重症急性胰腺炎患者腹腔内真菌感染与细菌感染的结局

Outcomes of intra-abdominal fungal vs. bacterial infections in severe acute pancreatitis.

作者信息

Vege Santhi Swaroop, Gardner Timothy B, Chari Suresh T, Baron Todd H, Clain Jonathan E, Pearson Randall K, Petersen Bret T, Farnell Michael B, Sarr Michael G

机构信息

Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA.

出版信息

Am J Gastroenterol. 2009 Aug;104(8):2065-70. doi: 10.1038/ajg.2009.280. Epub 2009 Jun 2.

DOI:10.1038/ajg.2009.280

PMID:19491825

Abstract

OBJECTIVES

Intra-abdominal infection in severe acute pancreatitis (SAP) has significant morbidity and mortality; however, reports conflict on the outcome of patients with intra-abdominal fungal infection (IFI). We aimed to compare the morbidity and mortality of IFI compared with intra-abdominal bacterial infection (IBI) and no intra-abdominal infection (NII) in patients with SAP.

METHODS

Medical records of 207 consecutive patients admitted with SAP (per the Atlanta classification) to the Mayo Clinic (Rochester, Minnesota) between 1992 and 2001 were reviewed. All intra-abdominal microbiology cultures from pancreatic and peri-pancreatic necrosis, abscess, and/or pseudocyst obtained at operation, endoscopic necrosectomy or computed tomography-guided aspiration were reviewed. Patients were divided into three groups-IFI, IBI, and NII. Primary fungal infections were those for which there had been no prior abdominal interventions, and secondary infections were those that followed a prior intervention. Our main outcome was in-hospital mortality and secondary outcomes included the presence of organ failure (OF), need for surgical intervention, need for intensive care unit (ICU) care, and duration of hospitalization.

RESULTS

The groups were similar in terms of baseline characteristics, use of prophylactic antibiotics, use of enteral/parenteral nutrition, development of necrosis, and peripancreatic fluid collections. Fifty-two percent of patients had an intra-abdominal infection; all of these developed bacterial infections and 30 (15%) developed concomitant fungal infections. There were 7 primary fungal infections and 23 secondary infections-no important outcome differences were noted between these groups. Compared with patients with IBI, patients with IFI had longer hospital (63 vs. 37 days, P<0.01) and ICU (28 vs. 9 days, P<0.01) stays and higher rates of OF (73 vs. 47%, P<0.04), but similar mortality rates (20 vs. 17%, P0.41). Multivariate analysis revealed the presence of OF (odds ratio (OR) 2.4, 95% confidence interval (CI) 1,7) and the need for ICU care (OR 4.3, 95% CI 1,28) to be associated with IFI.

CONCLUSIONS

Patients with SAP and IFI suffered greater in-hospital morbidity than did patients with IBI alone. Concomitant fungal infection, however, did not increase the in-hospital mortality rate.

摘要

目的

重症急性胰腺炎（SAP）患者发生腹腔内感染会导致显著的发病率和死亡率；然而，关于腹腔内真菌感染（IFI）患者的预后，报告结果存在冲突。我们旨在比较SAP患者中IFI与腹腔内细菌感染（IBI）和无腹腔内感染（NII）患者的发病率和死亡率。

方法

回顾了1992年至2001年间连续入住梅奥诊所（明尼苏达州罗切斯特）的207例符合亚特兰大分类标准的SAP患者的病历。对手术、内镜坏死组织清除术或计算机断层扫描引导下穿刺获取的胰腺及胰周坏死组织、脓肿和/或假性囊肿的所有腹腔内微生物培养结果进行了审查。患者被分为三组——IFI组、IBI组和NII组。原发性真菌感染是指此前未进行过腹部干预的感染，继发性感染是指在先前干预后发生的感染。我们的主要结局是住院死亡率，次要结局包括器官衰竭（OF）的存在、手术干预的必要性、重症监护病房（ICU）护理的必要性以及住院时间。

结果

三组在基线特征、预防性抗生素的使用、肠内/肠外营养的使用、坏死的发生以及胰周液体积聚方面相似。52%的患者发生了腹腔内感染；所有这些患者均发生了细菌感染，30例（15%）同时发生了真菌感染。有7例原发性真菌感染和23例继发性真菌感染——两组之间未观察到重要的结局差异。与IBI患者相比，IFI患者的住院时间（63天对37天，P<0.01）和ICU住院时间（28天对9天，P<0.01）更长，OF发生率更高（73%对47%，P<0.04），但死亡率相似（20%对17%，P=0.41）。多变量分析显示，OF的存在（比值比（OR）2.4，95%置信区间（CI）1.7）和ICU护理的必要性（OR 4.3，95%CI 1.28）与IFI相关。