切换至 "中华医学电子期刊资源库"
高级检索
中华损伤与修复杂志(电子版)

中华损伤与修复杂志(电子版) ›› 2023, Vol. 18 ›› Issue (06) : 491 -497. doi: 10.3877/cma.j.issn.1673-9450.2023.06.007

论著

严重烧伤患者鲍曼不动杆菌血流感染的危险因素及预后分析
涂家金†(), 廖武强, 刘金晶, 涂志鹏, 毛远桂   
  1. 341000　赣州市人民医院烧伤整形与创面修复科
    341000　赣州市人民医院烧伤整形与创面修复科；330006　南昌大学江西医学院第一临床医学院
    330006　南昌大学第一附属医院烧伤整形与创面修复医学中心
  • 收稿日期:2023-08-01 出版日期:2023-12-01
  • 通信作者: 涂家金

Risk factors and prognosis analysis of Acinetobacter baumannii bloodstream infection in patients with severe burns

Jiajin Tu†(), Wuqiang Liao, Jinjing Liu, Zhipeng Tu, Yuangui Mao   

  1. Department of Burn Orthopedics and Wound Repair, Ganzhou People′s Hospital, Ganzhou 341000, China
    Department of Burn Orthopedics and Wound Repair, Ganzhou People′s Hospital, Ganzhou 341000, China; First Clinical Medical College, Jiangxi Medical College of Nanchang University, Nanchang 330006, China
    Burn Plastic and Wound Repair Medical Center, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
  • Received:2023-08-01 Published:2023-12-01
  • Corresponding author: Jiajin Tu
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

涂家金, 廖武强, 刘金晶, 涂志鹏, 毛远桂. 严重烧伤患者鲍曼不动杆菌血流感染的危险因素及预后分析[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 491-497.

Jiajin Tu, Wuqiang Liao, Jinjing Liu, Zhipeng Tu, Yuangui Mao. Risk factors and prognosis analysis of Acinetobacter baumannii bloodstream infection in patients with severe burns[J]. Chinese Journal of Injury Repair and Wound Healing(Electronic Edition), 2023, 18(06): 491-497.

目的

探讨严重烧伤患者鲍曼不动杆菌(Ab)血流感染的危险因素，并对耐碳青霉烯类鲍曼不动杆菌(CRAB)血流感染患者预后情况进行分析，评估感染相关指标对CRAB血流感染严重烧伤患者预后的预测价值。

方法

选取2014年1月至2021年12月在南昌大学第一附属医院烧伤整形与创面修复医学中心确诊为血流感染的重度及以上烧伤患者212例为研究对象，根据血流感染细菌的不同分为Ab血流感染组(102例)和非Ab血流感染组(110例)，对比两组患者临床资料，分析严重烧伤患者Ab血流感染的危险因素。在Ab血流感染组中选取CRAB血流感染患者共98例，根据预后不同分为预后不良组(50例)和预后良好组(48例)，对比两组患者临床资料，分析预后不良的相关危险因素，并通过比较两组患者确诊后48 h内的感染相关指标，评估其对CRAB血流感染患者预后的预测价值。

结果

Ab血流感染组与非Ab血流感染组分析结果显示，合并其他部位Ab感染(OR＝1.859，95%CI：1.034~3.344，P＝0.038)、合并休克(OR＝1.926，95%CI：1.086~3.414，P＝0.025)和动脉置管时间(OR＝1.028，95%CI：1.002~1.055，P＝0.034)是严重烧伤患者Ab血流感染的独立危险因素。预后良好组和预后不良组对比结果显示，长时间机械通气(OR＝1.068，95%CI：1.018~1.121，P＝0.007)、Ⅲ度烧伤面积大(OR＝1.081，95%CI：1.034~1.130，P＝0.001)及高龄(OR＝1.074，95%CI：1.014~1.137，P＝0.015)是CRAB血流感染烧伤患者预后不良的独立影响因素。受试者工作特征(ROC)曲线显示，血小板(PLT)、降钙素原(PCT)和PLT联合PCT预测CRAB血流感染烧伤患者预后不良的曲线下面积分别为0.779(95%CI：0.677~0.880，P<0.001)、0.720(95%CI：0.604~0.836，P＝0.001)及0.836(95%CI：0.750~0.923，P<0.001)。

结论

合并其他部位Ab感染、合并休克和动脉置管时间是严重烧伤患者Ab血流感染的危险因素。长时间机械通气、Ⅲ度烧伤面积大及高龄是CRAB血流感染烧伤患者预后不良的影响因素。PLT和PCT对CRAB血流感染烧伤患者预后具有一定的预测价值。

关键词: 鲍曼不动杆菌, 血流感染, 烧伤, 耐药性, 降钙素原
Objective

To investigate the risk factors for Acinetobacter baumannii (Ab) bloodstream infection in patients with severe burns, analyze the prognosis of patients with carbapenem-resistant Acinetobacter baumannii (CRAB) bloodstream infection, and to assess the predictive value of infection-related indicators for the prognosis of severe burns patients with CRAB bloodstream infection.

Methods

A total of 212 patients with severe burns and diagnosed with bloodstream infection in the Burn Plastic and Wound Repair Medical Center, the First Affiliated Hospital of Nanchang University from January 2014 to December 2021 were selected for the study, and were divided into the Ab bloodstream infection group (102 cases) and the non-Ab bloodstream infection group (110 cases) according to the different bacteria of bloodstream infection, and the clinical data of the two groups were compared to explore the risk factors for Ab bloodstream infection in patients with severe burns. A total of 98 patients with CRAB bloodstream infection were selected from the Ab bloodstream infection group, and were divided into a poor prognosis group (50 cases) and a good prognosis group (48 cases) according to the prognosis. The risk factors associated with poor prognosis were analyzed by comparing the different clinical data of the two groups, and the predictive value for the prognosis of patients with CRAB bloodstream infection was evaluated by comparing the infection-related indexes of the two groups within 48 hours after diagnosis.

Results

Analysis of the Ab bloodstream infection group versus the non-Ab bloodstream infection group showed that combined Ab infection at other sites (OR=1.859, 95%CI: 1.034-3.344, P=0.038), combined shock (OR=1.926, 95%CI: 1.086-3.414, P=0.025) and duration of arterial cannulation (OR=1.028, 95%CI: 1.002-1.055, P=0.034) were independent risk factors for Ab bloodstream infection in patients with severe burns. Comparison between the good and poor prognosis groups showed that prolonged mechanical ventilation (OR=1.068, 95%CI: 1.018-1.121, P=0.007), large full-thickness burn area (OR=1.081, 95%CI: 1.034-1.130, P=0.001) and advanced age (OR=1.074, 95%CI: 1.014-1.137, P=0.015) were independent factors influencing poor prognosis in burns patients with CRAB bloodstream infection. Receiver operating characteristic (ROC) curves showed that the area under the curve for platelets (PLT), procalcitonin (PCT) and PLT combined with PCT to predict poor prognosis in burns patients with CRAB bloodstream infection was 0.779(95%CI: 0.677-0.880, P<0.001), 0.720(95%CI: 0.604-0.836, P=0.001) and 0.836(95%CI: 0.750-0.923, P<0.001).

Conclusion

Concomitant Ab infection at other sites, combined shock and duration of arterial cannulation are risk factors for Ab bloodstream infections in patients with severe burns. Prolonged mechanical ventilation, large full-thickness burn area burns and advanced age are factors affecting the poor prognosis of burn patients with CRAB bloodstream infection. PLT and PCT levels have some predictive value for the prognosis of burn patients with CRAB bloodstream infection.

Key words: Acinetobacter baumannii, Bloodstream infection, Burns, Drug resistance, Procalcitonin
表1 Ab血流感染组与非Ab血流感染组一般情况比较
项目 Ab血流感染组(n＝102) 非Ab血流感染组(n＝110) χ2值/Z值 P值
性别[例(%)]     0.406 0.524
男 74(72.55) 84(76.36)    
女 28(27.45) 26(23.64)    
ICU入住史[例(%)] 100(98.04) 109(99.09) 0.420 0.517
基础疾病史[例(%)] 17(16.67) 23(20.91) 0.622 0.430
年龄[岁，M(P25，P75)] 48.00(35.00，57.25) 50.00(41.00，56.00) －0.645 0.519
基础疾病数量[种，M(P25，P75)] 0(0，0) 0(0，0) －0.852 0.394
烧伤总面积[%，M(P25，P75)] 70(55，88) 65(49.75，82.50) －1.699 0.089
表2 Ab血流感染组与非Ab血流感染组的单因素分析
项目 Ab血流感染组(n＝102) 非Ab血流感染组(n＝110) χ2值/Z值 P值
机械通气[例(%)] 85(83.33) 75(68.18) 6.563 0.010
动脉置管[例(%)] 96(94.12) 88(80.00) 9.202 0.002
合并其他部位Ab感染[例(%)] 68(66.67) 52(47.27) 8.104 0.004
合并休克[例(%)] 54(52.94) 38(34.55) 7.291 0.007
合并MODS[例(%)] 23(22.55) 21(19.09) 0.385 0.535
伤后入院时间[h，M(P25，P75)] 4.00(2.75，4.00) 5.00(3.00，10.00) －2.227 0.026
Ⅲ度烧伤面积[%，M(P25，P75)] 45.00(26.00，62.00) 33.50(18.00，55.25) －2.652 0.008
机械通气时间[d，M(P25，P75)] 10.00(5.00，19.00) 8.00(0，16.00) －2.264 0.024
动脉置管时间[d，M(P25，P75)] 10.00(4.00，20.00) 8.00(2.00，14.50) －3.433 0.001
APACHEⅡ评分[分，M(P25，P75)] 10.00(6.00，14.00) 10.00(7.00，14.00) －0.447 0.655
表3 Ab血流感染组与非Ab血流感染组的多因素分析
项目 B SE Wald χ2 自由度 P值 OR值 95%CI
合并其他部位Ab感染 0.620 0.299 4.290 1 0.038 1.859 1.034~3.344
合并休克 0.655 0.292 5.032 1 0.025 1.926 1.086~3.414
动脉置管时间 0.028 0.013 4.483 1 0.034 1.028 1.002~1.055
表4 预后良好组和预后不良组的单因素分析
项目 预后良好组(n＝48) 预后不良组(n＝50) χ2值/Z值/t值 P值
动脉置管[例(%)] 42(87.5) 50(100.0) 6.658 0.010
机械通气时间[d，M(P25，P75)] 7.0(0.00~17.50) 11.5(7.00~20.25) －2.017 0.044
APACHEⅡ评分[分，M(P25，P75)] 8(4.00~12.00) 12(9.00~15.25) －3.481 <0.001
感染前使用抗生素种类数[种，M(P25，P75)] 4(3.25~5.75) 4(3.75~5.00) －0.903 0.367
抗生素总使用时间[d，M(P25，P75)] 55.5(38.25~73.00) 19.5(12.00~31.25) －6.021 <0.001
年龄(岁，±s) 43.69±13.86 50.66±1.30 －2.541 0.013
Ⅲ度烧伤面积(%，±s) 34.73±18.24 56.24±23.12 －5.100 <0.001
表5 预后良好组和预后不良组的多因素分析
项目 B SE Wald χ2 自由度 P值 OR值 95%CI
机械通气时间 0.066 0.025 7.236 1 0.007 1.068 1.018~1.121
抗生素总使用时间 －0.076 0.018 18.222 1 <0.001 0.927 0.895~0.960
Ⅲ度烧伤面积 0.078 0.023 11.781 1 0.001 1.081 1.034~1.130
年龄 0.071 0.029 5.948 1 0.015 1.074 1.014~1.137
表6 CRAB血流感染烧伤患者确诊48 h内感染相关指标的单因素分析
指标 预后良好组(n＝48) 预后不良组(n＝50) Z值/t值 P值
WBC[×109/L，M(P25，P75)] 10.72(7.85，13.22) 9.30(7.03，12.23) －1.567 0.117
PLT[×109/L，M(P25，P75)] 183.50(132.75，257.75) 118.00(66.75，156.25) －4.200 <0.001
PCT[ng/ml，M(P25，P75)] 4.08(2.22，6.04) 7.66(3.50，18.19) －3.366 0.001
D－二聚体[mg/L，M(P25，P75)] 3.22(2.03，4.80) 5.19(2.89，10.00) －2.935 0.003
ALB(g/L，±s) 30.22±3.38 29.14±5.18 1.231 0.222
表7 CRAB血流感染烧伤患者确诊48 h内感染相关指标的多因素分析
指标 B SE Wald χ2 自由度 P值 OR值 95%CI
PLT －0.020 0.007 9.828 1 0.002 0.98 0.967 0.992
PCT 0.198 0.097 4.126 1 0.042 1.219 1.007 1.475
图1 PLT、PCT及两者联合预测CRAB血流感染烧伤患者预后不良的ROC曲线
[1]
Harding CM, Hennon SW, Feldman MF. Uncovering the mechanisms of Acinetobacter baumannii virulence[J]. Nat Rev Microbiol, 2018, 16(2): 91-102.
[2]
Hu Y, Li D, Xu L, et al. Epidemiology and outcomes of bloodstream infections in severe burn patients: a six-year retrospective study[J]. Antimicrob Resist Infect Control, 2021, 10(1): 98.
[3]
Lee CM, Kim YJ, Jung SI, et al. Different clinical characteristics and impact of carbapenem-resistance on outcomes between Acinetobacter baumannii and Pseudomonas aeruginosa bacteraemia: a prospective observational study[J]. Sci Rep, 2022, 12(1): 8527.
[4]
Nunez Lopez O, Cambiaso-Daniel J, Branski LK, et al. Predicting and managing sepsis in burn patients: current perspectives[J]. Ther Clin Risk Manag, 2017, 13: 1107-1117.
[5]
Yeong EK, Sheng WH. Does early bloodstream infection pose a significant risk of in-hospital mortality in adults with burns？[J]. J Microbiol Immunol Infect, 2022, 55(1): 95-101.
[6]
王晓娟，赵春江，李荷楠，等. 2011年、2013年和2016年医院内获得性血流感染常见病原菌分布及其耐药性分析[J]. 生物工程学报，2018, 34(8): 1205-1217.
[7]
石江龙，程娜，向天新，等. 耐碳青霉烯类鲍曼不动杆菌血流感染的危险因素及预后的评估指标[J]. 中国感染控制杂志，2021, 20(12): 1082-1087.
[8]
Blot K, Hammami N, Blot S, et al. Gram-negative central line-associated bloodstream infection incidence peak during the summer: a national seasonality cohort study[J]. Sci Rep, 2022, 12(1): 5202.
[9]
Amanati A, Sajedianfard S, Khajeh S, et al. Bloodstream infections in adult patients with malignancy, epidemiology, microbiology, and risk factors associated with mortality and multi-drug resistance[J]. BMC Infect Dis, 2021, 21(1): 636.
[10]
Song J, Ozhathil DK, El AA, et al. C-reactive protein elevation is associated with increased morbidity and mortality in elderly burned patients[J]. Burns, 2023, 49(4): 806-812.
[11]
吴杨炀，曹玲，仲悦萍，等. 烧伤合并多重耐药革兰阴性菌感染的调查及院内感染发生危险因素的logistic分析[J]. 中国卫生统计，2021, 38(3): 396-398.
[12]
Gulen TA, Guner R, Celikbilek N, et al. Clinical importance and cost of bacteremia caused by nosocomial multi drug resistant acinetobacter baumannii[J]. International Journal of Infectious Diseases, 2015, 38: 32-35.
[13]
Ladhani HA, Yowler CJ, Claridge JA. Burn wound colonization, infection, and sepsis[J]. Surgical Infections, 2021, 22(1): 44-48.
[14]
Russo A, Bassetti M, Ceccarelli G, et al. Bloodstream infections caused by carbapenem-resistant Acinetobacter baumannii: Clinical features, therapy and outcome from a multicenter study[J]. J Infect, 2019, 79(2): 130-138.
[15]
Huang G, Yin S, Xiang L, et al. Epidemiological characterization of Acinetobacter baumannii bloodstream isolates from a Chinese Burn Institute: a three-year study[J]. Burns, 2016, 42(7): 1542-1547.
[16]
Paul M, Carrara E, Retamar P, et al. European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for the treatment of infections caused by multidrug-resistant Gram-negative bacilli (endorsed by European society of intensive care medicine)[J]. Clin Microbiol Infect, 2022, 28(4): 521-547.
[17]
Tacconelli E, Mazzaferri F, de Smet AM, et al. ESCMID-EUCIC clinical guidelines on decolonization of multidrug-resistant Gram-negative bacteria carriers[J]. Clin Microbiol Infect, 2019, 25(7): 807-817.
[18]
Righi E, Mutters NT, Guirao X, et al. ESCMID/EUCIC clinical practice guidelines on perioperative antibiotic prophylaxis in patients colonized by multidrug-resistant Gram-negative bacteria before surgery[J]. Clin Microbiol Infect, 2023, 29(4): 463-479.
[19]
Anggraini D, Santosaningsih D, Endraswari PD, et al. Multicenter study of the risk factors and outcomes of bloodstream infections caused by carbapenem-non-susceptible Acinetobacter baumannii in Indonesia[J]. Tropical Medicine and Infectious Disease, 2022, 7(8): 161.
[20]
Gu Y, Jiang Y, Zhang W, et al. Risk factors and outcomes of bloodstream infections caused by Acinetobacter baumannii: a case-control study[J]. Diagnostic Microbiology and Infectious Disease, 2021, 99(2): 115229.
[21]
Vardon-Bounes F, Ruiz S, Gratacap M, et al. Platelets are critical key players in sepsis[J]. International Journal of Molecular Sciences, 2019, 20(14): 3494.
[22]
Su M, Chen C, Li S, et al. Gasdermin D-dependent platelet pyroptosis exacerbates NET formation and inflammation in severe sepsis[J]. Nat Cardiovasc Res, 2022, 1(8): 732-747.
[23]
Torres MJM, Peterson JM, Wolf SE. Detection of infection and sepsis in burns[J]. Surgical Infections, 2021, 22(1): 20-27.
[1] 王雪菲, 海琳悦, 李立方, 肖春花. Luminal A型乳腺癌的内分泌治疗与化疗[J]. 中华乳腺病杂志(电子版), 2023, 17(05): 294-300.
[2] 姚咏明. 如何精准评估烧伤脓毒症患者免疫状态[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 552-552.
[3] 王成, 张慧君, 覃凤均, 陈辉. 网状植皮与ReCell表皮细胞种植在深Ⅱ度烧伤治疗中的疗效对比[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 498-502.
[4] 中华医学会烧伤外科学分会小儿烧伤学组. 儿童烧伤早期休克液体复苏专家共识(2023版)[J]. 中华损伤与修复杂志(电子版), 2023, 18(05): 371-376.
[5] 廖锵云, 王震, 林洁玉, 廖夏, 邓锦华, 李杰峰, 邓建维, 李明, 荣新洲. 虎门地区创伤弧菌感染的临床观察[J]. 中华损伤与修复杂志(电子版), 2023, 18(05): 394-398.
[6] 蔡柔妹, 曾洁梅, 黄伟丽, 谢文敏, 刘燕丹, 吴漫君, 蔡楚燕. 利用QC小组干预降低经烧伤创面股静脉置管导管相关性感染发生率的临床观察[J]. 中华损伤与修复杂志(电子版), 2023, 18(05): 399-404.
[7] 范帅华, 郭伟, 郭军. 基于机器学习的决策树算法在血流感染预后预测中应用现状及展望[J]. 中华实验和临床感染病杂志(电子版), 2023, 17(05): 289-293.
[8] 冯树森, 张东成, 郭奇, 张皓露, 陈阔. 两种手术方法对急性阑尾炎患者的临床疗效及对炎性因子的影响比较[J]. 中华普外科手术学杂志(电子版), 2023, 17(04): 447-450.
[9] 伍学成, 李远伟, 袁武雄, 王建松, 石泳中, 卢强, 李卓, 陈佳, 刘哲, 滕伊漓, 高智勇. 炎症介质谱联合降钙素原在尿源性脓毒血症中的诊断价值[J]. 中华腔镜泌尿外科杂志(电子版), 2023, 17(05): 476-480.
[10] 吴庆华, 冒勇, 闫效坤. AECOPD并发AKI的危险因素分析[J]. 中华肺部疾病杂志(电子版), 2023, 16(04): 529-531.
[11] 安钱, 徐彬, 陈志祥, 徐晶晶, 黄丹丹. PCT、CRP及SAA对呼吸机相关性肺炎病情严重程度和预后分析[J]. 中华肺部疾病杂志(电子版), 2023, 16(04): 544-546.
[12] 卓少宏, 林秀玲, 周翠梅, 熊卫莲, 马兴灶. CD64指数、SAA/CRP、PCT联合检测在小儿消化道感染性疾病鉴别诊断中的应用[J]. 中华消化病与影像杂志(电子版), 2023, 13(06): 505-509.
[13] 孙旻. 血液淀粉酶、C反应蛋白、降钙素原及乳酸脱氢酶在急性胰腺炎患者病情评价及预后预测中的价值[J]. 中华消化病与影像杂志(电子版), 2023, 13(05): 331-336.
[14] 杨艳丽, 陈昱, 赵若辰, 杜伟, 马海娟, 许珂, 张莉芸. 系统性红斑狼疮合并血流感染的危险因素及细菌学分析[J]. 中华临床医师杂志(电子版), 2023, 17(06): 694-699.
[15] 王燕, 郭蕊, 王淑杰. 老年烧伤气管切开患者死亡风险诊断模型构建及对策分析[J]. 中华诊断学电子杂志, 2023, 11(04): 249-253.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号