2024 年第 10 期 第 19 卷

急诊老年革兰阴性菌血流感染患者短期死亡的危险因素分析

Analysis of risk factors for short-term death in elderly patients with emergency Gram-negative bacteria bloodstream infection

作者：赵敏捷1田兆兴1付燕1王聪2崔北辰1

英文作者：Zhao Minjie1 Tian Zhaoxing1 Fu Yan1 Wang Cong2 Cui Beichen1

单位：1首都医科大学附属北京积水潭医院急诊科，北京100035；2首都医科大学附属北京朝阳医院急诊科，北京100020

英文单位：1Department of Emergency Beijing Jishuitan Hospital Capital Medical University Beijing 100035 China; 2Department of Emergency Beijing Chao-Yang Hospital Capital Medical University Beijing 100020 China

关键词：血流感染；急诊老年患者；革兰阴性菌；危险因素

英文关键词：Bloodstreaminfection;Elderlyemergencypatients;Gram-negativebacteria;Riskfactors

• 摘要：

• 目的 探讨急诊老年革兰阴性菌血流感染患者短期死亡的危险因素。方法 回顾性选取2015年1月1日至2019年12月31日首都医科大学附属北京积水潭医院急诊科收治的年龄≥65岁革兰阴性菌血流感染患者227例的临床资料。根据患者开始治疗90 d后死亡与否，将患者分为死亡组（41例）和生存组（186例）。采用Cox回归分析急诊老年革兰阴性菌血流感染患者死亡的独立危险因素。结果 病原菌以大肠埃希菌［140例（61.7%）］及肺炎克雷伯菌［39例（17.2%）］最为常见。感染部位方面，泌尿系感染最为常见［93例（41.0%）］，其次为肺部感染［51例（22.5%）］。生存组实体肿瘤、脑血管病、急性肾功能衰竭、急性肝功能衰竭、脓毒性休克、留置中心静脉导管、留置尿管、侵入性操作比例均低于死亡组，而早期合理使用抗菌药物比例高于死亡组（均P＜0.05）。生存组住院时间、心率、呼吸频率、D-二聚体定量、血尿素氮、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、查尔森合并症指数评分均短于/低于死亡组，而平均动脉压、血小板计数、血红蛋白、肌钙蛋白I均高于死亡组（均P＜0.05）。多因素Cox回归分析结果显示，实体肿瘤（风险比=3.109，95%置信区间：1.133~8.530，P=0.028）、急性肝功能衰竭（风险比=2.430，95%置信区间：1.072~5.511，P=0.033)、APACHEⅡ评分（风险比=1.216，95%置信区间：1.149~1.286，P＜0.001)是急诊老年革兰阴性菌血流感染患者死亡的独立危险因素，而早期合理使用抗菌药物是独立保护因素（风险比=0.269，95%置信区间：0.123~0.590，P=0.001)。结论 实体肿瘤、急性肝功能衰竭、APACHEⅡ评分是急诊老年革兰阴性菌血流感染患者死亡的独立危险因素，而早期合理使用抗菌药物可以降低患者的病死率，是独立保护因素。

• Objective To discuss the risk factors of short-term death in elderly patients in emergency department with Gram-negative bloodstream infection. Methods Totally 227 patients over 65 years old with Gram-negative bloodstream infections, admitted to the Department of Emergency, Beijing Jishuitan Hospital, Capital Medical University from January 1, 2015 to December 31, 2019, were selected retrospectively. Based on whether they survived after 90 d of treatment, the patients were divided into death group （41 cases）and survival group （186 cases）. The independent risk factors affecting the survival were studied by Cox regression model. Results The most common infection bacteria were Escherichia coli ［140 cases （61.7%）］ and Klebsiella pneumoniae ［39 cases （17.2%）］. As for the sites of infections, the most common were urinary system infections ［93 cases（41.0%）］ and pulmonary infections ［51 cases （22.5%）］. The proportions of solid tumors, cerebrovascular disease, acute renal failure, acute liver failure, septic shock, indwelling central venous catheter, indwelling urinary catheter and invasive operation in the survival group were lower than those in the death group, while the proportion of rational use of antimicrobial drugs in the early stage was higher than that in the death group (all P<0.05). The survival group′s length of hospital stay, heart rate, respiration, D-dimer quantification, blood urea nitrogen, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score, and Charleson comorbidity index score were shorter than/lower than those in the death group, while the mean arterial pressure, platelet count, hemoglobin, and troponin I were higher than those in the death group (all P<0.05). Multivariate Cox regression analysis showed that solid tumor ［hazard ratio (HR)=3.109, 95% confidence interval (CI): 1.133-8.530, P=0.028］, acute liver failure (HR=2.430, 95%CI: 1.072-5.511, P=0.033) and APACHEⅡ score (HR=1.216, 95%CI: 1.149-1.286, P<0.001) were the independent risk factors. However, early appropriate use of antibiotics could reduce the mortality rate, and it was an independent protective factor(HR=0.269, 95%CI: 0.123-0.590, P=0.001). Conclusions Solid tumor, acute liver failure and APACHE Ⅱ score are the independent risk factors for the elderly emergency patients with Gram-negative bacteria bloodstream infection, and early appropriate use of antibiotics can reduce the mortality rate.