脓毒症早期肠道菌群失调相关危险因素及其对预后的影响

目的分析脓毒症早期肠道菌群失调的相关危险因素以及其对患者预后的影响。 方法回顾性分析2017年10月至2019年9月江苏大学附属人民医院重症医学科收治的256例脓毒症患者的临床资料，依据入院第7天的粪便菌群分析结果以及肠道菌群失调严重程度将患者分为正常肠道菌群组（对照组，75例）、Ⅰ度失调组（34例）、Ⅱ度失调组（80例）和Ⅲ度失调组（67例）。收集患者急性病生理学和长期健康评价Ⅱ评分、基础病史、感染部位、白细胞计数、血小板计数、内毒素水平，以及患者使用抗生素、质子泵抑制剂、全肠外营养等情况；采用多因素Logistic回归分析影响肠道菌群失调的危险因素；采用Kaplan-Meier生存曲线分析4组患者肠道菌群失调与脓毒症预后的关系。 结果对照组、Ⅰ度失调组、Ⅱ度失调组及Ⅲ度失调组患者内毒素[（0.15 ± 0.11）、（0.14 ± 0.12）、（0.24 ± 0.11）、（0.26 ± 0.13）EU/mL，t = 16.317，P < 0.001]、质子泵抑制剂[42.7%（32/75）、41.2%（14/34）、71.2%（57/80）、74.6%（50/67），χ² = 24.547，P < 0.001]、全肠外营养[5.3%（4/75）、17.6%（6/34）、33.8%（27/80）、28.4%（19/67），χ² = 20.613，P < 0.001]、血管活性药物[28.0%（21/75）、26.5%（9/34）、57.5%（46/80）、50.7%（34/67），χ² = 19.181，P < 0.001]和糖尿病[16.0%（12/75）、14.7%（5/34）、38.8%（31/80）、38.8%（26/67），χ² = 16.383，P = 0.001]比较，差异均有统计学意义。将内毒素、质子泵抑制剂、全肠外营养、血管活性药物及糖尿病等因素纳入多因素Logistic回归分析，结果显示，内毒素[比值比（OR）= 3.749，95%置信区间（CI）（1.998，7.034），P < 0.001]和糖尿病[OR = 2.567，95%CI（1.272，5.180），P = 0.009]是脓毒症患者肠道菌群失调的独立危险因素。4组脓毒症患者28 d累计生存率比较，差异有统计学意义（χ² = 30.088，P < 0.001），且Ⅱ度失调组和Ⅲ度失调组患者的28 d累积生存率均显著低于对照组（χ² = 14.511、31.671，P均< 0.001），Ⅲ度失调组患者的28 d累积生存率显著低于Ⅰ度失调组（χ² = 8.059，P = 0.005）。 结论内毒素和糖尿病是脓毒症早期患者肠道菌群失调的独立危险因素，并且发生Ⅱ度或Ⅲ度肠道菌群失调提示预后更差。

Risk factors for intestinal dysbacteriosis in early stage of sepsis and its effect on prognosis

ObjectiveTo investigate risk factors for intestinal dysbacteriosis in the early stage of sepsis and its impact on patient's prognosis. MethodsThe clinical data of 256 patients with sepsis admitted to the Department of Critical Care Medicine of the Affiliated People's Hospital of Jiangsu University from October 2017 to September 2019 were retrospectively analyzed. According to the results of fecal flora analysis and the severity of intestinal dysbacteriosis on the 7th day of admission, patients were divided into a normal intestinal flora group (control group, 75 patients), a Ⅰ disorder group (34 patients), a Ⅱ disorder group (80 patients) and a Ⅲ disorder group (67 patients). Their acute physiology and chronic health evaluation Ⅱ score, basic medical history, infection site, leukocyte count, platelet count, endotoxin level, and use of antibiotics, proton pump inhibitors and total parenteral nutrition were collected. Then risk factors for intestinal dysbacteriosis were analyzed by the multivariate Logistic regression, and a Kaplan-Meier survival curve was used to analyze the relationship between patient's intestinal dysbacteriosis and prognosis in the four groups. ResultsThe level of endotoxin [(0.15 ± 0.11), (0.14 ± 0.12), (0.24 ± 0.11), (0.26 ± 0.13) EU/mL; t = 16.317, P < 0.001], use of proton pump inhibitors [42.7% (32/75), 41.2% (14/34), 71.2% (57/80), 74.6% (50/67); χ² = 24.547, P < 0.001], use of total parenteral nutrition [5.3% (4/75), 17.6% (6/34), 33.8% (27/80), 28.4% (19/67); χ² = 20.613, P < 0.001], use of vasoactive drugs [28.0% (21/75), 26.5% (9/34), 57.5% (46/80), 50.7% (34/67); χ² = 19.181, P < 0.001] and history of diabetes mellitus [16.0% (12/75), 14.7% (5/34), 38.8% (31/80), 38.8% (26/67); χ² = 16.383, P = 0.001] of patients were statistically significantly different in the four groups. Then endotoxin, proton pump inhibitors, total parenteral nutrition, vasoactive drugs and diabetes mellitus were included in the multivariate Logistic regression analysis. The results showed that endotoxin [odds ratio (OR) = 3.749, 95% confidence interval (CI) (1.998, 7.034), P < 0.001] and diabetes mellitus [OR = 2.567, 95%CI (1.272, 5.180), P = 0.009] were independent risk factors for intestinal dysbacteriosis in sepsis patients. The 28-d cumulative survival rate of patients was statistically significantly different in the four groups (χ² = 30.088, P < 0.001). It was significantly lower in the Ⅱ and Ⅲ disorder groups than in the control group (χ² = 14.511, 31.671; both P < 0.001), and it was significantly lower in the Ⅲ disorder group than in the Ⅰ disorder group (χ² = 8.059, P = 0.005). ConclusionEndotoxin and diabetes mellitus are independent risk factors for intestinal dysbacteriosis in patients with early sepsis, and the occurrence of Ⅱ or Ⅲ degree intestinal dysbacteriosis suggests a worse prognosis.