肝脓肿致脓毒血症的危险因素及早期诊断  

Risk factors and early diagnosis of sepsis caused by liver abscess

作　　者：齐文旗 黄椿媚 边帆[2] 葛勤敏[1] Qi Wenqi;Huang Chunmei;Bian Fan;Ge Qinmin(Department of Emergency,Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine,Shanghai 200092,China;Department of Nephrology,Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine,Shanghai 200092,China)

机构地区：[1]上海交通大学医学院附属新华医院急诊医学科,200092 [2]上海交通大学医学院附属新华医院肾脏内科,200092

出　　处：《中华急诊医学杂志》2019年第11期1383-1389,共7页Chinese Journal of Emergency Medicine

基　　金：上海市卫生和计划生育委员会科研课题(201740081)。

摘　　要：目的分析化脓性肝脓肿(pyogenic liver abscess,PLA)患者的临床特征和微生物特征,确定PLA致脓毒症的危险因素及早期诊断生物标志物。方法回顾性分析2013年1月至2017年6月上海交通大学医学院附属新华医院住院治疗的198例肝脓肿患者的人口学资料及临床资料。排除非细菌性肝脓肿、入院当天死亡及肿瘤转移患者,将198例肝脓肿患者根据病情进展分为脓毒症组及非脓毒症组,分析两组患者的一般资料,探讨肝脓肿致脓毒症的危险因素及早期诊断生物标志物及两组患者的预后。进一步将培养阳性的患者分为肺炎克雷伯杆菌组和非肺炎克雷伯杆菌组,分析两组患者的一般临床资料。在培养阳性的PLA患者中80.0%为肺炎克雷伯杆菌,其次是大肠杆菌。采用SPSS 19.0进行统计学分析,通过单因素和logistic多因素回归分析确定PLA致脓毒症的危险因素,通过受试者工作特性曲线(ROC曲线)分析入院时白细胞、中性粒细胞百分比及降钙素原(procalcitonin,PCT)的对肝脓肿进展为脓毒症的诊断价值。结果肝脓肿致脓毒症患者病死率20.8%,入院时白细胞计数、中性粒细胞百分比及PCT可预测PLA患者进展为脓毒症,AUC分别为0.76(95%CI:0.623~0.898)、0.818(95%CI:0.691~0.945)和0.869(95%CI:0.765~0.974)。合并糖尿病的患者发生肝脓肿后易进展为脓毒症。脓毒症组及非脓毒症组患者微生物特点差异无统计学意义(P>0.05)。合并脓毒症患者住院时间(length of stay,LOS)明显延长[(19.6±12.5)d vs(16.0±9.3)d,P=0.033]。结论糖尿病为肝脓肿进展为脓毒症的独立危险因素,肺炎克雷伯杆菌是目前肝脓肿的首位病原体。血糖控制不佳(糖化血红蛋白≥9.9%)患者易进展为脓毒症。肝脓肿患者白细胞≥12.55×109/L、中性粒细胞百分比≥84.8%及PCT≥6.96 ng/mL提示患者进展为脓毒症,进展为脓毒症后患者住院时间明显延长,病死率明显增加。Objective To analyze the clinical features and microbial characteristics of patients with pyogenic liver abscess(PLA),and to determine the risk factors and biomarkers for early diagnosis of sepsis caused by PLA.Methods The demographic and clinical data of 198 patients with liver abscess admitted to Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine from January 2013 to June 2017 were analyzed retrospectively.Patients with non-bacterial liver abscess,death on admission and tumor metastasis were excluded.The 198 patients with liver abscess were divided into the sepsis group and non-sepsis group according to the disease progression.The general data of the two groups were analyzed to explore the risk factors of sepsis caused by liver abscess,biomarkers for early diagnosis,and the prognosis.Patients with positive culture were further divided into the Klebsiella pneumoniae group and non-Klebsiella pneumoniae group,and the general clinical data of the two groups were analyzed.Among the PLA patients with positive culture,80.0%were Klebsiella pneumoniae,followed by E.coli.SPSS 19.0 software was used for statistical analysis,and univariate and logistic multivariate regression analysis was used to determined the risk factors of sepsis induced by PLA.The diagnostic value of white blood cell,neutrophil percentage and procalcitonin(PCT)at admission on the progression of liver abscess to sepsis was evaluated by the receiver operating characteristic(ROC)curve,area under the curve(AUC),sensitivity and specificity.Results The mortality of patients with sepsis caused by liver abscess was 20.8%.The white blood cell count,neutrophil percentage,and PCT at admission predicted the progression of sepsis in PLA patients,and the AUC were 0.76(95%CI:0.623-0.898),0.818(95%CI:0.691-0.945),and 0.869(95%CI:0.765-0.974),respectively.Patients with diabetes were prone to develop sepsis after the occurrence of liver abscess.There was no significant difference in microbial characteristics between the sepsis group and non-s

关 键 词：肝脓肿 脓毒症 危险因素 早期诊断 回顾性研究 

分 类 号：R73[医药卫生—肿瘤]