恶性血液病合并血流感染患者病原菌分布及其预后影响因素

Distribution of pathogenic bacteria and factors affecting prognosis of patients with malignant hematological diseases complicated with blood stream infection

摘要:

目的 分析恶性血液病合并血流感染患者的病原学特征及其预后影响因素。 方法 选取2016年1月-2022年5月遵义医科大学附属医院血液内科的恶性血液病合并血流感染的住院患者为研究对象。根据患者发生血流感染30 d内的治疗结局分为生存组和死亡组。分析患者的病原学特征及预后情况, 并采用单因素及logistic回归分析影响恶性血液病合并血流感染预后的危险因素。 结果 共纳入185例患者, 基础疾病以急性白血病为主(125例, 67.6%)。共分离197株病原菌, 革兰阴性菌109株(55.3%), 其中大肠埃希菌55株(27.9%); 革兰阳性菌86株(43.7%), 其中人葡萄球菌24株(12.2%); 真菌2株(1.0%)。大肠埃希菌中产超广谱β-内酰胺酶(EBSLs)菌株28株(50.9%); 肺炎克雷伯菌中产EBSLs菌株2株(10.0%); 耐甲氧西林的人葡萄球菌、表皮葡萄球菌、金黄色葡萄球菌的检出率分别为70.8%、71.4%、36.4%。单因素分析表明, 年龄≥70岁、粒细胞缺乏持续时间≥7 d、未合理使用抗菌药物、合并心功能不全、合并急性肾功能不全、感染性休克、肺部感染患者的30天病死率较高, 差异均有统计学意义(均P < 0.05)。多因素logistic回归分析表明, 粒细胞缺乏持续时间≥7 d[OR=3.306, 95%CI(1.224~8.927)]、合并心功能不全[OR=6.291, 95%CI(1.930~20.508)]、合并急性肾功能不全[OR=8.419, 95%CI(2.198~32.241)]、感染性休克[OR=22.150, 95%CI(3.639~134.806)]均为恶性血液病合并血流感染患者30天内死亡的独立危险因素(均P < 0.05)。 结论 恶性血液病合并血流感染最常见的病原菌中, 革兰阴性菌以大肠埃希菌为主, 革兰阳性菌以人葡萄球菌为主。影响恶性血液病合并血流感染患者预后的危险因素较多, 缩短粒细胞缺乏持续时间, 改善心功能不全、肾功能不全, 积极控制感染性休克是减少恶性血液病合并血流感染患者30天内死亡的有效措施。

关键词:恶性血液病;血流感染;病原菌;预后;危险因素

Abstract:

Objective To analyze the pathogenic characteristics and affecting factors for prognosis of patients with malignant hematological diseases complicated with blood stream infection (BSI). Methods Hospitalized patients with malignant hematological diseases complicated with BSI in the Department of Hematology in Affiliated Hospital of Zunyi Medical University between January 2016 and May 2022 were selected as the study subjects.Patients were divided into survival group and death group according to the treatment outcome within 30 days after BSI.Pathogenic characteristics and prognosis of patients were analyzed, risk factors for the prognosis of malignant hematological diseases complicated with BSI were analyzed by univariate and logistic regression. Results A total of 185 patients were included in study, the main underlying disease was acute leukemia (n=125, 67.6%).197 strains of pathogenic bacteria were isolated, 109 strains (55.3%) were Gram-negative bacteria, 55(27.9%) of which was Escherichia coli; 86 strains (43.7%) were Gram-positive bacteria, 24(12.2%) of which were Staphylococcus hominis; 2 strains were fungi (1.0%).28 strains (50.9%) of Escherichia coli and 2 strains (10.0%) of Klebsiella pneumoniae produced extended-spectrum β-lactamases.Isolation rates of methicillin-resistant coagulase negative staphylococcus, methicillin-resistant Staphylococcus epidermidis and methicillin-resistant Staphylococcus aureus were 70.8%, 71.4% and 36.4% respectively; univariate analysis showed that 30-day mortality was higher in patients with age ≥ 70 years, duration of agranulocytosis ≥ 7 days, irrational use of antimicrobial agents, combined with cardiac insufficiency, combined with acute renal insufficiency, septic shock and pulmonary infection, diffe-rences were all significant (all P < 0.05).Multivariate logistic regression analysis showed that duration of agranulocytosis ≥ 7 days (OR=3.306, 95%CI[1.224-8.927]), combined with cardiac insufficiency (OR=6.291, 95%CI[1.930-20.508]), combined with acute renal insufficiency (OR=8.419, 95%CI[2.198-32.241]), and septic shock (OR=22.150, 95%CI[3.639-134.806]) were all independent risk factors for 30-day mortality in patients with malignant hematological diseases complicated with BSI (all P < 0.05). Conclusion Among the most common pathogenic bacteria of malignant hematological diseases complicated with BSI, Escherichia coli is the main Gram-negative bacteria, and Staphylococcus hominis is the main Gram-positive bacteria.There are multiple risk factors affecting the prognosis of patients with malignant hematological diseases complicated with BSI.Shortening the duration of agranulocytosis, improving cardiac and renal function, and actively controlling septic shock are effective measures to reduce 30-day mortality in patients with malignant hematological diseases complicated with BSI.

Key words:malignant hematological disease;blood stream infection;pathogen;prognosis;risk factor