Tsai Sung-Sheng, Huang Jui-Chu, Chen Szu-Tah, Sun Jui-Hung, Wang Chih-Ching, Lin Shu-Fu, Hsu Brend Ray-Sea, Lin Jen-Der, Huang Shu-Yu, Huang Yu-Yao
Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan.
Chang Gung Med J. 2010 Sep-Oct;33(5):532-9.
Although diabetes mellitus is known as a major risk factor for Klebsiella pneumoniae infection, the differences in clinical characteristics between community-acquired and nosocomial K. pneumoniae bacteremia in diabetic patients have been rarely reported.
This retrospective analysis enrolled 193 adult diabetic patients with K. pneumoniae bacteremia hospitalized between January 2005 and December 2006. The chi-squared test, analysis of variance (ANOVA), Student's t test, Fisher exact test, and Cox regression model were used for statistical analysis.
Of the enrolled patients, 147 had community-acquired infections and 46 had nosocomial infections. Compared with the community group, the nosocomial group had higher rates of in-hospital mortality (41.3% vs. 18.4%, p=0.001), malignancy (50.0% vs. 19.0%, p<0.001), and leukopenia (21.7% vs. 5.4%, p=0.001) but had lower levels of serum C-reactive protein (124.3 mg/L vs. 188.7 mg/L, p=0.018) and HbA1c (8.1% vs. 9.5%, p=0.025). The rate of infection with the extended-spectrum β-lactamase-producing strain (ESBL infection) in the nosocomial group was 11 times higher than that in the community group (45.7% vs. 4.1%, p<0.001). ESBL infection accounted for 53% of mortality in the nosocomial group. Pneumonia was more common in the nosocomial group, while local abscess was more common in the community group. The risk factors for mortality were pneumonia, leukopenia, cirrhosis, and a high serum creatinine ratio (creatinine level at admission/baseline).
The nosocomial group had more ESBL infections which might account for the higher mortality. The HbA1c level during the course of infection did not affect the outcome. Pneumonia, leukopenia, cirrhosis, and a high serum creatinine ratio at admission were the risk factors for poor outcome.
尽管糖尿病被认为是肺炎克雷伯菌感染的主要危险因素，但糖尿病患者社区获得性与医院获得性肺炎克雷伯菌血症的临床特征差异鲜有报道。
本回顾性分析纳入了2005年1月至2006年12月期间住院的193例成年糖尿病肺炎克雷伯菌血症患者。采用卡方检验、方差分析（ANOVA）、学生t检验、Fisher精确检验和Cox回归模型进行统计分析。
在纳入的患者中，147例为社区获得性感染，46例为医院获得性感染。与社区组相比，医院获得性感染组的院内死亡率更高（41.3%对18.4%，p=0.001）、恶性肿瘤发生率更高（50.0%对19.0%，p<0.001）、白细胞减少发生率更高（21.7%对5.4%，p=0.001），但血清C反应蛋白水平更低（124.3mg/L对188.7mg/L，p=0.018），糖化血红蛋白（HbA1c）水平更低（8.1%对9.5%，p=0.025）。医院获得性感染组产超广谱β-内酰胺酶菌株（ESBL感染）的感染率比社区组高11倍（45.7%对4.1%，p<0.001）。ESBL感染占医院获得性感染组死亡率的53%。肺炎在医院获得性感染组更常见，而局部脓肿在社区组更常见。死亡的危险因素包括肺炎、白细胞减少、肝硬化和高血清肌酐比值（入院时肌酐水平/基线水平）。
医院获得性感染组有更多的ESBL感染，这可能是死亡率更高的原因。感染过程中的HbA1c水平不影响预后。肺炎、白细胞减少、肝硬化和入院时高血清肌酐比值是预后不良的危险因素。
