摘要目的 了解肺炎克雷伯菌血流感染(Klebsiella pneumoniae bloodstream infection,KPBSI)的临床特点、耐药情况及预后,分析死亡危险因素和耐药危险因素.方法 对复旦大学附属华山医院2015年4月至2017年4月住院的KP-BSI患者临床资料进行回顾性分析.计量资料采用t检验,计数资料采用x2检验或Fisher确切概率法;logistic回归分析独立的死亡危险因素.结果 74例KP-BSI患者中以男性多见(67.6％),中老年患者为主(78.4％),医院感染58例(78.4％),死亡24例(32.4％).广泛分布在全院各个科室,首位为感染科(29.7％),其次为ICU(23.0％).患者常合并多种基础疾病,以肺部感染(56.8％)最常见.有多重耐药(multiple drug resistance,MDR)菌株45例(60.8％),碳青霉烯类耐药肺炎克雷伯菌(Carbapenems resistant Klebsiella pneumoniae,CRKP)菌株29例(39.2％).MDR和非MDR患者之间院内感染(x2=4.655,P=0.031)、深静脉置管(x2=5.432,P=0.02)、有创机械通气(x2 =7.630,P=0.006)差异均有统计学意义;CRKP和非CRKP组之间深静脉置管(x2=5.923,P=0.015)、有创机械通气(x2=16.845,P=0.000)、其他导管(x2=4.009,P=0.045)和外科手术(x2=3.910,P=0.048)差异均有统计学意义.对所有患者进行APACHE Ⅱ评分,其中生存组50例(67.6％),评分为8.74±5.32;死亡组24例(32.4％),评分为16.46±6.62,生存组APACHEⅡ评分明显低于死亡组,差异有统计学意义(t=5.091,P=0.000).APACHE Ⅱ≥15是死亡的独立危险因素(B=-2.708,P=0.000).结论 KP-BSI耐药形势严峻,院内感染、有创机械通气和深静脉置管等倾人性操作可能是MDR血流感染的危险因素;深静脉置管、有创机械通气、其他导管和有外科手术可能是CRKP血流感染的危险因素;APACHE Ⅱ≥15是死亡的独立危险因素,对血流感染患者进行APACHE Ⅱ评分可以评估患者预后情况.

abstractsObjective To explore the clinical characteristics,drug resistance and prognosis of Klebsiella pneumoniae bloodstream infection (KP-BSI),and to analyze the risk factors of death and drug resistance.Methods The clinical data of hospitalized patients with KP-BSI from April 2015 to April 2017 in Huashan Hospital were retrospectively analyzed.Continuous variables were compared using t test.Categorical variables were compared using x2 test or Fisher exact test.The independent risk factors for death were determined by logistic regression model.Results The majority of the 74 patients with KP-BSI were male (67.6％) and elderly patients (78.4％).Nosocomial infection occurred in 58 cases (78.4％) and a total of 24 (32.4％) cases died.The patients were widely distributed in various departments of the hospital.The first was the Department of Infectious Diseases (29.7％),followed by the intensive care unit (23.0％).The patients were often complicated with various underlying diseases and the most common was pulmonary infection (56.8％).There were 45 (60.8％) multiple drug resistance (MDR) strains and 29 (39.2％) Carbapenems resistant Klebsiella pneumoniae (CRKP) strains.There were significant differences of nosocomial infections (x2 =4.655,P =0.031),deep venous catheters (x2 =5.432,P-0.02),and invasive mechanical ventilation (x2 =7.630,P =0.006) between MDR and non-MDR patients.Deep venous catheters (x2 =5.923,P=0.015),invasive mechanical ventilation (x2 =16.845,P=0.000),other catheters (x2 =4.009,P=0.045) and surgery (x2 =3.910,P=0.048) were all significantly different between CRKP and non-CRKP patients.APACHE Ⅱ scores were performed in all patients.The average APACHE Ⅱ score was 8.74-±5.32 of the 50 cases (67.6％) in the survival group and that was 16.46 ± 6.62 of the 24 cases (32.4％) in the death group.The APACHE Ⅱ score in the survival group was significantly lower than that in the death group.The difference was statistically significant (t=5.091,P=0.000).APACHE Ⅱ ≥15 was the independent factor of death (B =-2.708,P=0.000).Conclusions The situation of drug-resistant KP-BSI is severe in the clinic.According to the clinical data,nosocomial infections,invasive mechanical ventilation and deep venous catheters may be the risk factors for MDR bloodstream infection.Deep venous catheters,invasive mechanical ventilation,other catheters and surgery may be the risk factors for bloodstream infection with CRKP.APACHE Ⅱ ≥15 is the independent risk factor for death.The evaluation of APACHE Ⅱ score may predict the prognosis of patients with bloodstream infection.