃希菌(308株)凝固酶阴性葡萄球菌(245株),克雷伯菌属(102株),链球菌(78株),金黄色葡萄球菌(36株)。与2001年—2004年血培养结果相比,革兰氏阴性菌的比例降低(58.1%vs.71.5%,P=0.0469)；大肠埃希菌产ESBLs比率明显升高(50.4%vs.18.0%,P<0.0001)。
3.连续收集123株大肠埃希菌,共有62株菌产超广谱β内酰胺酶；均为CTX-M型超广谱β内酰胺酶,CTX-M-1群31株,CTX-M-9群37株,其中有6株菌同时产两群CTX-M型,测序比对出CTX-M-3、CTX-M-15、CTX-M-14等八种基因型。与未产酶大肠埃希菌血液感染组相比,产超广谱β内酰胺酶大肠埃希菌感染组预防使用抗生素特别是β内酰胺酶类抗生素更多(P＝0.0018和P=0.0036),院内感染比例更高(P=0.0014),导致的死亡更多(P=0.0152)；单因素分析发现死亡组感染性休克(10/21vs.6/102,P<0.0001)、肝性脑病(12/21vs.21/102,P=0.0006)和肾功能受损(P=0.0078)等比例高于存活组；逻辑回归分析发现,预用抗生素和预用头孢类抗生素均为产ESBLs大肠埃希菌血液感染肝硬化住院患者的独立危险因素(OR=4.184,95%CI=1.697-10.32和OR=4.365,95%CI=1.611-11.83)；院内感染也是产ESBLs的独立危险因素(OR=5.333,95%CI=1.850-15.37)。对于患者的愈后经逻辑回归分析：院内感染(OR=9.128,95%CI=1.850-15.37)、感染性休克(OR=14.55,95%CI=4.428-14.78).肝性脑病(OR=5.143,95%CI=1.913-13.82)和肾功能受损(OR=4.136,95%CI=1.374-12.46)都是影响愈后的独立危险因素。
结论
1.本研究发现：胃肠道出血和低白蛋白血症导致肝硬化住院患者感染独立危险因素。
2.与以前监测结果相比,肝硬化住院患者血液感染的细菌仍然以革兰氏阴性菌为主,但是比例下降；大肠埃希菌产超广谱β内酰胺酶比例显著升高。
3.肝硬化住院患者血液感染大肠埃希菌产超广谱β内酰胺酶主要基因型为CTX-M型；慎重预用抗生素,加强对重症肝病患者的管理。
BACKGROUND
There were500,000individuals in the world die each year from liver cirrhoses and the numbers are increasing steadily. Liver cirrhosis is now the fifth most common cause of death after heart disease, stroke, chest disease and cancer. However, unlike other major causes of mortality, liver cirrhosis rates are increasing rather than declining. For hepatologists worldwide, there have never been more challenges faced. Cirrhosis is considered an immunocompromised state that leads to a variety of infections, which then account for an approximate30%-50%mortality. Bacterial infections occer in32%to34%of admitted patients with cirrhosis. Apart from early recognition and better treatment of spontaneous bacterial peritonitis (SBP) leading to better survival, there has been little improvement in overall survival rates in recent decades:infections still account for a4-fold increase in mortality among patients with cirrhosis. There are many data about the infections risk factors, independent risk facters, distrabution of pathogens, antibiotics resistence spectrum of patients with cirrhosis in different countries and parts worldwide. But the data were not same. But there were no data on distribution fo infections, pathogen and bacterial resistence spectrum of bloodstream infection, and E. coli bacterimia in patients with cirrhosis in China. These data are necessary to help docters prevention, early diagnosis, and proper management of these infections to improve survival.
AIM
1. To investigate the infection rate in hospitalized patients with liver cirrhosis and to assess the risk facors of infections.
2. To analyze the spectrum of bacteria and bacterial resistence in hospitalized patients with liver cirrhosis. To find changes by comparing the data from2001to2004.
3. To identify the risk factors for bloodstream infections caused by extended-spectrum beta-lactamase(ESBLs)-producing Escherichia coli in hospitalized patients with liver cirrhosis and the associated clinical outcomes of bacteremia..
METHODS
1. The prospective study was performed to assess the risk of bacterial infection in420hospitalized patients with liver cirrhosis. The data collected included age, gender, etiology of liver disease, reason for admission, admission site, origin of admission, endoscopic sclerotherapy or banding, variables of the Child-Pugh score (serum bilirubin and albumin, prothrombin time, degree of ascites, and encephalopathy), timing of bacterial infection after hospitalization, duration of hospitalization, and discharge status (alive vs dead). Univariate Analysis and logistic regression were used to analyse the risk fachors and independent risk factors of infections.
2. Auto bacterial culture system and identification system were performed to analyze the spectrum of1017bacteria and the antibiotic resistence. The changes of spectrum of bacteria and bacterial resistence were found by comparing with the data of2001to2004.
3.62ESBLs-producing E coli were genotyped by multi-PCR, PCR, sequancing and blast. Case control research was performed. Risk facters and independent risk factors were analyzed by univariate analysis, multivariate analysis, and logistic regression between research group and control group.
RESULTS
1. Twenty-eight (20%) patients developed an infection during their hospitalization. of Spontaneous bacterial peritonitis (32%) were the most common infections. Univariate analysis showed that patients who developed an infection were more likely to have a low serum albumin level, gastrointestinal bleeding, to stay in the intensive care unit, and to undergo therapeutic endoscopy. Logistic regression identified gastrointestinal bleeding (OR=4.3,95%CI=1.7-10.9) and a low serum albumin (OR=1.3,95%CI=1.03-1.22) as the only two variables independently associated with the development of an infection..
2.30genera,88species and1017strains were obtained from the blood cultures in patients with liver cirrhosis, including1014-strain aerobic isolates (99.7%),0anaerobic isolates (0.0%) and3fungi (0.3%). The most common pathogens were Escherichia coli(308strains), coagulase-negative Staphylococcus(245strains), and Klebsiella spp.(102strains), streptotococcus spp.(78strains), and staphylococcus aus(36strains). Compared with the data of2001-2004, there was a big decrease of the rate of gram-negtive bacteria(P=0.0469). ESBLs-producing rate in E coli had an markable increase (P<0.0001)
3. A total of123non-duplicate clinical isolates of E coli were consecutively collected from liver cirrhosis patients with bloodstream infection.62clinical isolates were detected to produce CTX-M type ESBLs. there were31CTX-M-1group and37CTX-M-9group, including6stains habouring both CTX-M-1and CTX-M-9group. Eight CTX-M genotypes were confirmed by sequencing of the PCR products, including CTX-M-3, CTX-M-14, CTX-M-15, CTX-M-24, CTX-M-28, CTX-M-31, CTX-M-65and CTX-M-79. Previous antibiotic treatment, previous beta-lactamase antibiotic treatment,and nosco were the independent risk factor for bacteremia due to ESBLs-producing E coli (OR=4.184,95%CI=1.697-10.3, OR=4.365,95%CI=1.611-11.83, and OR=5.333,95%CI=1.850-15.37, respectively). nosocomial infection, septic shock, encephalopathy, and renal impired t reatment were the independent risk factors for higher mortality rate (OR=9.128,95%CI=1.850-15.37, OR=14.55,95%CI=4.428-14.78, OR=5.143,95%CI=1.913-13.82, and OR=4.136,95%CI=1.374-12.46, respectively).
CONCLUSIONS:
1. Our present study indicates that patients with liver cirrhosis who are admitted for gastrointestinal bleeding and low serum albumin level have a higher risk of developing a infection during their hospitalization than other cirrhotic patients.
2. The most common pathogens isolated from blood cultures in patients with liver cirrhosis were gram-negtive bacteria. But the rate of ESBLs-producing E coli was higher than the data of2001-2004.
3. The dominant genotype of ESBLs produced by E coli isolated from bloodstream infection in patients with liver cirrhosis were CTX-M. Quick detection and early appropriate antibiotic treatment and prevention are urgently needed for ESBLs-producing E coli bacterimia in patients with cirrhosis.
引文
1. Roger Williams. Global Challenges in Liver Disease. Hepatology.2006 Sep;44(3):521-6.
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2. Bonnel AR, Bunchorntavakul C, Reddy KR. Immune dysfunction and infections in patients with cirrhosis. Clin Gastroenterol Hepatol 2011; 9: 727-738.
3. Wong F, Bernardi M, Balk R, et al. Sepsis in cirrhosis:report on the 7th meeting of the International Ascites Club. Gut 2005; 54:718-725.
4. Borzio M, Salerno F, Piantoni L, et al. Bacterial infection in patients with advanced cirrhosis:a multicentre prospective study. Dig Liver Dis 2001; 33: 41-48.
5. Fernandez J, Navasa M, Gomez J, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology 2002; 35:140-148
6. Arvaniti V, D'Amico G, Fede G, et al. Infections in patients with cirrhosis increase mortality 4-fold and should be used in determining prognosis. Gastroenterology 1256;2010:1246-1256,e1241-e1245.
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17. Mathurin S, Chapelet A, Spanevello V et al.Infections in hospitalized patients with cirrhosis. Medicina (B Aires).2009;69(2):229-38.
18. Borzio M, Salerno F, Piantoni L, et al. Bacterial infection in patients with advanced cirrhosis:a multicentre prospective study. Dig Liver Dis.2001 Jan-Feb;33(1):41-8.
19. de Mattos AA, Coral GP, Menti E et al. Arq Gastroenterol. Bacterial infection in cirrhotic patient.2003 Jan-Mar;40(1):11-5.
20. Chen SY, Tsai CL, Lin CH, et al. Impact of liver cirrhosis on mortality in patients with community-acquired bacteremia. Diagn Microbiol Infect Dis. 2009 Jun;64(2):124-30.
21. Hortiwakul T, Nagij S, Chusri S, et al. Nosocomial bloodstream infection in Songklanagarind Hospital:outcome and factors influencing prognosis. J Med Assoc Thai.2012 Feb;95(2):170-4.
22. Caly WR, Strauss E. A prospective study of bacterial infections in patients with cirrhosis. J Hepatol.1993;18:353-358.
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27. Mathurin S, Chapelet A, Spanevello V et al. Infections in hospitalized patients with cirrhosis. Medicina (B Aires).2009;69(2):229-38.
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32. Yakar T, Guclu M, Serin E, et al. A recent evaluation of empirical cephalosporin treatment and antibiotic resistance of changing bacterial profiles in spontaneous bacterial peritonitis. Dig Dis Sci 2010;55:1149-1154.
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