肝硬化合并医院耐碳青霉烯类肠杆菌科细菌血流感染患者临床特点及预后的研究

目的 探讨肝硬化合并医院耐碳青霉烯类肠杆菌科细菌(carbapenem-resistant Enterobacteriaceae，CRE)血流感染(bloodstream infection，BSI)患者的临床特征及预后。方法 运用电子数据库选取解放军总医院第五医学中心2013年1月至2017年12月某重症肝病科室收治的174例肝硬化合并医院肠杆菌科细菌BSI患者。分析CRE-BSI患者临床特征及预后。根据30d预后将所有患者分为生存和死亡两组，应用Logistic回归分析CRE感染是否是影响肝硬化合并医院肠杆菌科细菌BSI患者预后的危险因素。结果 46例(26.4%)为CRE-BSI患者，128例(73.6%)为碳青霉烯类敏感肠杆菌科细菌(carbapenem-sensitive Enterobacteriaceae，CSE)BSI患者。肺炎克雷伯菌(27株)是肝硬化合并CRE-BSI最常见病原菌。CRE-BSI组发生脓毒症30例(65.2%)。发生感染时，CRE-BSI组男性比例、脓毒症发生率、ALB、Cre、CRP、肺炎克雷伯菌比例均高于CSE-BSI组(P均＜0.05)；CRE-BSI组WBC、大肠埃希菌比例均低于CSE-BSI组(P均＜0.05)。CRE-BSI组哌拉西林、哌拉西林/三唑巴坦、氨曲南、头孢唑林、头孢呋辛、头孢替坦、头孢他啶、头孢曲松、头孢吡肟、亚胺培南、美罗培南、左氧氟沙星、环丙沙星、呋喃妥因、复方磺胺甲噁唑、庆大霉素、阿米卡星耐药率均高于CSE-BSI组(P均＜0.05)。CRE-BSI组30d死亡率(71.7%)显著高于CSE-BSI组(24.2%)(χ2=32.863，P<0.001)。多变量Logistic回归显示脓毒症、CRE感染是影响肝硬化合并医院肠杆菌科细菌BSI患者30d预后的独立性危险因素。结论 肝硬化合并医院CRE-BSI患者存在高脓毒症发生率、高抗菌药物耐药率和高30d死亡率。CRE感染与肝硬化合并医院肠杆菌科细菌BSI患者的预后密切相关。

The study on clinical characteristics and prognosis of patients with liver cirrhosis complicated with nosocomial carbapenem-resistant Enterobacteriaceae bloodstream infection

Objective To investigate the clinical characteristics and prognosis of patients with liver cirrhosis complicated with nosocomial carbapenem-resistant Enterobacteriaceae (CRE) bloodstream infection (BSI). Methods 174 patients with liver cirrhosis complicated with nosocomial Enterobacteriaceae BSI in a severe liver disease department of the Fifth Medical Center of Chinese PLA General Hospital were selected using electronic database fromJanuary 2013 to December 2017. The clinical characteristics and prognosis of patients with liver cirrhosis complicated with CRE-BSI were analyzed. All patients were divided into a survival group and a death group according to the 30-day prognosis. Logistic regression analysis was used to analyze whether the CRE infection is a risk factor for the prognosis of patients with liver cirrhosis complicated with nosocomial Enterobacteriaceae BSI. Results 46 cases (26.4%) were CRE-BSI patients, and 128 cases (73.6%) were carbapenem-sensitive Enterobacteriaceae (CSE) BSI patients. Klebsiella pneumoniae (27 strains) was the most common pathogen of patients with liver cirrhosis complicated with CRE-BSI. 30 cases (65.2%) of sepsis occurred in the CRE-BSI group. When BSI occurs, the proportions of males, sepsis, and Klebsiella pneumoniae, the levels of ALB, Cre, and CRP in the CRE-BSI group were higher than those in the CSE-BSI group (P<0.05). The levels of WBC and the proportions of Escherichia coli in CRE-BSI group was lower than those in the CSE-BSI group (P<0.05). The resistance rates against piperacillin, piperacillin tazobactam, aztreonam, cefazolin, cefuroxime, cefotetan, ceftazidime, ceftriaxone, cefepime, imipenem, meropenem, levofloxacin, ciprofloxacin, nitrofurantoin, cotrimoxazole, gentamicin and amikacin in the CRE-BSI group were higher than those in CSE-BSI group (P<0.05). The 30-day mortality rates of patients were significantly higher in the CRE-BSI group (71.7%) than in the CSE-BSI group (24.2%) (χ2 =32.863, P<0.001). Multivariate logistic regression analysis showed that sepsis and CRE infection were independent risk factors for 30-day prognosis of patients with liver cirrhosis complicated with Enterobacteriaceae BSI. Conclusion Patients with liver cirrhosis complicated with nosocomial CRE-BSI had high proportions of sepsis, high resistance rates against antibiotics, and high 30-day mortality rates. The CRE infection was closely related to the prognosis of patients with liver cirrhosis complicated with nosocomial Enterobacteriaceae