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肝硬化合并细菌性肺炎的危险因素及其预后分析

Analysis of risk factors and prognosis of cirrhosis combined with bacterial pneumonia

摘要:

目的:研究肝硬化合并细菌性肺炎患者病原菌学、抗菌药物优选方案及其预后的影响因素。方法:收集河北医科大学第三医院肝病科肝硬化患者324例资料,其中合并细菌性肺炎217例,对比分析患者基线特征、影响抗菌治疗效果及预后的因素,用logistic回归分析筛选预测抗菌疗效指标,并建立预测模型,用受试者工作特征曲线评估所建模型与Child-Turcorto-Pugh、终末期肝病模型、终末期肝病模型联合血清钠模型预测治疗效果的价值。结果:慢性HBV及HCV感染为肝硬化主要病因,其次为隐源性肝硬化和酒精性肝硬化,合并糖尿病、心脑血管及慢性阻塞性肺病为细菌性肺炎易感因素。随着感染的发生,中性粒细胞与淋巴细胞比值、血清C反应蛋白、降钙素原、丙氨酸转氨酶及总胆红素水平显著升高。病原学分析结果显示,前3位病原菌为肺炎克雷伯杆菌、鲍曼不动菌、铜绿假单胞菌及金黄色葡萄球菌。肺炎克雷伯杆菌对头孢曲松耐药率达50.0%,头孢他啶、头孢吡肟、头孢哌酮舒巴坦耐药率均为27.8%。抗菌治疗以含β内酰胺酶抑制剂的哌拉西林他唑巴坦及亚胺培南效果为佳。回归分析结果显示年龄、降钙素原、白蛋白与抗菌效果显著相关,依此建立PAA模型,并与Child-Turcorto-Pugh、终末期肝病模型、终末期肝病模型联合血清钠模型对比疗效预测效能,证实PAA敏感度为94.12% ,特异度为93.62%,显著高于其他模型。结论:肝硬化并发细菌性肺炎常见病原菌为肺炎克雷柏杆菌为主的革兰阴性杆菌,亦可见金黄色葡萄球菌等革兰阳性球菌,老年、糖尿病及应用激素等患者易继发真菌感染,以年龄、降钙素原及血清白蛋白建立的PAA模型可较准确预测抗菌效果,指导临床治疗及判断预后。

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abstracts:

Objective:To study the bacterial pathogen, the optimal plan of antibacterial drugs and the prognostic factors in patients with liver cirrhosis combined with bacterial pneumonia.Methods:Data of 324 cases with liver cirrhosis from the Department of Traditional and Western Medical Hepatology, the Third Hospital of Hebei Medical University were collected, including 217 cases of bacterial pneumonia. Baseline characteristics of the patients, factors affecting the efficacy of antibacterial treatment and prognosis were compared and analyzed. Logistic regression analysis was used to screen and predict the antibacterial efficacy indicators and a prediction model was established. Receiver operating characteristic curve was used to evaluate the value of the established model and Child-Turcortte-Pugh, model for end-stage liver disease, and model for end-stage liver disease combined with serum sodium concentration predict the therapeutic efficacy.Results:Chronic HBV and HCV infections were the main causes of cirrhosis, followed by cryptogenic cirrhosis and alcoholic cirrhosis. Diabetes, cardio-cerebrovascular and chronic obstructive pulmonary disease were susceptible factors for bacterial pneumonia. As infection occurred, the ratio of neutrophils to lymphocytes, serum C-reactive protein, procalcitonin, alanine aminotransferase, and total bilirubin levels had increased significantly. The results of pathogenic analysis showed that the top three pathogenic bacteria were Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Staphylococcus aureus. The resistance rate of Klebsiella pneumoniae to ceftriaxone was 50.0%, and that of ceftazidime, cefepime, and cefoperazone sulbactam were 27.8%. Imipenem and piperacillin tazobactam containing β-lactamase inhibitors were the most effective antibacterial therapies. Regression analysis showed that age, procalcitonin, and albumin was significantly correlated with antibacterial effects. The PAA model was established and had predicted the efficacy of Child-Turcortte-Pugh, model for end-stage liver disease, and model for end-stage liver disease combined with serum sodium. The specificity and sensitivity of the PAA was confirmed to be 94.12% and 93.62%, which was significantly higher than other models.Conclusion:The main common pathogenic bacterium of cirrhosis combined with bacterial pneumonia is Klebsiella pneumonia (G-bacilli). In addition, gram positive cocci (Staphylococcus aureus) and other are also visible. The elderly, diabetics and patients using hormones are prone to secondary fungal infections. Age, procalcitonin and serum albumin can accurately predict the antibacterial effect, guide clinical treatment and judge the prognosis of the established PAA model.

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作者: 张潇潇 [1] 杨杨 [1] 赵文 [1] 崔璐瑶 [1] 王一奇 [1] 南月敏 [1]
期刊: 《中华肝脏病杂志》2020年28卷7期 561-566页 MEDLINEISTICPKUCSCDCA
栏目名称: 肝纤维化·肝硬化
DOI: 10.3760/cma.j.cn501113-201200624-00344
发布时间: 2020-09-15
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