万古霉素血清谷浓度与急性肾损伤发生及临床疗效关系的研究

发布时间：2018-07-10 00:49

  本文选题：谷浓度 + 万古霉素　； 参考：《南京大学》2014年硕士论文

【摘要】：第一部分万古霉素血清谷浓度与急性肾损伤发生的关系目的探讨万古霉素治疗革兰阳性菌感染过程中血清谷浓度与急性肾损伤发生之间的关系,并分析万古霉素相关急性肾损伤(AKI)患者的临床特点。方法采用前瞻性研究的方法,纳入南京大学医学院附属鼓楼医院重症医学科2013年2月至2014年1月万古霉素经验性或目标性抗感染治疗的74例患者,检测万古霉素血清谷浓度、血肌酐、肌酐清除率,万古霉素的用药剂量及疗程。根据万古霉素治疗期问血肌酐变化,分为AKI组和非AKI组,比较两组患者首次万古霉素血清谷浓度、平均谷浓度和最大谷浓度,并进一步纳入Logistic多因素回归分析,对多因素回归分析有显著性差异的指标绘制受试者工作特征曲线(ROC)。结果纳入研究的74例患者中19例发生AKI,发生率为25.7%,其中57.9%AKI患者肾功能恢复。AKI组患者首次万古霉素谷浓度、平均谷浓度、最大谷浓度均高于非AKI组(均P0.05)。Logistic多因素回归分析结果显示,万古霉素平均谷浓度是引起万古霉素相关AKI发生的危险因素(OR=1.133,95%CI,1.029-1.247,P=0.011),万古霉素平均谷浓度预测AKI的ROC曲线下面积为0.815(95%CI,0.709-0.920),P=0.000,最佳截断值为17.3mg/L,其敏感度和特异度分别为52.6%,83.6%。结论重症感染患者万古霉素治疗重症感染期间可能发生急性肾损伤,万古霉素平均谷浓度是引起急性肾损伤的独立危险因素,平均谷浓度≥17.3mg/L的患者发生AKI的风险增加。第二部分不同万古霉素血清谷浓度对重症感染患者临床疗效的影响目的探讨不同水平万古霉素谷浓度对重症感染患者临床疗效和细菌清除的影响。方法纳入南京大学医学院附属鼓楼医院重症医学科2013年2月至2014年1月万古霉素经验性或目标性抗感染的74例患者,用药期间检测患者万古霉素血清谷浓度,并监测患者用药前后临床症状、感染相关指标(如体温、白细胞计数、中性粒细胞百分比、C反应蛋白、血降钙素原)、细菌培养和胸部X线的变化。根据万古霉素治疗结束后的临床疗效和细菌清除情况,分别将患者分为临床有效组和临床无效组、细菌清除组和未清除组,分别比较两组患者的万古霉素平均谷浓度；并根据患者万古霉素平均谷浓度分为四组：A组(10 mg/L)、B组(10-15 mg/L)、C组(15-20 mg/L)、D组(≥20 mg/L),比较四组患者临床有效率、细菌清除率和住院病死率。结果临床有效组平均谷浓度高于临床无效组均(P0.05),不同万古霉素血清谷浓度患者临床疗效和细菌清除率比较,B、C、D组高于A组,差异具有统计学意义(均P0.05),四组住院病死率无统计学差异。结论万古霉素治疗重症感染的临床疗效和细菌学疗效与血清谷浓度有关,万古霉素谷浓度≥10mg/L临床疗效和细菌学清除更佳。
[Abstract]:Part I the relationship between the concentration of serum vancomycin and the occurrence of acute renal injury objective to explore the relationship between serum concentration of vancomycin and the occurrence of acute renal injury during the treatment of Gram-positive bacteria infection. The clinical features of vancomycin associated acute renal injury (AKI) were analyzed. Methods from February 2013 to January 2014, 74 patients with vancomycin were enrolled in the Department of intensive Medicine, Gulou Hospital affiliated to Medical College of Nanjing University. The serum concentrations of vancomycin were measured. Serum creatinine, creatinine clearance rate, vancomycin dosage and course of treatment. According to the changes of serum creatinine during vancomycin treatment, the patients were divided into AKI group and non-AKI group. The serum concentration of vancomycin, mean valley concentration and maximum valley concentration were compared between the two groups. The operating characteristic curve (ROC) was drawn for the indexes with significant difference in multivariate regression analysis. Results AKI was found in 19 of 74 patients in the study, with an incidence of 25.7.The mean valley concentration of vancomycin in 57.9 AKI patients was the highest in the AKI group. The maximum valley concentration was higher than that in non-AKI group (P0.05). Logistic regression analysis showed that the maximum valley concentration was higher than that in non-AKI group. The mean valley concentration of vancomycin was a risk factor for the occurrence of vancomycin-related AKI (OR1.13395 CIQ 1.029-1.247P0. 011). The area under the ROC curve for predicting the mean valley concentration of vancomycin was 0.815 (95CI0.709-0.920) P0. 000, the best truncation value was 17.3 mg / L, the sensitivity and specificity were 52.6 mg / L and 83.6respectively. Conclusion Vancomycin may occur acute renal injury during the treatment of severe infection. The mean valley concentration of vancomycin is an independent risk factor for acute renal injury. Patients with mean valley concentration 鈮，

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