CAJ | 학술논문

目的：分析重症加强治疗病房（ICU）血流感染脓毒症患者的病原菌特征以及混合血流感染的危险因素和预后。方法回顾性分析2012年10月12日至2014年12月1日广东省人民医院6个ICU中年龄≥18岁且血培养阳性脓毒症患者的临床资料，根据分离出病原菌的数量将患者分为混合感染组和单一感染组。比较两组患者临床资料及病原菌分布情况，采用多因素logistic回归分析筛选混合血流感染的危险因素，采用Kaplan-Meier生存曲线分析患者血培养阳性后90 d存活率。结果共纳入299例患者，分离出病原菌450株，其中革兰阳性球菌246株（占54.67%），革兰阴性杆菌167株（占37.11%），真菌37株（占8.22%）。混合血流感染91例，单一血流感染208例。与单一感染组相比，混合感染组患者年龄更大（岁：73.19±18.02比60.83±18.06，t＝-5.447，P＝0.000）；有脑血管疾病〔39.56%（36/91）比17.79%（37/208），χ2＝16.261，P＝0.000〕或慢性肾功能不全〔15.38%（14/91）比7.21%（15/208），χ2＝4.828，P＝0.028〕基础疾病的比例更高；最近90 d内住院且住院时间≥2 d的比例更高〔73.63%（67/91）比61.54%（128/208），χ2＝4.078，P＝0.043〕；进行机械通气时间〔d：4（0，17）比1（0，6），U＝7673.000，P＝0.006〕和血培养前住院时间〔d：21（7，40）比9（3，17），U＝6441.500，P＝0.006〕更长；入院前30 d内静脉使用抗菌药物的比例更高〔84.62%（77/91）比66.83%（139/208），χ2＝9.989，P＝0.002〕。多因素logistic回归分析显示：高龄〔优势比（OR）＝1.032，95%可信区间（95%CI）＝1.015～1.050，P＝0.000〕、患脑血管疾病（OR＝2.247，95%CI＝1.234～4.090，P＝0.008）、机械通气时间长（OR＝1.041，95%CI＝1.014～1.069，P＝0.003）和最近90 d内住院且住院时间≥2 d（OR＝1.968，95%CI＝1.079～3.592，P＝0.027）是混合血流感染的独立危险因素。与单一感染组相比，混合感染组ICU住院时间〔d：46（22，77）比13（7，22），U＝3148.000，P＝0.000〕和总住院时间〔d：81（47，118）比28（17，46），U＝3620.000，P＝0.000〕明显延长，ICU病死率〔65.93%（60/91）比43.75%（91/208），χ2＝12.463， P＝0.000〕和住院病死率〔68.13%（62/91）比45.67%（95/208），χ2＝12.804，P＝0.000〕明显升高。Kaplan-Meier生存曲线分析显示，混合感染组90 d累积存活率较单一感染组显著降低（χ2＝8.513，P＝0.004）。结论 ICU血流感染病原菌以革兰阳性球菌为主。混合血流感染的独立危险因素为高龄、患脑血管疾病、机械通气时间长和90 d内住院史。混合血流感染可延长患者住院时间，增加病死率。目的：分析重癥加彊治療病房（ICU）血流感染膿毒癥患者的病原菌特徵以及混閤血流感染的危險因素和預後。方法迴顧性分析2012年10月12日至2014年12月1日廣東省人民醫院6箇ICU中年齡≥18歲且血培養暘性膿毒癥患者的臨床資料，根據分離齣病原菌的數量將患者分為混閤感染組和單一感染組。比較兩組患者臨床資料及病原菌分佈情況，採用多因素logistic迴歸分析篩選混閤血流感染的危險因素，採用Kaplan-Meier生存麯線分析患者血培養暘性後90 d存活率。結果共納入299例患者，分離齣病原菌450株，其中革蘭暘性毬菌246株（佔54.67%），革蘭陰性桿菌167株（佔37.11%），真菌37株（佔8.22%）。混閤血流感染91例，單一血流感染208例。與單一感染組相比，混閤感染組患者年齡更大（歲：73.19±18.02比60.83±18.06，t＝-5.447，P＝0.000）；有腦血管疾病〔39.56%（36/91）比17.79%（37/208），χ2＝16.261，P＝0.000〕或慢性腎功能不全〔15.38%（14/91）比7.21%（15/208），χ2＝4.828，P＝0.028〕基礎疾病的比例更高；最近90 d內住院且住院時間≥2 d的比例更高〔73.63%（67/91）比61.54%（128/208），χ2＝4.078，P＝0.043〕；進行機械通氣時間〔d：4（0，17）比1（0，6），U＝7673.000，P＝0.006〕和血培養前住院時間〔d：21（7，40）比9（3，17），U＝6441.500，P＝0.006〕更長；入院前30 d內靜脈使用抗菌藥物的比例更高〔84.62%（77/91）比66.83%（139/208），χ2＝9.989，P＝0.002〕。多因素logistic迴歸分析顯示：高齡〔優勢比（OR）＝1.032，95%可信區間（95%CI）＝1.015～1.050，P＝0.000〕、患腦血管疾病（OR＝2.247，95%CI＝1.234～4.090，P＝0.008）、機械通氣時間長（OR＝1.041，95%CI＝1.014～1.069，P＝0.003）和最近90 d內住院且住院時間≥2 d（OR＝1.968，95%CI＝1.079～3.592，P＝0.027）是混閤血流感染的獨立危險因素。與單一感染組相比，混閤感染組ICU住院時間〔d：46（22，77）比13（7，22），U＝3148.000，P＝0.000〕和總住院時間〔d：81（47，118）比28（17，46），U＝3620.000，P＝0.000〕明顯延長，ICU病死率〔65.93%（60/91）比43.75%（91/208），χ2＝12.463， P＝0.000〕和住院病死率〔68.13%（62/91）比45.67%（95/208），χ2＝12.804，P＝0.000〕明顯升高。Kaplan-Meier生存麯線分析顯示，混閤感染組90 d纍積存活率較單一感染組顯著降低（χ2＝8.513，P＝0.004）。結論 ICU血流感染病原菌以革蘭暘性毬菌為主。混閤血流感染的獨立危險因素為高齡、患腦血管疾病、機械通氣時間長和90 d內住院史。混閤血流感染可延長患者住院時間，增加病死率。
목적：분석중증가강치료병방（ICU）혈류감염농독증환자적병원균특정이급혼합혈류감염적위험인소화예후。방법회고성분석2012년10월12일지2014년12월1일광동성인민의원6개ICU중년령≥18세차혈배양양성농독증환자적림상자료，근거분리출병원균적수량장환자분위혼합감염조화단일감염조。비교량조환자림상자료급병원균분포정황，채용다인소logistic회귀분석사선혼합혈류감염적위험인소，채용Kaplan-Meier생존곡선분석환자혈배양양성후90 d존활솔。결과공납입299례환자，분리출병원균450주，기중혁란양성구균246주（점54.67%），혁란음성간균167주（점37.11%），진균37주（점8.22%）。혼합혈류감염91례，단일혈류감염208례。여단일감염조상비，혼합감염조환자년령경대（세：73.19±18.02비60.83±18.06，t＝-5.447，P＝0.000）；유뇌혈관질병〔39.56%（36/91）비17.79%（37/208），χ2＝16.261，P＝0.000〕혹만성신공능불전〔15.38%（14/91）비7.21%（15/208），χ2＝4.828，P＝0.028〕기출질병적비례경고；최근90 d내주원차주원시간≥2 d적비례경고〔73.63%（67/91）비61.54%（128/208），χ2＝4.078，P＝0.043〕；진행궤계통기시간〔d：4（0，17）비1（0，6），U＝7673.000，P＝0.006〕화혈배양전주원시간〔d：21（7，40）비9（3，17），U＝6441.500，P＝0.006〕경장；입원전30 d내정맥사용항균약물적비례경고〔84.62%（77/91）비66.83%（139/208），χ2＝9.989，P＝0.002〕。다인소logistic회귀분석현시：고령〔우세비（OR）＝1.032，95%가신구간（95%CI）＝1.015～1.050，P＝0.000〕、환뇌혈관질병（OR＝2.247，95%CI＝1.234～4.090，P＝0.008）、궤계통기시간장（OR＝1.041，95%CI＝1.014～1.069，P＝0.003）화최근90 d내주원차주원시간≥2 d（OR＝1.968，95%CI＝1.079～3.592，P＝0.027）시혼합혈류감염적독립위험인소。여단일감염조상비，혼합감염조ICU주원시간〔d：46（22，77）비13（7，22），U＝3148.000，P＝0.000〕화총주원시간〔d：81（47，118）비28（17，46），U＝3620.000，P＝0.000〕명현연장，ICU병사솔〔65.93%（60/91）비43.75%（91/208），χ2＝12.463， P＝0.000〕화주원병사솔〔68.13%（62/91）비45.67%（95/208），χ2＝12.804，P＝0.000〕명현승고。Kaplan-Meier생존곡선분석현시，혼합감염조90 d루적존활솔교단일감염조현저강저（χ2＝8.513，P＝0.004）。결론 ICU혈류감염병원균이혁란양성구균위주。혼합혈류감염적독립위험인소위고령、환뇌혈관질병、궤계통기시간장화90 d내주원사。혼합혈류감염가연장환자주원시간，증가병사솔。
ObjectiveTo investigate the clinical characteristics and pathogenic microorganisms in culture-positive sepsis, to identify its risk factors, and evaluate the prognosis on polymicrobial infection in intensive care unit (ICU).Methods A descriptive retrospective study was conducted. Clinical data of patients aged≥ 18 years, diagnosed as culture-positive sepsis, and admitted to six ICUs of Guangdong General Hospital from October 12th, 2012 to December 1st, 2014 were enrolled. Based on the number of isolated pathogens, patients were divided into polymicrobial infection group (≥two pathogens) and monomicrobial infection group (one pathogen) to investigate the clinical characteristics of patients with culture-positive sepsis and the causative pathogens. Multiple logistic regression was conducted to identify the risk factors for polymicrobial infection. Kaplan-Meier curve was plotted to analyze a 90-day survival rate from the onset of positive blood culture.Results 299 patients with positive blood culture were enrolled. A total of 450 strains of pathogens were isolated including 246 gram-positive cocci (54.67%), 167 gram-negative bacilli (37.11%) and 37 fungi (8.22%). Ninety-one patients had polymicrobial infection, and 208 with monomicrobial infection. Compared with monomicrobial infection group, patients suffering from polymicrobial infection had more advanced age (years: 73.19±18.02 vs. 60.83±18.06,t = -5.447,P = 0.000), also with higher incidence of cerebrovascular diseases [39.56% (36/91) vs. 17.79% (37/208),χ2 = 16.261,P = 0.000] or chronic renal insufficiency [15.38% (14/91) vs. 7.21% (15/208),χ2 = 4.828,P = 0.028], higher incidence of recent hospital stay (≥2 days) within 90 days [73.63% (67/91) vs. 61.54% (128/208),χ2 = 4.078,P = 0.043], longer mechanical ventilation duration [days: 4 (0, 17) vs. 1 (0, 6),U = 7 673.000,P = 0.006], longer length of hospital stay before blood was drawn for culture [days: 21 (7, 40) vs. 9 (3, 17),U = 6 441.500,P = 0.006], and higher incidence of pre-admission intravenous use of antibiotics [84.62% (77/91) vs. 66.83% (139/208),χ2 = 9.989,P = 0.002]. Multiple logistic regression analysis showed that advanced age [odd ratio (OR) = 1.032, 95% confidential interval (95%CI) = 1.015-1.050,P = 0.000], cerebrovascular diseases (OR = 2.247, 95%CI = 1.234-4.090,P = 0.008), prolonged mechanical ventilation (OR =1.041, 95%CI = 1.014-1.069,P = 0.003), and recent hospital stay (≥2 days) within 90 days (OR = 1.968, 95%CI =1.079-3.592,P = 0.027) were the independent risk factors for polymicrobial infection. In the polymicrobial infection group, the length of ICU stay [days: 46 (22, 77) vs. 13 (7, 22),U = 3 148.000,P = 0.000] and hospital stay [days:81 (47, 118) vs. 28 (17, 46),U = 3 620.000,P = 0.000] were significantly longer, and the ICU mortality [65.93%(60/91) vs. 43.75% (91/208),χ2 = 12.463,P = 0.000] and hospital mortality [68.13% (62/91) vs. 45.67% (95/208),χ2 = 12.804,P = 0.000] were significantly higher, and on the other hand the 90-day survival rate was significantly lower than that in the monomicrobial infection group (χ2 = 8.513,P = 0.004).Conclusions The most common pathogen of ICU sepsis is gram-positive cocci. Independent risk factors for polymicrobial infections were found to be advanced age, occurrence of cerebrovascular disease, prolonged mechanical ventilation, and recent hospitalization. Polymicrobial infection is associated with longer length of ICU and hospital stay, as well as higher mortality.