Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
BMC Infect Dis. 2021 Apr 17;21(1):366. doi: 10.1186/s12879-021-06055-1.
Over the past decades, Klebsiella pneumoniae (K. pneumoniae) infections have been increasing and affected immunocompromised patients nosocomially and communally, with extended-spectrum β-lactamase (ESBL) production becoming a major concern. Patients with rheumatic autoimmune diseases, mostly receiving immunosuppressive therapy, are vulnerable to various infections, including K. pneumoniae. However, few have investigated K. pneumoniae infections in this specific population. This study aimed to identify factors associated with ESBL production and mortality of K. pneumoniae pneumonia among patients with rheumatic autoimmune diseases in the Emergency Department.
We retrospectively investigated patients with rheumatic diseases who were diagnosed with K. pneumoniae pneumonia. The diagnosis of K. pneumoniae pneumonia was based on clinical manifestations, radiological findings and microbiological testing results. Prognostic factors and risk factors for ESBL production were determined with univariate and multivariate logistic regression analysis. Empirical therapy and antimicrobial susceptibility data were also collected.
Of 477 K. pneumoniae pneumonia patients, 60 were enrolled into this study. The in-hospital mortality was 28.3%. Septic shock, ICU admission, the need for mechanical ventilation and change of antibiotics due to clinical deterioration, all related to mortality, were included as unfavorable clinical outcomes. Multivariate analysis suggested that ESBL production (OR, 6.793; p = 0.012), initial PCT ≥ 0.5 ng/ml (OR, 5.024; p = 0.033) and respiratory failure at admission (OR, 4.401; p = 0.046) predicted increased mortality. ESBL production was significantly associated with dose of corticosteroids (OR, 1.033; p = 0.008) and CMV viremia (OR, 4.836; p = 0.032) in patients with rheumatic autoimmune diseases. Abnormal leukocyte count (OR, 0.192; p = 0.036) was identified as a protective factor of ESBL-producing K. pneumoniae pneumonia. The most commonly used empirical antibiotic was ceftazidime, while most isolates showed less resistance to carbapenems and amikacin in susceptibility testing.
K. pneumoniae pneumonia could be life-threatening in patients with rheumatic autoimmune diseases. Our findings suggested that ESBL production, initial PCT ≥ 0.5 ng/ml and respiratory failure at admission were independent factors associated with poor prognosis. Dose of corticosteroids and CMV viremia, predicting ESBL production in K. pneumoniae pneumonia, may help make individualized antibiotic decisions in clinical practice.
在过去几十年中，肺炎克雷伯菌（K. pneumoniae）感染不断增加，影响了医院和社区中的免疫功能低下患者，其中产超广谱β-内酰胺酶（ESBL）的情况令人尤为关注。患有风湿性自身免疫性疾病的患者大多接受免疫抑制治疗，易发生各种感染，包括肺炎克雷伯菌感染。然而，很少有研究关注这一特定人群中的肺炎克雷伯菌感染。本研究旨在确定风湿性自身免疫性疾病患者中与产 ESBL 的肺炎克雷伯菌肺炎相关的因素，并评估其预后。
我们回顾性调查了在急诊科被诊断为肺炎克雷伯菌肺炎的风湿性疾病患者。肺炎克雷伯菌肺炎的诊断基于临床表现、影像学表现和微生物学检测结果。使用单因素和多因素逻辑回归分析确定产 ESBL 的预测因素和危险因素。还收集了经验性治疗和抗菌药物敏感性数据。
在 477 例肺炎克雷伯菌肺炎患者中，有 60 例纳入本研究。住院死亡率为 28.3%。脓毒症休克、入住 ICU、需要机械通气以及因临床恶化而更换抗生素均与死亡率相关，被视为不良临床结局。多因素分析提示产 ESBL（OR，6.793；p=0.012）、初始降钙素原（PCT）≥0.5ng/ml（OR，5.024；p=0.033）和入院时呼吸衰竭（OR，4.401；p=0.046）与死亡率增加相关。产 ESBL 与风湿性自身免疫性疾病患者的皮质类固醇剂量（OR，1.033；p=0.008）和巨细胞病毒血症（OR，4.836；p=0.032）显著相关。白细胞计数异常（OR，0.192；p=0.036）被确定为产 ESBL 的肺炎克雷伯菌肺炎的保护因素。经验性抗生素最常使用头孢他啶，而药敏试验中大多数分离株对碳青霉烯类和阿米卡星的耐药性较低。
肺炎克雷伯菌肺炎可能对风湿性自身免疫性疾病患者构成生命威胁。我们的研究结果表明，产 ESBL、初始 PCT≥0.5ng/ml 和入院时呼吸衰竭是与不良预后相关的独立因素。预测肺炎克雷伯菌产 ESBL 的皮质类固醇剂量和巨细胞病毒血症可能有助于在临床实践中做出个体化的抗生素决策。
