The prognostic risk factors of gram-negative bacterial bloodstream infection in the Intensive Care Unit
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摘要: 目的 探求导致ICU内革兰阴性菌血流感染(BSI)患者预后的危险因素。方法 纳入2013年1月1日-2019年12月31日期间于我院ICU收治的革兰阴性菌BSI患者163例，按28 d内患者的死亡情况，将其分为生存组和死亡组。研究两组患者的临床特点，进一步分析影响革兰阴性菌BSI患者28 d病死率的相关危险因素。结果 163例革兰阴性菌BSI患者中，生存组82例(50.3%)，死亡组81例(49.7%)。具体病原菌分布情况如下：肺炎克雷伯菌52例(31.9%)，大肠埃希菌45例(27.6%)，鲍曼不动杆菌35例(21.5%)，铜绿假单胞菌7例(4.3%)，嗜麦芽窄食单胞菌例(3.7%)，洋葱伯克霍尔德菌5例(3.1%)。单因素分析结果显示：生存组和死亡组中的年龄、住院时间、鲍曼不动杆菌BSI、大肠埃希菌BSI、多重耐药菌、恰当的抗感染治疗、机械通气、消化道出血、感染性休克、APACHEⅡ评分、SOFA评分、肌酐、尿素氮、估算的肾小球滤过率(eGFR)、动脉血乳酸差异有统计学意义(P< 0.05)。多因素logistic回归分析显示，年龄(OR=1.072，95%CI1.026~1.121，P=0.002)、住院时间(OR=0.923，95%CI0.923~0.985，P=0.004)、多重耐药菌(OR=6.399，95%CI1.203~34.037，P=0.030)、不恰当的抗感染治疗(OR=18.471，95%CI2.827~120.686，P=0.002)、发生感染性休克(OR=5.865，95%CI1.176~29.255，P=0.031)、SOFA评分(OR=1.934，95%CI1.368~2.734，P< 0.001)是影响ICU革兰阴性菌血流感染28 d病死率的独立危险因素。结论 高龄、发生感染性休克、高SOFA评分、多重耐药菌、不恰当的经验性抗感染治疗为ICU内革兰阴性菌血流感染预后的独立危险因素Abstract: Objective To explore the prognostic risk factors of patients with gram-negative bacterial bloodstream infection(BSI) in the Intensive Care Unit(ICU).Methods One hundred and sixty-three patients with gram-negative BSI treated in ICU of our hospital from January 1, 2013 to December 31, 2019 were included. According to whether the patients died or not within 28 days, they were divided into two groups: survival group and death group. The clinical characteristics of the two groups were studied, and the relevant risk factors affecting the 28 day mortality of patients with gram-negative BSI were further analyzed.Results Among 163 patients with gram-negative BSI, 82 cases(50.3%) were in the survival group and 81 cases(49.7%) were in the death group. The distribution of specific pathogens was as follows: 52 cases of Klebsiella pneumoniae(31.9%), 45 cases of Escherichia coli(27.6%), 35 cases of Acinetobacter baumannii(21.5%), 7 cases of Pseudomonas aeruginosa(4.3%), 6 cases of Stenotrophomonas maltophilia(3.7%), and 5 cases of Burkholderia cepacia(3.1%). Univariate analysis showed that there were significant differences in age, length of hospital stay, Acinetobacter baumannii BSI, Escherichia coli BSI, multidrug resistant bacteria, appropriate anti infection treatment, mechanical ventilation, gastrointestinal bleeding, septic shock, Apache Ⅱ score, SOFA score, creatinine, urea nitrogen, estimated glomerular filtration rate (eGFR) and arterial blood lactic acid between the survival group and the death group (P< 0.05).Multivariate logistic regression analysis showed that age(OR=1.072, 95%CI1.026-1.121,P=0.002), length of hospital stay(OR=0.923, 95%CI0.923-0.985,P=0.004), multidrug resistant bacteria(OR=6.399, 95%CI1.203-34.037,P=0.030), inappropriate anti infective treatment(OR=18.471, 95%CI2.827-120.686,P=0.002) Septic shock(OR=5.865, 95%CI1.176-29.255,P=0.031) and SOFA score(OR=1.934, 95%CI1.368-2.734,P< 0.001) were independent risk factors affecting the 28 day mortality of gram-negative bacterial bloodstream infection in ICU.Conclusion Old age, septic shock, high SOFA score, multi drug resistant bacteria and inappropriate empirical anti infection treatment are independent risk factors for the prognosis of gram-negative bacterial bloodstream infection in ICU.
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Key words:
- intensive care unit /
- gram-negative bacteria /
- bloodstream infection /
- risk factors
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表 1 患者一般资料的单因素分析
X±S，例(%)，M(P25，P75) 指标 所有患者(163例) 生存组(82例) 死亡组(81例) 统计值 P 性别 男 102(62.57) 50(60.97) 52(64.20) 0.181 0.671 女 61(37.43) 32(39.03) 29(35.80) 年龄/岁 57.68±17.57 54.76±1.84 60.94±2.01 5.730 0.017 住院时间/d 21(11，39) 25.5(15.00，44.00) 18.00(6.00，24.00) 14.289 < 0.001 住ICU时间/d 10(5，20) 10.00(5.00，19.25) 11.00(5.00，19.25) 0.056 0.812 基础疾病 139(85.3) 67(81.7) 72(88.9) 1.674 0.196 外科手术 83(51.0) 47(57.3) 36(44.4) 2.702 0.100 有创机械通气 132(81.0) 56(68.3) 76(93.8) 17.251 < 0.001 静脉置管 126(77.3) 63(76.8) 63(77.8) 0.021 0.885 CRRT 30(18.4) 12(14.6) 18(22.2) 1.562 0.211 消化道出血 29(17.8) 9(11.0) 20(24.7) 5.241 0.022 感染性休克 57(35.0) 23(28.0) 34(42.0) 22.989 < 0.001 APACHE Ⅱ 18(13，26) 15(12，20) 24(17，30) 34.698 < 0.001 SOFA 8(5，11) 6(4，8) 10(8，14) 48.344 < 0.001 
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表 2 实验室指标的单因素分析
M(P25，P75) 实验室指标 生存组(82例) 死亡组(81例) 统计值 P 白细胞/(×109·L-1) 12.15(8.48，19.34) 10.26(5.71，16.37) 3.442 0.064 淋巴细胞/(×109·L-1) 0.78(0.46，1.18) 0.6(0.37，1.30) 3.060 0.080 血小板/(×109·L-1) 88.00(38.75，160.75) 119.00(53.00，184.50) 1.930 0.165 CRP/(mg·L-1) 117.20(62.89，213.13) 104.12(38.83，166.16) 2.910 0.088 PCT/(ng·mL-1) 22.58(2.05，72.77) 12.41(1.26，59.24) 1.728 0.189 总胆红素/(μmol·L-1) 18.55(11.54，28.91) 19.30(10.30，43.47) 0.000 0.987 谷丙转氨酶/(U·L-1) 40.00(25.75，84.00) 38.00(26.50，86.50) 0.046 0.830 谷草转氨酶/(U·L-1) 48.00(27.00，103.25) 61.00(28.50，149.50) 0.488 0.485 前白蛋白/(mg·L-1) 114.26(52.75，187.50) 95.36(52.96，155.00) 1.174 0.278 白蛋白/(g·L-1) 29.25(25.90，35.28) 28.70(24.50，33.30) 1.025 0.311 血尿素氮(mmol·L-1) 10.40(6.83，15.31) 13.90(8.06，21.91) 7.184 0.007 血肌酐/(μmol·L-1) 97.45(68.73，149.93) 122.70(79.35，241.85) 5.839 0.016 eGFR/(mL·min-1·1.73m-2) 75.50(48.50，100.39) 57.00(23.00，95.50) 4.195 0.041 动脉血乳酸/(mmol·L-1) 2.50(1.41，4.56) 3.33(1.46，6.86) 4.066 0.044
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表 3 微生物学结果及经验性抗感染治疗比较分析
例(%) 病原菌及治疗 生存组(例82) 死亡组(81例) 统计值 P 肺炎克雷伯菌 23(28.0) 29(35.8) 1.128 0.288 大肠埃希菌 31(37.8) 14(17.3) 8.586 0.003 鲍曼不动杆菌 12(14.6) 23(28.4) 4.576 0.032 铜绿假单胞菌 5(6.1) 2(2.5) 1.305 0.253 嗜麦芽窄食单胞菌 4(4.9) 2(2.5) 0.667 0.414 洋葱伯克霍尔德菌 2(2.4) 3(3.7) 0.219 0.640 其他革兰阴性菌 5(6.1) 8(9.9) 0.793 0.373 耐药性及抗感染治疗 多重耐药菌 33(40.2) 57(70.4) 14.956 < 0.001 恰当的抗生素治疗 53(64.6) 30(37.0) 12.418 < 0.001
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表 4 Logistic多元回归分析
变量 β SE Wald P OR 95%CI 年龄 0.070 0.023 9.526 0.002 1.072 1.026~1.121 住院时间 0.048 0.016 8.307 0.004 0.954 0.923~0.985 鲍曼不动杆菌BSI 0.508 0.754 0.454 0.501 1.661 0.379~7.277 大肠埃希菌BSI 1.064 0.827 1.656 0.198 0.345 0.068~1.745 多重耐药菌 1.856 0.853 4.738 0.030 6.399 1.203~34.037 恰当的抗感染治疗 2.916 0.958 9.273 0.002 18.471 2.827~120.686 机械通气 0.929 0.864 1.156 0.282 2.531 0.466~13.758 消化道出血 0.677 0.934 0.526 0.468 1.969 0.316~12.272 感染性休克 1.769 0.820 4.654 0.031 5.865 1.176~29.255 APACHE Ⅱ 0.001 0.051 0.000 0.984 0.999 0.905~1.103 SOFA 0.660 0.177 13.941 < 0.001 1.934 1.368~2.734 BUN 0.072 0.054 1.741 0.187 1.074 0.966~1.195 肌酐 0.004 0.004 1.124 0.289 0.996 0.987~1.004 eGFR 0.007 0.012 0.348 0.555 1.007 0.983~1.032 动脉血乳酸 0.090 0.119 0.568 0.451 1.094 0.866~1.383
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