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肺炎克雷伯菌肝脓肿的临床特征及预后影响因素分析

丁蕊 谢雯 刘丽改 王琦 曹颖

引用本文:
Citation:

肺炎克雷伯菌肝脓肿的临床特征及预后影响因素分析

DOI: 10.3969/j.issn.1001-5256.2022.07.023
基金项目: 

北京市科委科技计划重大项目 (D171100003117005)

北京市医院管理中心消化内科学科协同发展中心消化专项重点项 (XXZ0402)

北京市医院管理中心重点医学专业发展计划 (ZYLX201808)

伦理学声明:本研究方案于2021年3月2日经由首都医科大学附属北京地坛医院伦理委员会批准,批号:伦研字(2021)第(006)-01号。
利益冲突声明:本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。
作者贡献声明:谢雯负责课题设计,拟定写作思路;丁蕊负责资料收集,文章撰写;王琦负责指导撰写文章;刘丽改、曹颖负责收集数据,资料分析。
详细信息
    通信作者:

    谢雯,xiewen6218@163.com

Clinical features of Klebsiella pneumoniae liver abscess and influencing factors for prognosis

Research funding: 

Beijing Municipal Science and Technology Commission (D171100003117005);

Digestive Medical Coordinated Development Center of Beijing Municipal Administration (XXZ0402);

Beijing Hospitals Authority of Hospitals Clinical Medicine Development of Special Funding Support (ZYLX201808)

More Information
  • 摘要:   目的  探讨肺炎克雷伯菌肝脓肿的临床特点及预后影响因素。  方法  回顾性选取2010年1月— 2020年1月在首都医科大学附属北京地坛医院住院、并且血培养或脓液培养阳性的肝脓肿患者。根据病原学结果分为肺炎克雷伯菌组(KP组)与非肺炎克雷伯菌组(非KP组)。比较两组之间临床特点。计量资料两组间比较采用两独立样本t检验或Mann-Whitney U检验。计数资料两组间比较采用χ2检验。采用多因素logistic回归分析筛选预后不良的独立影响因素,建立Nomogram预测模型,通过C-index对模型进行内部验证,利用决策曲线对模型进行分析。  结果  共纳入89例有明确病原学结果的肝脓肿患者,KP组48例,非KP组41例。与非KP组患者比较,KP组患者合并2型糖尿病(χ2=12.508,P<0.001)、高血压病(χ2=4.215,P=0.040)、脂肪性肝病(χ2=6.832,P=0.009)的比例较高,而合并恶性肿瘤病史(χ2=15.039,P<0.001)、人类免疫缺陷病毒(HIV)感染(χ2=15.039,P<0.001)、胆囊结石病史(χ2=5.834,P=0.016)的比例较低,KP组患者发生死亡结局的比例(χ2=4.115,P=0.042)亦较非KP组低。KP组白细胞计数(Z=-2.087,P=0.037)、血红蛋白(t=4.67,P<0.001)、纤维蛋白原(Z=-3.300,P=0.001)、C反应蛋白(Z=-3.276,P=0.001)、降钙素原(Z=-0.361,P<0.001)、ALT(Z=-2.436,P=0.015)水平较非KP组高。多因素logistic回归分析显示,合并脓毒症[比值比(OR)=9.110,95%CI: 1.268~65.443,P=0.028]、肺部感染(OR=17.720,95%CI: 2.661~118.010,P=0.003)、低白蛋白水平(OR=0.815,95%CI: 0.692~0.960,P=0.016)是肝脓肿预后不良危险因素,超声引导下脓腔穿刺治疗(OR=8.551,95%CI: 1.549~47.195,P=0. 014)为预后较好保护因素。  结论  KP肝脓肿可能更易发生于糖尿病、高血压、脂肪性肝病人群。合并脓毒症、肺部感染、低白蛋白水平是肝脓肿预后不良危险因素,超声引导下脓腔穿刺治疗为较好预后保护因素。基于本研究构建的列线图预测模型对肝脓肿患者进行干预治疗可改善患者预后。

     

  • 图  1  89例病原学阳性肝脓肿患者病原学分布

    Figure  1.  Etiological distribution of 89 patients with positive pathogen

    图  2  基于logistics回归模型绘制的Nomogram列线图

    Figure  2.  The Nomogram based on logistic regression model

    图  3  Nomogram模型校准曲线

    Figure  3.  The calibration curves of the nomogram mode

    图  4  Nomogram模型DCA

    Figure  4.  The DCA of the nomogram model

    表  1  KP组与非KP组患者基本资料比较

    Table  1.   Comparison of basic characteristics between the KP and non-KP patients

    指标 总例数(n=89) KP组(n=48) 非KP组(n=41) 统计值 P
    年龄(岁) 54.4±13.0 55.2±12.7 53.5±13.4 t=0.610 0.541
    性别(男/女,例) 61/28 30/18 31/10 χ2=1.762 0.184
    基础疾病[例(%)]
      2型糖尿病 35(39.3) 27(56.3) 8(19.5) χ2=12.508 <0.001
      高血压 27(30.3) 19(39.6) 8(19.5) χ2=4.215 0.040
      脂肪性肝病 17(19.1) 14(29.2) 3(7.3) χ2=6.832 0.009
      HIV 17(19.1)) 2(4.2) 15(36.6) χ2=15.039 <0.001
      胆囊结石 13(14.6) 3(6.3) 10(24.4) χ2=5.834 0.016
      腹腔手术史 26(29.2) 11(22.9) 15(36.6) χ2=1.998 0.158
      肝硬化 9(10.1) 2(4.2) 7(17.1) χ2=2.757 0.097
      恶性肿瘤 17(19.1) 2(4.2) 15(36.6) χ2=15.039 <0.001
      慢性肾病 3(3.4) 1(2.1) 2(4.9) χ2=0.019 0.889
    病死率[例(%)] 5(5.6) 0 5(12.2) χ2= 4.115 0.042
    下载: 导出CSV

    表  2  KP组与非KP组患者肝脓肿影像学资料及实验室指标比较

    Table  2.   Comparison of image and laboratory findings between the KP and non-KP patients

    指标 总例数(n=89) KP组(n=48) 非KP组(n=41) 统计值 P
    病灶个数[例(%)] χ2=0.027 0.870
      单发 60(67.4) 32(66.7) 28(68.3)
      ≥2个 29(32.6) 16(33.3) 13(31.7)
    病灶位置[例(%)] χ2=0.622 0.733
      右叶 61(68.5) 33(68.8) 28(68.3)
      左叶 15(16.9) 7(14.6) 8(19.5)
      左右叶 13(14.6) 8(16.7) 5(12.2)
    最大直径(cm) 7.6(4.9~9.9) 8.1(6.4~10.2) 7.0(4.5~8.4) Z=-2.305 0.021
    气腔形成[例(%)] 14(15.7) 9(18.8) 5(12.2) χ2=0.717 0.397
    腹腔积液[例(%)] 18(20.2) 6(12.5) 12(29.3) χ2=3.854 0.050
    脾肿大[例(%)] 28(31.5) 17(35.4) 11(26.8) χ2=0.756 0.385
    白细胞计数(×109/L) 9.6(7.4~13.3) 10.6(8.5~14.0) 8.6(6.4~11.9) Z=-2.087 0.037
    中性粒细胞计数(×109/L) 7.8(6.0~11.4) 8.7(6.9~11.5) 7.2(5.0~10.4) Z=-1.885 0.060
    血红蛋白(g/L) 114.3±21.5 123.1±18.5 103.9±20.2 t=4.670 <0.001
    ALT(U/L) 47.5(23.6~111.8) 66.8(28.7~125.7) 37.7(22.4~60.6) Z=-2.436 0.015
    总胆红素(μmol/L) 15.9(7.9~31.0) 16.2(7.9~33.5) 15.7(9.3~21.1) Z=-0.638 0.526
    碱性磷酸酶(U/L) 132.1(85.3~200.2) 154.8(101.2~198.0) 117.2(73.6~202.2) Z=-1.000 0.319
    白蛋白(g/L) 31.8±5.7 32.3±5.6 31.1±5.9 t=0.950 0.344
    肌酐(μmol/L) 62.9(53.0~83.3) 62.9(53.0~103.2) 62.9(54.0~80.0) Z=-0.560 0.578
    INR 1.25(1.17~1.41) 1.3(1.2~1.4) 1.2(1.1~1.4) Z=-0.758 0.451
    纤维蛋白原(mg/dL) 487.0(379.0~591.5) 515.5(464.8~631.2) 455.0(365.0~487.0) Z=-3.300 0.001
    C反应蛋白(mg/L) 156.0(79.9~242.6) 185.4(116.4~293.1) 116.4(51.8~187.0) Z=-3.276 0.001
    降钙素原(ng/mL) 1.4(0.4~10.6) 2.4(0.9~26.6) 0.8(0.2~3.4) Z=-0.361 <0.001
    住院费用(万元) 4.6(2.8~7.2) 4.0(2.8~5.7) 5.1(3.3~8.0) Z=-1.465 0.144
    下载: 导出CSV

    表  3  肝脓肿预后影响因素的多因素logistic回归分析

    Table  3.   Multivariate logistic regression analysis of prognostic factors in patients with liver abscess

    变量 回归系数 SE Wald OR 95%CI P
    脓毒症(有/无) 2.209 1.006 4.823 9.110 1.268~65.443 0.028
    肺部感染(有/无) 2.875 0.967 8.830 17.720 2.661~118.010 0.003
    超声穿刺(未做/做) 2.146 0.872 6.062 8.551 1.549~47.195 0.014
    白蛋白 - 0.205 0.083 6.034 0.815 0.692~0.960 0.016
    纤维蛋白原 - 0.005 0.003 3.131 0.995 0.990~1.001 0.077
    高密度脂蛋白 2.341 1.726 1.839 10.388 0.353~33.285 0.175
    下载: 导出CSV
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