Meini Simone, Sozio Emanuela, Bertolino Giacomo, Sbrana Francesco, Ripoli Andrea, Pallotto Carlo, Viaggi Bruno, Andreini Roberto, Attanasio Vittorio, Rescigno Carolina, Atripaldi Luigi, Leonardi Silvia, Bernardo Mariano, Tascini Carlo
Internal Medicine Unit, Felice Lotti Hospital of Pontedera, Azienda Unità Sanitaria Locale Toscana Nord-Ovest, Pisa, Italy.
Infectious Disease Unit, Department of Medicine, University of Udine, Udine, Italy.
Front Med (Lausanne). 2021 Apr 15;8:627830. doi: 10.3389/fmed.2021.627830. eCollection 2021.
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection; no current clinical measure adequately reflects the concept of dysregulated response. Coagulation plays a pivotal role in the normal response to pathogens (immunothrombosis), thus the evolution toward sepsis-induced coagulopathy could be individuate through coagulation/fibrinolysis-related biomarkers. We focused on the role of D-dimer assessed within 24 h after admission in predicting clinical outcomes in a cohort of 270 patients hospitalized in a 79 months period for meningitis and/or bloodstream infections due to ( = 162) or ( = 108). Comparisons were performed with unpaired -test, Mann-Whitney-test or chi-squared-test with continuity correction, as appropriate, and multivariable logistic regression analysis was performed with Bayesian model averaging. In-hospital mortality was 14.8% for the overall population, significantly higher in than in patients: 19.1 vs. 8.3%, respectively ( = 0.014). At univariable logistic regression analysis the following variables were significantly associated with in-hospital mortality: pneumococcal etiology, female sex, age, ICU admission, SOFA score, septic shock, MODS, and D-dimer levels. At multivariable analysis D-dimer showed an effect only in subgroup: as 500 ng/mL of D-dimer increased, the probability of unfavorable outcome increased on average by 4%. Median D-dimer was significantly higher in than in patients (1,314 vs. 1,055 ng/mL, = 0.009). For in-hospital mortality was 0% for D-dimer <500 ng/mL, very low (3.5%) for D-dimer <7,000 ng/mL, and increased to 26.1% for D-dimer >7,000 ng/mL. Kaplan-Meier analysis of in-hospital mortality showed for infections a statistically significant difference for D-dimer >7,000 ng/mL compared to values <500 ng/mL ( = 0.021) and 500-3,000 ng/mL ( = 0.002). For the mortality risk resulted always high, over 10%, irrespective by D-dimer values. In conclusion, D-dimer is rapid to be obtained, at low cost and available everywhere, and can help stratify the risk of in-hospital mortality and complications in patients with invasive infections due to : D-dimer <500 ng/mL excludes any further complications, and a cut-off of 7,000 ng/mL seems able to predict a significantly increased mortality risk from much <10% to over 25%.
脓毒症被定义为由宿主对感染的失调反应引起的危及生命的器官功能障碍；目前尚无临床措施能充分反映失调反应的概念。凝血在对病原体的正常反应（免疫血栓形成）中起关键作用，因此可通过凝血/纤维蛋白溶解相关生物标志物来确定向脓毒症诱导的凝血病的演变。我们重点研究了入院后24小时内评估的D - 二聚体在预测270例患者临床结局中的作用，这些患者在79个月期间因肺炎链球菌（n = 162）或金黄色葡萄球菌（n = 108）感染导致脑膜炎和/或血流感染而住院。根据情况，采用不成对t检验、曼 - 惠特尼检验或连续性校正的卡方检验进行比较，并采用贝叶斯模型平均法进行多变量逻辑回归分析。总体人群的住院死亡率为14.8%，肺炎链球菌感染患者的死亡率显著高于金黄色葡萄球菌感染患者：分别为19.1%和8.3%（P = 0.014）。在单变量逻辑回归分析中，以下变量与住院死亡率显著相关：肺炎球菌病因、女性性别、年龄、入住重症监护病房、序贯器官衰竭评估（SOFA）评分、感染性休克、多器官功能障碍综合征（MODS）和D - 二聚体水平。在多变量分析中，D - 二聚体仅在肺炎链球菌亚组中显示出作用：随着D - 二聚体每增加500 ng/mL，不良结局的概率平均增加4%。肺炎链球菌感染患者的D - 二聚体中位数显著高于金黄色葡萄球菌感染患者（1314 vs. 1055 ng/mL，P = 0.009）。对于肺炎链球菌感染，D - 二聚体<500 ng/mL时住院死亡率为0%，D - 二聚体<7000 ng/mL时非常低（3.5%），而D - 二聚体>7000 ng/mL时则升至26.1%。住院死亡率的Kaplan - Meier分析显示，对于肺炎链球菌感染，D - 二聚体>7000 ng/mL与<500 ng/mL（P = 0.021）和500 - 3000 ng/mL（P = 0.002）相比，在统计学上有显著差异。对于金黄色葡萄球菌感染，无论D - 二聚体值如何，死亡风险始终很高，超过10%。总之，D - 二聚体获取迅速、成本低且随处可得，有助于对肺炎链球菌侵袭性感染患者的住院死亡率和并发症风险进行分层：D - 二聚体<500 ng/mL可排除任何进一步的并发症，而7000 ng/mL的临界值似乎能够预测死亡率风险从远低于10%显著增加到超过25%。
