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重症颅脑损伤患者气管切开术后继发肺部真菌感染的危险因素分析
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| 篇名： | 重症颅脑损伤患者气管切开术后继发肺部真菌感染的危险因素分析 |
| TITLE： | |
| 摘要： | 目的：探讨重症颅脑损伤患者气管切开术后继发肺部真菌感染的危险因素，为临床预防和治疗提供参考。方法：采用回顾性研究方法，选择2014年1月－2017年6月鄂州市中心医院（以下简称“我院”）收治的气管切开术后继发肺部真菌感染的重症颅脑损伤患者87例，作为观察组；选择同期住院且术后未继发肺部真菌感染的重症颅脑损伤患者87例，作为对照组。分析观察组患者感染真菌的分布及耐药情况，采用χ2检验和二分类Logistic分析对重症颅脑损伤患者气管切开术后继发肺部真菌感染的危险因素进行探讨。结果：我院观察组患者送检临床标本174份，检出真菌7种共87株，检出率较高的菌种为白色假丝酵母菌（41株，47.13％）和光滑假丝酵母菌（23株，26.44％）。白色假丝酵母菌和热带假丝酵母菌对氟康唑、伊曲康唑、氟胞嘧啶等常用抗真菌药的耐药率低于20％；光滑假丝酵母菌对氟康唑、伊曲康唑、氟胞嘧啶的耐药率超过25％，对两性霉素B和制霉素的耐药率低于20％。χ2检验和二分类Logistic分析结果显示，低蛋白血症、入院时格拉斯哥昏迷评分（GCS）（＜8分）、入院时肌酐清除率（＜30 mL/min）、气管切开辅助通气时间（≥7 d）、抗菌药物使用时间（≥14 d）、抗菌药物联合应用、使用碳青霉烯类药物、使用全身糖皮质激素均为继发肺部真菌感染的独立危险因素[比值比分别为3.02、2.98、2.21、2.05、2.48、2.35、4.74、5.97，95％置信区间分别为（1.59，5.74）、（1.58，5.63）、（1.18，4.41）、（1.11，3.78）、（1.34，4.59）、（1.27，4.34）、（2.49，8.35）、（3.08，11.49），P＜0.05]。结论：我院重症颅脑损伤患者气管切开术后继发肺部感染的真菌以白色假丝酵母菌和光滑假丝酵母菌为主，对常用抗真菌药普遍较为敏感。低蛋白血症、入院时GCS评分、入院时肌酐清除率、气管切开辅助通气时间、抗菌药物联合应用、使用碳青霉烯类药物、使用全身糖皮质激素是重症颅脑患者气管切开术后继发肺部真菌感染的独立危险因素。临床应重视上述危险因素的预测价值，提高诊疗的敏感性和特异性，并根据药敏试验结果合理选用抗真菌药；同时，对于存在上述因素的高危患者，临床应及时给予早期预防性或经验性抗真菌治疗。 |
| ABSTRACT： | OBJECTIVE： To investigate the risk factors for secondary pulmonary fungal infection in patients with severe craniocerebral trauma after tracheotomy， and to provide reference for clinical prevention and treatment. METHODS： In retrospective study， 87 severe craniocerebral trauma patients with secondary pulmonary fungal infection after tracheotomy were selected from Ezhou Municipal Central Hospital （called “our hospital” for short） during Jan. 2014-Jun. 2017 as observation group； 87 severe craniocerebral trauma inpatients without secondary pulmonary fungal infection after tracheotomy were selected as control group. The distribution and drug resistance of infected fungal in observation group were analyzed. χ2 test and binary Logistic analysis were adopted to investigate risk factors of secondary pulmonary fungal infection in patients with severe craniocerebral trauma after tracheotomy. RESULTS： Totally 174 clinical specimens were detected in observation group of our hospital； 7 kinds of fungus were detected and isolated from 87 strains， and the fungi with high detection rate were Candida albicans（41 strains， 47.13％） and Candida glabrata （23 strains， 26.44％）. The resistance rates of C. albicans and Candida tropicalis to commonly used antifungal agents as fluconazole， itraconazole and fluoncytosine were lower than 20％； resistance rates of C. glabrata to fluconazole， itraconazole and fluoncytosine were more than 25％， to amphotericin B and nystatin were lower than 20％. χ2 test and binary Logistic analysis showed that independent risk factors of secondary pulmonary fungal infection included hypoproteinemia， Glasgow coma score （GCS ，＜8 points） at admission， serum creatinine clearance （＜30 mL/min） at admission， tracheal incision ventilation time （≥7 days）， the time of antibiotics use （≥14 days） ， combined use of antibiotics， the use of carbapenems and systemic glucocorticoid [odd ratios were 3.02， 2.98， 2.21， 2.05， 2.48， 2.35， 4.74， 5.97； 95％CI were（1.59，5.74）， （1.58，5.63）， （1.18，4.41）， （1.11，3.78）， （1.34，4.59）， （1.27，4.34）， （2.49，8.35），（3.08，11.49），P＜0.05]. CONCLUSIONS： The fungus of secondary pulmonary fungal infection in patients with severe craniocerebral trauma after tracheotomy in our hospital are mainly C. albicans and C. glabrata， which are sensitive to commonly used antifungal agents. Hypoproteinemia， GCS at admission， serum creatinine clearance rate at admission， tracheal incision ventilation time， the time of antibiotics use， combined use of antibiotics， the use of carbapenems and systemic glucocorticoid are independent risk factors of secondary fungal infection in patients with severe craniocerebral trauma after tracheotomy. It is necessary to pay attention to predictive value of above risk factors， improve sensitivity and specificity of diagnosis and treatment. Antifungal agent should be selected rationally according to the results of drug sensitivity test. At the same time， early prophylactic or empirical antifungal treatment should be given in time for high risk patients with above factors. |
| 期刊： | 2018年第29卷第8期 |
| 作者： | 熊丽，张莹，刘斌，陈胜利，李玉娟 |
| AUTHORS： | XIONG Li，ZHANG Ying，LIU Bin，CHEN Shengli，LI Yujuan |
| 关键字： | 重症颅脑损伤；气管切开术；继发肺部真菌感染；危险因素 |
| KEYWORDS： | Severe craniocerebral trauma； Tracheotomy； Secondary pulmonary fungal infection； Risk factors |
| 阅读数： | 274 次 |
| 本月下载数： | 5 次 |
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