影响血液病恶性肿瘤患者医院获得性革兰阴性杆菌菌血症早期死亡率的因素：154 例回顾性分析。
Factors influencing the early mortality in haematological malignancy patients with nosocomial Gram negative bacilli bacteraemia: a retrospective analysis of 154 cases.
机构信息
Department of Infectious Diseases and Clinical Microbiology, Erciyes University Faculty of Medicine, Kayseri, Turkey.
出版信息
Braz J Infect Dis. 2013 Mar-Apr;17(2):143-9. doi: 10.1016/j.bjid.2012.09.010. Epub 2013 Feb 26.
BACKGROUND
The aim of this study is to assess the factors influencing the early mortality (7-day after index blood culture) in haematological malignancy patients with Gram negative bacilli (GNB) bacteraemia.
METHODS
Infection control committee records were reviewed to identify the cases between March 2006 and June 2011. Only one bacteraemic episode per patient was included in the study.
RESULTS
A total of 154 patients with GNB bacteraemia were identified. The early mortality rate was 19.5% (30 out of 154). Blood cultures revealed Enterobacteriacea in 120 patients (Escherichia coli; 86, Klebsiella spp.; 28, Enterobacter cloacea; 6) and glucose non-fermenting GNB in 34 patients (Pseudomonas aeruginosa; 15, Acinetobacter baumannii; 11, Stenotrophomonas maltophilia; 7, Burkholderia cepacia; 1). Forty (33.3%) out of 120 Enterobacteriaceae were extended spectrum beta-lactamase (ESBL) producers and 18 (52.9%) out of 34 glucose non-fermenting GNB were multidrug resistant. Carbapenems were administered as first line therapy in 139 out of 154 patients. In univariate analysis Pitt's bacteraemia score, presence of aplastic anaemia, bacteraemia caused by glucose non-fermentating GNB, inappropriate empirical antibacterial treatment, presence of severe sepsis or septic shock, unable to achieve microbiological cure, and intensive care unit (ICU) acquired bacteraemia were associated with mortality. Multivariate analysis showed ICU acquired bacteraemia (OR, 12.55; 95% CI, 2.34-67.38, p=0.003) as an independent factor associated with early mortality.
CONCLUSION
Haematological malignancy patients who require ICU care are at high risk for early mortality related to GNB bacteraemia. Based on the local findings pointing out high rate of multidrug resistance, carbapenems combined with colistin seems to be a reasonable approach as empirical treatment of these patients. However, increasing carbapenem resistance rate is of concern.
背景
本研究旨在评估影响血液恶性肿瘤患者革兰氏阴性杆菌（GNB）菌血症早期死亡率（指数血培养后 7 天）的因素。
方法
回顾感染控制委员会的记录，以确定 2006 年 3 月至 2011 年 6 月期间的病例。每位患者仅纳入一次菌血症发作。
结果
共确定 154 例 GNB 菌血症患者。早期死亡率为 19.5%（30/154）。血培养显示肠杆菌科 120 例（大肠埃希菌 86 例，克雷伯菌属 28 例，阴沟肠杆菌 6 例），葡萄糖非发酵 GNB 34 例（铜绿假单胞菌 15 例，鲍曼不动杆菌 11 例，嗜麦芽窄食单胞菌 7 例，洋葱伯克霍尔德菌 1 例）。肠杆菌科 40 例（33.3%）为超广谱β-内酰胺酶（ESBL）生产者，34 例葡萄糖非发酵 GNB 中 18 例（52.9%）为多药耐药菌。154 例患者中，139 例一线治疗使用碳青霉烯类。单因素分析显示，Pitt 菌血症评分、再生障碍性贫血、非发酵葡萄糖 GNB 引起的菌血症、经验性抗菌治疗不当、严重脓毒症或感染性休克、无法获得微生物学治愈以及重症监护病房（ICU）获得性菌血症与死亡率相关。多因素分析显示 ICU 获得性菌血症（OR，12.55；95%CI，2.34-67.38，p=0.003）是与早期死亡率相关的独立危险因素。
结论
需要 ICU 治疗的血液恶性肿瘤患者发生与 GNB 菌血症相关的早期死亡率较高。根据当地发现的高耐药率，碳青霉烯类联合黏菌素似乎是这些患者经验性治疗的合理方法。然而，碳青霉烯类耐药率的增加令人担忧。
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