心脏植入装置感染的危险因素及处理策略分析

发布时间：2018-05-12 01:21

本文选题：心脏植入装置 + 感染　；参考：《浙江大学》2016年博士论文

【摘要】：目的探讨心脏植入装置感染的危险因素及处理策略。方法回顾性分析1995年1月至2016年2月在浙江大学医学院附属第二医院心血管内科住院治疗的心脏植入装置感染患者60例。收集患者的基本临床资料、处理策略及随访资料,对患者合并疾病、手术次数、囊袋血肿等危险因素进行总结分析,探讨心脏植入装置感染的危险因素,及心脏植入装置感染后不同处理策略的临床预后。结果60例患者,女性25例(41.7%),平均年龄66.3±13.4岁；20例(33.3%)病原菌培养阳性,40%为金黄色葡萄球菌。感染发生在CIED植入/更换术后14天到96个月(中位：18个月),其中早期感染(1月)6例(10%)、中期感染(1-12月)23例(38.3%)、延迟感染(12～24月)10例(16.7%)、远期感染(24月)21例(35%)；早期感染患者中,女性(p=0.037)、术后曾发生囊袋血肿的患者(p=0.037) CIED感染的发生率显著增加；延迟感染患者中,合并疾病中伴有糖尿病(p=0.020)、冠状动脉粥样硬化性心脏病(p=0.007)、心肌病(p=0.020)、心功能不全(p=0.038),及曾植入复杂类型的CIED(包括ICD、CRT-P/D)(p=0.021)的患者CIED感染的发生率显著增加。其中CRT-P/D感染患者5例,感染发生率为1.2%；CRT植入术后的感染风险与高龄(p=0.044),及合并脑梗死(p=0.042)、痛风(p0.001)、甲状腺功能减退(p0.001)、肿瘤(p0.001)显著相关。60例患者中,表现为单纯囊袋感染52例(86.7%),全身感染8例(13.3%)。合并糖尿病(p=0.047)、低蛋白血症(p=0.047)的患者,发生单纯囊袋感染风险增加；合并心肌病(p=0.007)、心功能不全(p=0.031)的患者全身感染的发生率显著增加。所有患者入院后行清创引流13例(22%),电极离断12例(20%),导线拔除35例(58%)；不同感染程度患者的处理策略选择的差异均无统计意义。患者入院后抗生素平均应用14.9±8.0天；全身感染组抗生素平均使用天数显著多于单纯囊袋感染组[(19.7±10.2) vs (13.0±6.5), p=0.048]。 CIED感染处理后随访1-90个月(中位：48个月)。其中15例感染复发,复发率为25.0%,发生于抗感染治疗后1-27个月(中位：5个月)；导线拔除组的感染复发率显著降低(清创引流vs导线拔除,46.2%vs 5.7%,p=0.013；电极离断vs导线拔除,53.8%vs 5.7%,p0.001)。根据导线拔除方式,分为经静脉组(38例)和开胸组(4例)。开胸组电极导线植入时间显著长于经静脉组[(105.7±48.2)vs(49.0±44.0),p=0.042]；住院天数显著长于经静脉组[(14.9±4.6)vs(24.3±8.1),p=0.005]。两组患者均未出现严重并发症,手术成功率及复发率均无显著差异。结论本中心CIED感染病原菌以金黄色葡萄球菌为主。女性,复杂类型CIED,术后囊袋血肿及伴有冠状动脉粥样硬化性心脏病、糖尿病、心肌病、心功能不全均可影响CIED感染患者的感染时期；高龄,合并脑梗死、痛风、甲状腺功能减退、肿瘤是CRT植入患者感染的高危因素；合并糖尿病、低蛋白血症是发生单纯囊袋感染的危险因素,合并心肌病、心功能不全是发生全身血行感染的危险因素。拔除导线,将CIED完全移除是感染患者的最佳处理策略。经静脉途径可有效拔除电极导线,减少患者住院天数。
[Abstract]:Objective to investigate the risk factors and treatment strategies for the infection of the heart implantation device. Methods a retrospective analysis was made of 60 cases of heart implant infection in the Second Affiliated Hospital of Zhejiang University from January 1995 to February 2016. The basic clinical data, treatment strategies and follow-up data were collected, and the patients were combined with the patients. The risk factors such as disease, operation times, bag hematoma and other risk factors were summarized and analyzed. The risk factors of infection in the heart implantation device were discussed, and the clinical prognosis of different treatment strategies after the infection of the heart implantation device. The results were 60 cases, 25 women (41.7%), the average age was 66.3 + 13.4 years, 20 cases (33.3%) were positive for pathogenic bacteria and 40% were golden yellow grapes. The infection occurred from 14 days to 96 months after CIED implantation / replacement (median: 18 months), of which 6 cases (10%) were early infection (10%), 23 cases (38.3%), 10 cases (16.7%) of delayed infection (12~24 months), 21 cases (24) (24) in delayed infection (12~24 months), and early infection patients (p=0.037) and patients who had sack hematoma after operation (p=0.03 7) the incidence of CIED infection was significantly increased; in patients with delayed infection, the incidence of CIED infection was significantly increased in patients with complicated diseases, including diabetes (p=0.020), coronary atherosclerotic heart disease (p=0.007), cardiomyopathy (p=0.020), cardiac insufficiency (p=0.038), and patients who had implanted complex types of CIED (including ICD, CRT-P/D) (p=0.021). Among the 5 cases of CRT-P/D infection, the incidence of infection was 1.2%; the risk of infection after CRT implantation was associated with the age (p=0.044), the combined cerebral infarction (p=0.042), the gout (p0.001), the hypothyroidism (p0.001), and the tumor (p0.001) significantly related to the.60 cases, 52 cases (86.7%), 8 cases of systemic infection (13.3%), and diabetes mellitus (p=0). .047), patients with hypoproteinemia (p=0.047) increased the risk of simple bag infection; the incidence of systemic infection in patients with cardiomyopathy (p=0.007) and cardiac insufficiency (p=0.031) increased significantly. All patients underwent debridement drainage in 13 cases (22%) after admission, 12 cases (20%), 35 cases (58%); The average use of antibiotics was 14.9 + 8 days after admission, and the average use of antibiotics in the whole body infection group was significantly more than that of the simple bag infection group [(19.7 + 10.2) vs (13 + 6.5), and the p=0.048]. CIED infection was followed up for 1-90 months (median: 48 months). Among them, 15 cases had recurrent infection and recurrence rate. 25%, 1-27 months after anti infection treatment (median: 5 months); the recurrence rate of infection in the wire extraction group was significantly lower (debridement and drainage vs wire extraction, 46.2%vs 5.7%, p=0.013; electrode removal vs wire extraction, 53.8%vs 5.7%, p0.001). According to the method of wire extraction, it was divided into the vein group (38 cases) and the open chest group (4 cases). The electrode guide in the open chest group. The time of line implantation was significantly longer than that of the vein group [(105.7 + 48.2) vs (49 + 44), p=0.042], and the number of days in hospital was significantly longer than that of the transvenous Group [(14.9 + 4.6) vs (24.3 + 8.1)). There were no serious complications in the group p=0.005]. two, and there was no significant difference in the success rate and recurrence rate of the operation. Conclusion the pathogen of CIED infection in this center is with Staphylococcus aureus. Women, complex type CIED, postoperatively sack hematoma and coronary atherosclerotic heart disease, diabetes, cardiomyopathy, cardiac insufficiency can affect the infection period of CIED infected patients; older age, combined cerebral infarction, gout, hypothyroidism, tumor are the high risk factors of CRT implantation in patients with infection; combined diabetes, low protein Anemia is a risk factor for a simple bag infection. Cardiomyopathy combined with cardiac insufficiency is a risk factor for systemic blood infection. Removal of traverse and complete removal of CIED are the best treatment strategies for infected patients. Through the intravenous route, the electrode leads can be removed effectively to reduce the number of patients in hospital.

【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R541

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