周婷+梁秀婷++吴洁

[摘要] 目的 探討多重耐药鲍曼不动杆菌（MDR-AB）血流感染患者临床特征和影响预后的危险因素。 方法 回顾性分析2012年1月～2015年12月解放军总医院MDR-AB血流感染患者相关临床资料，根据14 d死亡情况分为存活和死亡组，应用单因素分析及多因素Logistic回归分析探讨患者死亡的危险因素。 结果 本研究纳入157例患者，55.4%来自ICU，14 d总体死亡率为54.8%。单因素分析表明存活组在恶性肿瘤、免疫抑制治疗、中性粒细胞缺乏、机械通气、PBS方面低于死亡组（P < 0.05），在接受“适当治疗”、治疗方案包含舒巴坦方面高于死亡组（P < 0.05）。多因素分析表明恶性肿瘤（OR=4.78，95%CI：1.30～15.32，P < 0.05）、中性粒细胞缺乏（OR=16.01，95%CI：1.64～172.21，P < 0.05），高PBS（OR=0.47，95%CI：0.32～0.63，P < 0.05）是MDR-AB血流感染患者早期死亡的独立危险因素。血液系统恶性肿瘤患者因常伴有中性粒细胞缺乏，生存分析示其预后要明显劣于实体肿瘤患者（P < 0.05）；存活组使用含舒巴坦制剂比例显著高于死亡组（P < 0.05），但多因素分析并未发现其为死亡保护因素。 结论 MDR-AB血流感染人群多为病情较重的ICU患者，病死率较高。恶性肿瘤、中性粒细胞缺乏，高PBS是MDR-AB血流感染患者早期死亡的独立危险因素。含舒巴坦制剂可作为临床治疗MDR-AB血流感染的一种选择，但其效果需进一步探究。

[关键词] 血流感染；多重耐药鲍曼不动杆菌；危险因素；预后

[中图分类号] R571 [文献标识码] A [文章编号] 1673-7210（2017）11（a）-0060-04

A retrospective analysis of clinical features and prognostic of patients with bloodstream infections caused by multi-drug resistant Acinetobacter baumannii

ZHOU Ting* LIANG Xiuting* WU Jie

Department of Respiratory， Chinese PLA General Hospital， Beijing 100853， China

[Abstract] Objective To analyze the clinical manifestations and risk factors of patients with bloodstream infections （BSI） caused by multi-drug resistant Acinetobacter baumannii （MDR-AB）. Methods Clinical data of patients with BSI caused by MDR-AB hospitalized in Chinese PLA General Hospital from January 2012 to December 2015 were analyzed retrospectively. According to the 14-day survival after diagnosis， the patients were divided into survival group and death group. The risk factors of death were investigated by single-factor analysis and multifactor Logistic regression analysis. Results Among the 157 patients， 55.4% were collected from ICU， and the 14-day mortality was 54.8%. Single-factor analysis showed that the survival group was significantly lower than the death group in malignancy， immunosuppressive therapy， neutropenia，ventilator use and Pitt Bacteremia Score （PBS）， with statistically significant difference （P < 0.05）. And the survival group was significantly higher than the death group in appropriate therapy and treatment with Sulbactam， with statistically significant difference （P < 0.05）. Multifactor Logistic regression analysis showed malignancy （OR=4.78， 95%CI： 1.30-15.32， P < 0.05）， neutropenia （OR=16.01， 95%CI： 1.64-172.21， P < 0.05） and increased PBS （OR=0.47， 95%CI： 0.32-0.63， P < 0.05） were independent risk factors of 14-day mortality. Patients with hematological malignancies were often accompanied with neutropenia， and the survival analysis revealed that mortality in patients with hematological malignancies was higher than that in patients with solid tumors （P < 0.05）.The percentage of patients treated with antibiotics containing Sulbactam in the survival group was significantly higher than that in the death group （P < 0.05）， but it was not revealed as a death protection factor in multivariate analysis. Conclusion The patients with BSI caused by MDR-AB usually have serious sunder lying diseases from ICU， and the mortality is quite high. Malignancy， neutropenia and increased PBS are independent risk factors of early mortality. Antimicrobial regimens containing Sulbactam may be a candidate for the treatment of BSI caused by MDR-AB， but its clinical efficacy deserves further exploration.endprint

[Key words] Bloodstream infection； Multidrug-resistant Acinetobacter baumannii； Risk factors； Prognosis

鲍曼不动杆菌为非发酵革兰氏阴性杆菌，是引起院内重症感染的主要要病原菌之一，其中该菌所致的血流感染患者的死亡率高达29%～63%[1-3]。因近年来多重耐药（MDR）甚至泛耐药（XDR）鲍曼不动杆菌在我国广泛流行，而临床可选择的有效抗菌药物又十分有限，故由MDR或XDR菌株所致血流感染死亡率可能会更高。既往研究分析了鲍曼不动杆菌血流感染患者的临床特点及预后危险因素，如菌株耐药性，疾病严重程度，抗感染治疗是否恰当，及是否合并免疫抑制等均可能与预后相关[2-4]。但这些研究样本量较小，有些也并未区分是定植还是感染或未考虑患者合并症的严重程度等。因此，为了进一步明确多重耐药鲍曼不动杆菌（MDR-AB）血流感染患者的临床特点和影响其预后的相关危险因素，本研究回顾分析了解放军总医院（以下简称“我院”）2012年1月～2015年12月MDR-AB血流感染患者的临床资料。……