医院获得性念珠菌血症的临床特征及预后分析

摘要

目的 了解医院获得性念珠菌血症患者的临床特征和病原菌种类,探讨影响其预后的危险因素.方法 回顾性分析北京安贞医院2003年1月-2013年12月医院获得性念珠菌血症174例,描述其临床特征、病原菌种类,探讨预后相关危险因素,采用t检验和x2检验进行预后单因素分析,采用Logistic回归进行预后多因素分析.结果 观察期间,共有174例入选,其中男108例(62.1％),女66例(37.9％);平均年龄(53.9±27.3)岁,年龄＜18岁31例(17.8％),18～＜65岁56例(32.2％),≥65岁87例(50.0％);ICU患者59例(33.9％),心外科58例(33.3％),呼吸内科21例(12.1％),普外科14例(8.0％),另有神经内科、血管外科、骨科等.所有患者均有发热,起病时体温37.5～37.9℃3例(1.7％),38.0～38.9℃81例(46.6％),39.0～39.9℃85例(48.9％),体温≥40.0℃5例(2.9％);外周血白细胞计数升高(＞10×109/L)162例(93.1％),中性粒细胞比例升高(＞0.75) 166例(95.4％),血小板下降(＜100×109/L) 24例(13.8％).病原菌株中白念珠菌99例(56.9％),光滑念珠菌37例(21.3％),近平滑念珠菌20例(11.5％),克柔念珠菌11例(6.3％),热带念珠菌4例(2.3％),其他念珠菌3例(1.7％).死亡患者87例,病死率50.0％(87/174);单因素分析显示高龄、血小板减少、低白蛋白血症、肾功能不全、留置导尿管与医院获得性念珠菌血症患者死亡相关;多因素分析结果显示低白蛋白血症、合并细菌血症、留置导尿管为医院获得性念珠菌血症死亡的独立危险因素.结论 医院获得性念珠菌血症以ICU及外科感染者最常见;病原菌仍以白念珠菌为主,病死率高;高龄、低白蛋白血症、合并细菌血症、留置导尿管与医院获得性念珠菌血症患者死亡相关.%Objective To analyze the clinical features,etiology and prognostic factors of nosocomial candidemia in Beijing Anzhen Hospital.Methods A total of 174 cases of nosocomial candidemia identified during the period from January 2003 to December 2013 in Anzhen Hospital were reviewed retrospectively.The underlying conditions,risk factors,clinical manifestations and outcome were described and analyzed.The prognostic factors were analyzed by both univariate analysis including t-test and Chisquare test,and multivariate regression analysis.Results The 174 patients included 108 (62.1％) males and 66 (37.9％) females.The mean age of patients was 53.9±27.3 years,specifically:＜18 years (31/174,17.8％),18-＜ 65 years (56/174,32.2％),and ≥ 65 years (87/174,50.0％).About one-third (59/174,33.9％) of the patients were treated in ICU,followed by cardiac surgery ward (58/174,33.3％),respiratory medicine ward (21 / 174,12.1％),general surgery ward (14/174,8.0％),neurology ward (7/174,4.0％),vascular surgery (6/174,3.4％),and orthopedic ward (3/174,1.7％).Fever was documented in all cases,including 37.5-37.9 ℃ in 3 (1.7％) cases,38.0-38.9 ℃ in 81 (46.6％) cases,39.0-39.9 ℃ in 85 (48.9％) cases,and ≥ 40.0 ℃ in 5 (2.9％) cases.Increased peripheral blood WBC (＞10×109/L) was reported in 162 (93.1％) cases.The percentage of neutrophils (＞75％) was reported in 166 (95.4％) cases.Thrombocytopenia (＜ 100 × 109/ L) was documented in 24 (13.8％) cases.The most frequently isolated pathogen was C.albicans (99/174,56.9％),followed by C.parapsilosis (37/174,21.3％),C.glabrata (20/174,11.5％),C.krusei (11/174,6.3％),C.tropicalis (4/174,2.3％),and other Candida spp.(3/174,1.7％).The death rate was 50.0％ (87/174).Univariate analysis showed that old age,thrombocytopenia,hypoalbuminemia,renal insufficiency,indwelling urinary catheter were associated with death of candidemia patients.Multivariate analysis showed that hypoalbuminemia,bacterial co-infection,and indwelling urinary catheter were independent risk factors of death in nosocomial candidemia.Conclusions Nosocomial candidemia is more common in the patients treated in ICU and surgery ward.The most common pathogen of nosocomial candidemia is C.albicans associated with high mortality.Old age,hypoalbuminemia,bacterial co-infection,and indwelling urinary catheter are associated with death in nosocomial candidemia.