危重症评分和生物标志物在血流感染肺炎病原学诊断及预后评估中的价值  

Diagnostic and predictive value of critical illness scores and biomarkers in bloodstream infection-associated pneumonia

作　　者：闫圣涛[1,2] 孙力超[2] 练睿 沈美佳[1] 赵学诚 张国强 Yan Shengtao;Sun Lichao;Lian Rui;Shen Meijia;Zhao Xuecheng;Zhang Guoqiang(Graduate School of Peking Union Medical Collage,Beijing 100730,China;Department of Emergency,China-Japan Friendship Hospital,Beijing 100029,China)

机构地区：[1]北京协和医学院研究生院,北京100730 [2]中日友好医院急诊科,北京100029

出　　处：《中华危重病急救医学》2020年第6期681-685,共5页Chinese Critical Care Medicine

基　　金：国家自然科学基金(81871600,81601725);国家临床重点专科建设项目(2013-544)。

摘　　要：目的比较多种危重症评分及生物标志物对血流感染肺炎患者的早期和晚期预后评估价值以及降钙素原(PCT)在病原学诊断中的价值。方法收集2014年1月至2018年12月就诊于中日友好医院急诊科最终诊断为肺炎且就诊24 h内至少有1次血培养阳性患者的资料,以就诊当天首次参数计算序贯器官衰竭评分(SOFA)、急诊脓毒症死亡风险评分(MEDS)、Logistic器官功能不全评分(LODS)、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)。比较不同革兰染色细菌感染者之间,以及20 d或60 d不同预后患者之间各指标的差异;用受试者工作特征曲线(ROC)分析生物标志物对单一细菌感染所致肺炎的鉴别诊断价值,以及几种危重症评分及生物标志物对肺炎患者28 d和60 d死亡的预测价值。结果在540例单一细菌感染所致血流感染肺炎患者中,革兰阳性菌(GPB)感染256例(47.4%),革兰阴性菌(GNB)感染284例(52.6%);28 d病死率为29.4%(159/540),60 d病死率为36.3%(196/540)。PCT在GNB感染肺炎患者中明显高于GPB感染者〔g/L:1.99(0.32,13.19)比0.45(0.13,3.53),P<0.01〕。无论是28 d死亡患者还是60 d死亡患者,各危重症评分和生物标志物均高于相应存活患者。ROC曲线分析显示:①PCT对单一细菌血流感染肺炎患者诊断的最佳截断值为0.48μg/L,ROC曲线下面积(AUC)为0.739〔95%可信区间(95%CI)为0.686~0.793〕;当PCT>4.49μg/L时,诊断GNB感染的特异度可达81.8%,阳性预测值(PPV)为75.0%;当PCT>10.16μg/L时,诊断GNB感染的特异度可达91.2%。②在预测肺炎患者28 d和60 d预后方面,SOFA评分的AUC最大〔28 d:0.818(95%CI为0.768~0.867),60 d:0.800(95%CI为0.751~0.849)〕;当SOFA评分>8.5分时,预测血流感染肺炎患者28 d和60 d死亡的特异度分别达90.5%及91.6%。PCT预测血流感染肺炎患者28 d和60 d死亡的AUC分别为0.637(95%CI为0.575~0.700)及0.628(95%CI为0.569~0.688);当PCT>8.15μg/L时,预测患者28 d死亡的特异度达80.2%,阴性预�Objective To compare the early and late predictive value of several critical illness scores(CISs)and biomarkers in patients with bloodstream infection(BSI)-associated pneumonia,and to identify the value of procalcitonin(PCT)in etiological diagnosis.Methods Patients with at least one positive blood culture within 24 hours admission to department of emergency of China-Japan Friendship Hospital from January 2014 to December 2018 and with final diagnosis of pneumonia were enrolled.Sequential organ failure assessment(SOFA),mortality in emergency department sepsis(MEDS),Logistic organ dysfunction system(LODS),and acute physiology and chronic health evaluationⅡ(APACHEⅡ)scores were calculated based on the first parameters on the day of admission.Differences of various indicators among different Gram-stained bacterial infections and among patients with different prognosis at 28-day or 60-day were compared.Receiver operating characteristic(ROC)curve was used to analyze the value of biomarkers in differential diagnosis of pneumonia caused by single bacterial infection,and the predictive value of several CISs and biomarkers on 28-day and 60-day death of patients with pneumonia.Results Among 540 patients with pneumonia caused by single bacterial infection,256(47.4%)patients with Gram-positive bacteria(GPB)infection and 284(52.6%)with Gram-negative bacteria(GNB)infection.The 28-day mortality was 29.4%(159/540)and the 60-day mortality was 36.3%(196/540).PCT level was significantly higher in patients with GNB infection than that in GPB infected patients[μg/L:1.99(0.32,13.19)vs.0.45(0.13,3.53),P<0.01].There were significant differences of CISs and biomarkers between death group and survival group in predicting 28-day and 60-day mortality in BSI-associated pneumonia.ROC curve analysis showed that:①the optimal cut-off value of PCT in the diagnosis of single bacterial infection was 0.48μg/L,with the area under ROC curve(AUC)was 0.739[95%confidence interval(95%CI)was 0.686-0.793].When PCT value was greater than 4.49μg/L,the

关 键 词：危重症评分 降钙素原 肺炎 血流感染 预后 

分 类 号：R563.1[医药卫生—呼吸系统]