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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
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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/OL]. 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/OL]. 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
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