血清降钙素原对早期抗菌治疗无效的社区获得性肺炎病因诊断的意义  

Diagnostic value of serum procalcitonin in identifying the etiology of non-responding community-acquired pneumonia after initial antibiotic therapy

作　　者：汪铮[1] 张晓菊[1] 吴纪珍[1] 张文平[1] 况红艳[1] 李晓[1] 轩伟霞[1] 王凯[1] 马利军[1] 

机构地区：[1]郑州大学人民医院呼吸与危重症医学科,450003

出　　处：《中华结核和呼吸杂志》2014年第11期824-830,共7页Chinese Journal of Tuberculosis and Respiratory Diseases

基　　金：河南省卫生厅指导性计划项目（2011030007）

摘　　要：目的 探讨血清降钙素原检测对早期抗菌治疗无效的社区获得性肺炎（CAP）病因诊断的临床意义.方法 回顾性分析郑州大学人民医院2011年6月至2013年1月收治的符合CAP入选标准的232例住院患者的临床资料及对早期抗菌治疗的反应.早期治疗无效的定义为经验性治疗72 h后临床症状持续存在或恶化,或发展为急性呼吸衰竭需要通气支持,或出现感染性休克.对评价为治疗无效的患者行支气管镜、经皮肺穿刺活检及实验室检查.采用双抗免疫夹心法检测血清降钙素原水平.分别采用单因素t检验、方差分析、Mann-Whitney U检验、Kruskal-Wallis秩和检验、x2检验比较治疗无效组和治疗有效组的临床特征,构造logistic多元回归模型以分析治疗无效的危险因素,建立受试者工作特征曲线以确定最佳诊断界值.结果 纳入的232例CAP住院患者中,男124例,女108例,平均年龄（46 ±20）岁,其中36例早期抗菌治疗无效.Logistic回归分析结果显示,早期治疗无效的危险因素包括低蛋白血症、2型糖尿病、脾切除术后、肺炎严重度指数（PSI）为Ⅳ-Ⅴ级及病灶范围浸润≥3个肺叶.无效的原因依次为感染（23例）和误诊（11例）,另有2例病因不明.抗感染治疗失败组23例中16例初始抗感染治疗未覆盖病原体,其中细菌感染11例中初始抗感染未覆盖病原菌的有5例,病原菌耐药4例,有感染并发症者8例（肺炎旁性胸腔积液、脓胸、败血症及转移性脓肿各2例）.抗感染治疗失败组入院时的降钙素原水平为0.19 （0.07 -0.66） μg/L,显著高于误诊组的0.06 （0.05-0.08） μg/L.抗感染治疗失败组23例中,细菌感染11例（革兰阳性球菌5例,革兰阴性杆菌6例）,非细菌感染12例,入院时降钙素原水平分别为0.66（0.19 -5.80） μg/L和0.08（0.05-0.20） μg/L.非细菌感染12例（结核4例,真菌3例,非典型病原体3例,病毒2例）,各病原体组入院时降钙素原�Objective This study was to investigate the diagnostic value of serum procalcitonin （PCT） in identifying the etiology of non-responding community-acquired pneumonia （CAP） after initial antibiotic therapy.Methods A retrospective analysis was performed for 232 hospitalized CAP patients admitted to the People＇ s Hospital of Zhengzhou University during June 2013 and January 2014.Early treatment failure was defined as the presence of persistent fever （＞ 38 ℃） and/or clinical symptoms （malaise,cough,expectoration,dyspnea） or deterioration after at least 72 h of initial antimicrobial treatment,or development of respiratory failure requiring mechanical ventilation,or septic shock.Bronchoscopy or transthoracic lung biopsy was performed in case of early treatment failure when indicated.Serum level of PCT was detected by double antibody sandwich method.The differences between 2 or more groups were compared using 2-independent student t test,one-way ANOVA; Mann-Whitney U test,KruskalWallis rank sum test,or x2 test.Risk factors and odds ratios for nonresponsiveness were analyzed by setting up a Logistic regression model.The diagnostic values of PCT were determined by receiver operating characteristic curves （ROC curves）.Results Of the 232 CAP patients enrolled,124 were male and 108 were female,with an average age of （46 ± 20） years.Thirty-six patients failed to respond to the initial antibiotic therapy.As shown by Logistic regression analysis,the risk factors for treatment failure included hypoalbuminemia,type 2 diabetes,previous history of splenectomy,PSI 4-5 grade,and lung infiltration ≥ 3 lobes.The most common causes of non-responsiveness were antimicrobial insufficiency （n =23）,and misdiagnosis of noninfectious mimics of pneumonia （n =11）,with 2 cases of unidentified etiology.The serum PCT level in admission was 0.19 （0.07-0.66） μg/L in the antimicrobial insufficiency subgroup,which was significantly higher than that in the misdiagnosis subgroup [0.06 （0.05-0.08）μg/L;P �

关 键 词：肺炎 社区获得性感染 医疗无效 降钙素原 

分 类 号：R563.1[医药卫生—呼吸系统]