儿童肝移植术后早期血流感染的危险因素及对预后的影响  

Early bloodstream infection after pediatric liver transplantation:risk factors and prognostic effects

作　　者：邹国寅 董冲[2] 孙超[2] 王凯[2] 张威[2] 魏新哲 王若凡 兰翔宇 高伟[2] Zou Guoyin;Dong Chong;Sun Chao;Wang Kai;Zhang Wei;Wei Xinzhe;Wang Ruofan;Lan Xiangyu;Gao Wei(First Central Clinical College,Tianjin Medical University,Tianjin 300070,China;Department of Pediatric Transplantation,Organ Transplantation Center,First Central Municipal Hospital,Tianjin 300192,China)

机构地区：[1]天津医科大学一中心临床学院,天津300070 [2]天津市第一中心医院器官移植中心儿童器官移植科,天津300192

出　　处：《中华小儿外科杂志》2024年第3期208-216,共9页Chinese Journal of Pediatric Surgery

基　　金：天津市医学重点学科(专科)建设项目资助。

摘　　要：目的探讨儿童肝移植受者术后早期(3个月内)血流感染的患病率和致病菌分布情况,并分析血流感染(blood stream infection,BSI)和由多重耐药菌(multi-drug resistant organism,MDRO)引起的BSI的高危因素和预后。方法收集并分析2016年8月至2020年12月在天津市第一中心医院器官移植中心儿童器官移植科进行肝移植的872例患儿的临床资料,根据手术后早期BSI的发生情况以及病原菌是否为MDRO将患儿分为3组:非BSI组(765例)、非MDRO BSI组(73例)和MDRO BSI组(34例)。采用单变量分析和多元logistic回归分析,确定术后早期BSI的独立危险因素,比较各组患儿生存率和术后并发症发生率。结果872例患儿中,共有107例(12.3%,107/872)在术后3个月内分离出207株病原菌。207株病原菌中有25种不同的病原体,其中肺炎克雷伯杆菌(30.9%,64/207)、屎肠球菌(23.7%,49/207)占比较高。共有34例患儿中分离出MDRO 76株(36.7%,76/207),其中以耐碳青霉烯肺炎克雷伯菌(56株)为主。术前1个月内抗生素暴露、手术时长、重症监护病房停留时间、术后再次手术、术后低磷血症和低镁血症是术后早期BSI发生的独立危险因素。术前1个月抗生素暴露、腹腔引流时间、术后低磷血症和再移植是术后早期MDRO引起BSI的独立危险因素。与非BSI组相比,另外两组的术后并发症发生率明显更高,包括肝动脉血栓、胆道狭窄、巨细胞病毒感染和肺感染。与非MDRO BSI组和非BSI组相比,MDRO BSI患儿的1年和3年生存率显著降低(76.5%比94.5%和95.8%,P<0.001;73.5%比94.5%和95.4%,P<0.001)。结论儿童肝移植术后早期BSI的发生率仍然很高,MDRO BSI的占比较大且预后不佳。移植术后早期MDRO BSI的独立危险因素包括术前1个月内抗生素暴露、腹腔引流时间、术后低磷血症和再移植,预防儿童肝移植术后早期MDRO BSI有助于改善预后。Objective To explore the prevalence and pathogen distribution of early(within 3 months)bloodstream infection(BSI)after pediatric liver transplantation(LT)and analyze the high-risk variables and prognosis of BSI due to multidrug-resistant organism(MDRO).Methods Between August 2016 and December 2020,the relevant clinical data were reviewed for 872 children undergoing LT at First Central Municipal Hospital.According to the postoperative occurrence of early BSI and whether or not infected bacteria belonged to MDRO,they were assigned into three groups of non-BSI group(n=765),non-MDRO BSI(n=73)and MDRO BSI(n=34).The independent risk variables of early postoperative BSI were identified by univariate and multiple Logistic regression analyses.Survival rates and postoperative complications of three groups were compared.Results Among them,209 pathogen strains in 25 different types were isolated from 107 patients(12.3%,107/872)within Month 3 post-LT.A large majority were Klebsiella pneumoniae(30.9%,64/207)and Enterococcus faecium(23.7%,49/207).Seventy-six MDRO strains were isolated from 34 recipients(36.7%,76/207),mostly carbapenem-resistant K.pneumoniae(56 strains).Antibiotic exposure within one month pre-LT,operative duration,length of ICU stay,reoperation post-LT and hypophosphatemia/hypomagnesemia post-LT were independent risk factors for early postoperative BSI.And early postoperative MDRO BSI was associated with antibiotic exposure within one month pre-LT,abdominal drainage time,postoperative hypophosphatemia and retransplantation.As compared with non-BSI group,another two groups had significantly higher occurrences of postoperative complications,including hepatic artery thrombosis,biliary stricture,cytomegalovirus infection and pulmonary infection.The 1/3-year survival rates were significantly lower in MDRO BSI group than those in non-MDRO BSI and non-BSI groups(76.5%vs 94.5%and 95.8%,P<0.001;73.5%vs 94.5%and 95.4%,P<0.001).Conclusions Early BSI post-LT is common in children.Most cases who have MDRO BSI have a poor pr

关 键 词：肝移植 儿科学 血流感染 预后 危险因素 

分 类 号：R726.5[医药卫生—儿科]