摘要目的 探讨短期低剂量系统性糖皮质激素治疗对重症社区获得性肺炎(SCAP)患者临床结局的影响.方法 采用多中心回顾性研究方法,收集2013年1月1日至2015年12月31日在北京、山东和云南三省5家教学医院收治的SCAP住院患者病例资料.根据是否接受糖皮质激素治疗,将患者分为激素组和非激素组.收集入选患者的性别、年龄、基础疾病,入院当天的血常规、生化检查和影像学资料(多次检查者取最异常值),支持治疗,并发症(需要胰岛素治疗的高血糖和消化道出血)以及临床结局〔早期(0～3 d)治疗失败、晚期(4～14 d)治疗失败、30 d病死率,治疗失败定义为需要无创或有创机械通气、需要使用血管活性药物或死亡〕.采用单因素和多因素Logistic回归分析评估短期低剂量系统性糖皮质激素对SCAP患者临床结局的影响.结果 对3 561例免疫功能正常的成人或青年社区获得性肺炎(CAP)患者进行筛选,最终共有132例SCAP患者纳入分析,其中激素组24例,非激素组108例.激素组患者甲泼尼龙使用剂量(0.6±0.1)mg·kg-1·d-1,使用时间(4.0±1.7)d.与非激素组比较,激素组患者年龄较小〔岁:70.5(59.0,75.0)比80.0(76.0,85.0)〕,男性〔41.7% (10/24)比72.2%(78/108)〕及基础疾病为心血管病〔16.7%(4/24)比42.6%(46/108)〕、脑血管病〔0%(0/24)比40.7%(44/108)〕和意识改变比例〔16.7%(4/24)比40.7%(44/108)〕较低,基础疾病为慢性阻塞性肺病〔COPD, 41.7%(10/24)比13.0%(14/108)〕、哮喘〔25.0%(6/24)比1.9%(2/108)〕、慢性肝病〔8.3%(2/24)比0%(0/108)〕和呼吸频率≥30次/min的比例〔33.3%(8/24)比9.3%(10/108)〕较高,差异均有统计学意义(均P＜0.05);且激素组患者应用符合指南的经验性抗感染治疗、早期需要无创机械通气、晚期出现消化道出血、早期和晚期出现需要胰岛素治疗的高血糖比例均明显高于非激素组〔50.0%(12/24)比21.3%(23/108),33.3%(8/24)比7.4% (8/108),20.8%(5/24)比4.6%(5/108),20.8%(5/24)比1.9%(2/108),37.5%(9/24)比2.8%(3/108),均P＜0.05〕.经性别、年龄、基础疾病和是否应用符合指南的经验性抗感染治疗校正的Logistic回归方程显示,短期低剂量系统性糖皮质激素治疗可增加SCAP患者晚期需要使用血管活性药物〔优势比(OR)＝3.369,95%可信区间(95%CI)＝1.369～6.133,P＝0.035〕、晚期出现需要胰岛素治疗的高血糖(OR＝4.738,95%CI＝1.890～8.652, P＝0.017)和30 d死亡(OR＝2.187,95%CI＝1.265～4.743,P＝0.002)的风险.结论 短期低剂量系统性糖皮质激素治疗使得SCAP患者临床结局恶化,不应常规联合应用.

abstractsObjective To assess the impact of short-term, low-dose systemic glucorticosteroids treatment on the clinical outcomes in patients with severe community-acquired pneumonia (SCAP). Methods A multi-center retrospective study was conducted. Data of patients hospitalized with SCAP in five teaching hospitals from Beijing, Shandong and Yunnan Provinces from January 1st, 2013 to December 31st, 2015 were reviewed. Patients were divided into steroids group and non-steroids group according to whether treated with glucorticosteroids during the disease course or not. Data of patients were reviewed, including gender, age, underlying disease, blood routine, biochemical examination and radiology findings (the worst value was recorded if there were more than one value), supportive treatment, complications (hyperglycemia needing insulin treatment and gastrointestinal bleeding) and clinical outcomes [early (0-3 days) treatment failure, late (4-14 days) treatment failure and 30-day mortality, treatment failure was defined as one of the followings: needing noninvasive or invasive ventilation, needing vasopressor use or death]. Univariate and multivariate Logistic regression was performed to evaluate the impact of short-term, low-dose systemic glucorticosteroids on the clinical outcomes in SCAP patients. Results Overall, 3 561 immunocompetent adult and adolescent patients with community-acquired pneumonia (CAP) were screened, 132 SCAP patients were entered into final analysis, including 24 patients in steroids group and 108 patients in non-steroids group. The patients in steroids group were prescribed with methylprednisolone (0.6±0.1) mg·kg-1·d-1 for (4.0±1.7) days. Compared with patients in non-steroids group, patients in steroids group showed younger age [years old: 70.5 (59.0, 75.0) vs. 80.0 (76.0, 85.0)], less frequency of male [41.7% (10/24) vs. 72.2% (78/108)], less comorbidities with cardiovascular [16.7% (4/24) vs. 42.6% (46/108)] and cerebrovascular disease [0% (0/24) vs. 40.7% (44/108)], less confusion [16.7% (4/24) vs. 40.7% (44/108)]; more frequency of chronic obstructive pulmonary disease [COPD, 41.7% (10/24) vs. 13.0% (14/108)], asthma [25.0% (6/24) vs. 1.9% (2/108)], chronic hepatic disease [8.3% (2/24) vs. 0% (0/108)] and respiratory rate≥30 times/min [33.3% (8/24) vs. 9.3% (10/108)] with significant differences (all P < 0.05), the proportion of guideline-based empirical antimicrobial therapy, early needing noninvasive ventilation, late gastrointestinal bleeding, early and late hyperglycemia needing insulin treatment were higher in steroids group than non-steroids group [50.0% (12/24) vs. 21.3% (23/108), 33.3% (8/24) vs. 7.4% (8/108), 20.8% (5/24) vs. 4.6% (5/108), 20.8% (5/24) vs. 1.9% (2/108), 37.5% (9/24) vs. 2.8% (3/108), all P < 0.05]. Adjusted by gender, age, comorbidities and empirical antimicrobial therapy, Logistic regression confirmed short-term, low-dose systemic glucorticosteroids was associated with higher risk for vasopressor usage [odds ratio (OR) = 3.369, 95% confidence interval (95%CI) = 1.369-6.133, P = 0.035], hyperglycaemia needing insulin treatment (OR = 4.738, 95%CI = 1.890-8.652, P = 0.017) in late stage and 30-day mortality (OR = 2.187, 95%CI = 1.265-4.743, P = 0.002). Conclusion Adjunctive treatment with short-term, low-dose systemic glucorticosteroids worsen the clinical outcomes and should not be used to SCAP patients routinely.