两种非社区获得性自发性腹膜炎的临床对比研究及影响短期生存的预测因素分析

发布时间：2018-05-03 11:31

  本文选题：自发性细菌性腹膜炎 + 肝硬化　； 参考：《浙江大学》2017年硕士论文

【摘要】：目的:比较医院获得性和医疗相关性自发性细菌性腹膜炎的临床异同点及病原学现况,并明确影响非社区获得性自发性细菌性腹膜炎短期生存的预测因素,为临床治疗提供帮助。材料和方法:收集2014年1月-2016年6月我院感染科收治的首次发生自发性细菌性腹膜炎且腹水培养阳性的肝硬化患者的临床资料,在排除社区获得性自发性细菌性腹膜炎后,共纳入42例患者。结果:在19例医院获得性自发性细菌性腹膜炎(NA-SBP)和23例医疗相关性自发性细菌性腹膜炎(HCA-SBP)患者的对比中,HCA-SBP组白细胞计数显著大于NA-SBP组(10.6±1.9 VS6.0±0.7,p0.001),同时HCA-SBP组腹水多形核白细胞(PMN)计数也明显大于 NA-SBP 组(2938.6±1000.9VS664.9±359.0,p=0.013)。两组其余基线值及住院后出现的并发症等方面对比均无明显差异。在对相关因素进行校对后,两组患者28天死亡率无明显差异(p=0.274,0.429[0.094-1.959])。病原学现况对比中,NA-SBP组以革兰阳性菌为主(63.2%),HCA-SBP组以革兰阴性菌为主(52.2%),两组对第三代头孢菌素和氟喹诺酮类抗生素均有较高的耐药性,分别为 36.8%VS 21.7%(p=0.281)和 42.1%VS 26.1%(p=0.273)。NA-SBP 组和 HCA-SBP组均有较高的肠球菌感染率,分别为21.1%和17.4%(p=1.000)。在所有患者中只有1例对碳青霉烯类药物耐药,其他均为敏感菌。在单因素生存分析中发现,白细胞10*10^9/L、MELD评分20分、MELD-Na评分25分、合并肝癌、并发急性肾损伤和肝性脑病(3-4级)都与非社区获得性SBP28天内死亡明显相关。在多因素分析中,急性肾损伤与非社区获得性SBP28天死亡明显相关(p=0.037,56.088[1.272-2474.005])。结论:在首次发生非社区获得性SBP的肝硬化患者中,不同的病原菌来源与短期死亡无关(NA-SBPVSHCA-SBP),且两组的基本临床特征相似。在非社区获得性SBP中,对第三代头孢菌素和氟喹诺酮类药物都有较高的耐药性,但对碳青霉烯类的耐药性很低。第三代头孢菌素对非社区获得性SBP的经验性治疗可能并不充分。此外住院过程中出现急性肾损伤是预测非社区获得性SBP28天死亡的独立危险因素。
[Abstract]:Objective: to compare the clinical similarities and differences between hospital-acquired and medically related spontaneous bacterial peritonitis and its etiological status, and to determine the predictors of short-term survival of non-community-acquired spontaneous bacterial peritonitis. To provide assistance for clinical treatment. Materials and methods: the clinical data of patients with spontaneous bacterial peritonitis and positive ascites culture were collected from January 2014 to June 2016 in the infectious department of our hospital to exclude community-acquired spontaneous bacterial peritonitis. A total of 42 patients were included. Results: in 19 patients with nosocomial spontaneous bacterial peritonitis (NA-SBP) and 23 patients with medically associated spontaneous bacterial peritonitis (HCA-SBP), the white blood cell count in HCA-SBP group was significantly higher than that in NA-SBP group (10.6 卤1.9 VS6.0 卤0.7p 0.001g), and that in HCA-SBP group was significantly higher than that in HCA-SBP group. The number of PMNs in NA-SBP group was significantly higher than that in NA-SBP group (2938.6 卤359.0 卤359.0 1000.9VS664.9 卤0.013). There were no significant differences in baseline values and complications after hospitalization between the two groups. After proofreading the related factors, there was no significant difference in the 28 day mortality between the two groups (P = 0.274), 0.429 [0.094-1.959]. The main pathogens in NA-SBP group were Gram-positive bacteria (63.2B) and HCA-SBP (52.2%). Both groups had high resistance to the third generation cephalosporins and fluoroquinolones. The infection rates of Enterococcus in 42.1%VS 26.1%(p=0.273).NA-SBP group and HCA-SBP group were higher than those in 42.1%VS 26.1%(p=0.273).NA-SBP group (21.1%) and HCA-SBP group (17.4%). Only one patient was resistant to carbapenem in all patients, and the others were sensitive bacteria. In univariate survival analysis, leukocyte 10 ^ 9 / L meld score 20% and MELD-Na score 25%, liver cancer complicated with acute renal injury and hepatic encephalopathy (grade 3-4) were significantly correlated with non-community-acquired SBP28 death within days. In multivariate analysis, there was a significant correlation between acute renal injury and mortality on non-community-acquired SBP28 days (0.037%) 56.088 [1.272-2474.005]. Conclusion: in patients with liver cirrhosis with non-community-acquired SBP for the first time, the origin of different pathogens is not related to short-term death, and the basic clinical characteristics of the two groups are similar. In non-community-acquired SBP, the third generation cephalosporins and fluoroquinolones have high resistance, but the resistance to carbapenems is very low. The third generation cephalosporins may not be sufficient in the empirical treatment of non-community-acquired SBP. In addition, acute renal injury during hospitalization is an independent risk factor for non-community-acquired SBP28 death.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R572.2
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本文编号：1838319