血清降钙素原对早期抗菌治疗无效的社区获得性肺炎病因诊断的意义
혈청강개소원대조기항균치료무효적사구획득성폐염병인진단적의의
Diagnostic value of serum procalcitonin in identifying the etiology of non-responding community-acquired pneumonia after initial antibiotic therapy
  • 万方数据
    中华结核和呼吸杂志 중화결핵화호흡잡지
    Chinese Journal of Tuberculosis and Respiratory Diseases
    2014年 11期 824-830 ,共7页

    汪铮%张晓菊%吴纪珍%张文平%况红艳%李晓%轩伟霞%王凯%马利军

    왕쟁%장효국%오기진%장문평%황홍염%리효%헌위하%왕개%마리군

    肺炎%社区获得性感染%医疗无效%降钙素原 肺炎%社區穫得性感染%醫療無效%降鈣素原
    폐염%사구획득성감염%의료무효%강개소원
    Pneumonia%Community-acquired infections%Medical futility%Procalcitonin
    目的 探讨血清降钙素原检测对早期抗菌治疗无效的社区获得性肺炎(CAP)病因诊断的临床意义.方法 回顾性分析郑州大学人民医院2011年6月至2013年1月收治的符合CAP入选标准的232例住院患者的临床资料及对早期抗菌治疗的反应.早期治疗无效的定义为经验性治疗72 h后临床症状持续存在或恶化,或发展为急性呼吸衰竭需要通气支持,或出现感染性休克.对评价为治疗无效的患者行支气管镜、经皮肺穿刺活检及实验室检查.采用双抗免疫夹心法检测血清降钙素原水平.分别采用单因素t检验、方差分析、Mann-Whitney U检验、Kruskal-Wallis秩和检验、x2检验比较治疗无效组和治疗有效组的临床特征,构造logistic多元回归模型以分析治疗无效的危险因素,建立受试者工作特征曲线以确定最佳诊断界值.结果 纳入的232例CAP住院患者中,男124例,女108例,平均年龄(46 ±20)岁,其中36例早期抗菌治疗无效.Logistic回归分析结果显示,早期治疗无效的危险因素包括低蛋白血症、2型糖尿病、脾切除术后、肺炎严重度指数(PSI)为Ⅳ～Ⅴ级及病灶范围浸润≥3个肺叶.无效的原因依次为感染(23例)和误诊(11例),另有2例病因不明.抗感染治疗失败组23例中16例初始抗感染治疗未覆盖病原体,其中细菌感染11例中初始抗感染未覆盖病原菌的有5例,病原菌耐药4例,有感染并发症者8例(肺炎旁性胸腔积液、脓胸、败血症及转移性脓肿各2例).抗感染治疗失败组入院时的降钙素原水平为0.19 (0.07 ～0.66) μg/L,显著高于误诊组的0.06 (0.05～0.08) μg/L.抗感染治疗失败组23例中,细菌感染11例(革兰阳性球菌5例,革兰阴性杆菌6例),非细菌感染12例,入院时降钙素原水平分别为0.66(0.19 ～5.80) μg/L和0.08(0.05～0.20) μg/L.非细菌感染12例(结核4例,真菌3例,非典型病原体3例,病毒2例),各病原体组入院时降钙素原水平差异无统计学意义(F=3.025,P=0.094).用入院时降钙素原＞0.13 μg/L区分细菌感染和其他原因导致的治疗无效时,其敏感度、特异度和受试者工作特征曲线下面积分别为100％ (11/11)、83％ (19/23)和0.955.用入院时降钙素原＞0.13 μg/L区分感染与非感染导致的治疗无效时,其敏感度、特异度和受试者工作特征曲线下面积分别为65％(14/23)、91％(10/11)和0.802.结论 未覆盖感染病原体、出现感染并发症和误诊分别是CAP早期抗菌治疗无效的主要原因;初诊时降钙素原水平难以预测CAP患者对治疗的反应,但其水平及动态变化有助于判断细菌感染引起的治疗无效的CAP.
    목적 탐토혈청강개소원검측대조기항균치료무효적사구획득성폐염(CAP)병인진단적림상의의.방법 회고성분석정주대학인민의원2011년6월지2013년1월수치적부합CAP입선표준적232례주원환자적림상자료급대조기항균치료적반응.조기치료무효적정의위경험성치료72 h후림상증상지속존재혹악화,혹발전위급성호흡쇠갈수요통기지지,혹출현감염성휴극.대평개위치료무효적환자행지기관경、경피폐천자활검급실험실검사.채용쌍항면역협심법검측혈청강개소원수평.분별채용단인소t검험、방차분석、Mann-Whitney U검험、Kruskal-Wallis질화검험、x2검험비교치료무효조화치료유효조적림상특정,구조logistic다원회귀모형이분석치료무효적위험인소,건립수시자공작특정곡선이학정최가진단계치.결과 납입적232례CAP주원환자중,남124례,녀108례,평균년령(46 ±20)세,기중36례조기항균치료무효.Logistic회귀분석결과현시,조기치료무효적위험인소포괄저단백혈증、2형당뇨병、비절제술후、폐염엄중도지수(PSI)위Ⅳ～Ⅴ급급병조범위침윤≥3개폐협.무효적원인의차위감염(23례)화오진(11례),령유2례병인불명.항감염치료실패조23례중16례초시항감염치료미복개병원체,기중세균감염11례중초시항감염미복개병원균적유5례,병원균내약4례,유감염병발증자8례(폐염방성흉강적액、농흉、패혈증급전이성농종각2례).항감염치료실패조입원시적강개소원수평위0.19 (0.07 ～0.66) μg/L,현저고우오진조적0.06 (0.05～0.08) μg/L.항감염치료실패조23례중,세균감염11례(혁란양성구균5례,혁란음성간균6례),비세균감염12례,입원시강개소원수평분별위0.66(0.19 ～5.80) μg/L화0.08(0.05～0.20) μg/L.비세균감염12례(결핵4례,진균3례,비전형병원체3례,병독2례),각병원체조입원시강개소원수평차이무통계학의의(F=3.025,P=0.094).용입원시강개소원＞0.13 μg/L구분세균감염화기타원인도치적치료무효시,기민감도、특이도화수시자공작특정곡선하면적분별위100％ (11/11)、83％ (19/23)화0.955.용입원시강개소원＞0.13 μg/L구분감염여비감염도치적치료무효시,기민감도、특이도화수시자공작특정곡선하면적분별위65％(14/23)、91％(10/11)화0.802.결론 미복개감염병원체、출현감염병발증화오진분별시CAP조기항균치료무효적주요원인;초진시강개소원수평난이예측CAP환자대치료적반응,단기수평급동태변화유조우판단세균감염인기적치료무효적CAP.
    Objective This study was to investigate the diagnostic value of serum procalcitonin (PCT) in identifying the etiology of non-responding community-acquired pneumonia (CAP) after initial antibiotic therapy.Methods A retrospective analysis was performed for 232 hospitalized CAP patients admitted to the People' s Hospital of Zhengzhou University during June 2013 and January 2014.Early treatment failure was defined as the presence of persistent fever (＞ 38 ℃) and/or clinical symptoms (malaise,cough,expectoration,dyspnea) or deterioration after at least 72 h of initial antimicrobial treatment,or development of respiratory failure requiring mechanical ventilation,or septic shock.Bronchoscopy or transthoracic lung biopsy was performed in case of early treatment failure when indicated.Serum level of PCT was detected by double antibody sandwich method.The differences between 2 or more groups were compared using 2-independent student t test,one-way ANOVA; Mann-Whitney U test,KruskalWallis rank sum test,or x2 test.Risk factors and odds ratios for nonresponsiveness were analyzed by setting up a Logistic regression model.The diagnostic values of PCT were determined by receiver operating characteristic curves (ROC curves).Results Of the 232 CAP patients enrolled,124 were male and 108 were female,with an average age of (46 ± 20) years.Thirty-six patients failed to respond to the initial antibiotic therapy.As shown by Logistic regression analysis,the risk factors for treatment failure included hypoalbuminemia,type 2 diabetes,previous history of splenectomy,PSI 4-5 grade,and lung infiltration ≥ 3 lobes.The most common causes of non-responsiveness were antimicrobial insufficiency (n =23),and misdiagnosis of noninfectious mimics of pneumonia (n =11),with 2 cases of unidentified etiology.The serum PCT level in admission was 0.19 (0.07-0.66) μg/L in the antimicrobial insufficiency subgroup,which was significantly higher than that in the misdiagnosis subgroup [0.06 (0.05-0.08)μg/L;P ＜ 0.01].The antimicrobial insufficiency subgroup included 11 cases of bacterial infection (5 of G + cocci and 6 of G-bacilli) and 12 cases of nonbacterial infection; their PCT levels were 0.66 (0.19-5.80) μg/L and 0.08 (0.05-0.20) μg/L,respectively (P ＜ 0.01).There was no statistically significant difference among PCT levels of the 4 subgroups of nonbacterial infections (4 tuberculosis,3 fungi,3 atypical pathogens,2 viruses) (F =3.025,P =0.094).The cut-off values of PCT were ＞ 0.13 μg/L and ＞ 0.115 μg/L for differentiating non-responsiveness originated from bacterial infection or other causes,and infection vs non-infection,which yielded a sensitivity of 100％ (11/11) and 65％ (14/23),specificity of 83％ (19/23) and 91％ (10/11),and AUC of 0.955 and 0.802,respectively.Conclusions Antibiotic failure to cover the microbial pathogens,infectious complications and misdiagnosis are the most common causes of early treatment failure in patients with CAP.Serum PCT level fails to predict non-responsiveness,but is suggestive of bacterial infections in hospitalized CAP patients with early treatment failure.
    원문보기 원문다운로드 사이트로이동
저자의 최근 논문