Analysis of the Situation and Influencing Factors of Fungal Detection in Adult Patients with Severe Diseases in Tibet Region
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摘要:目的 探究西藏地区成人重症患者真菌检出现状，并进一步分析真菌检出的影响因素。方法 回顾性纳入2018年1月1日至2019年12月31日西藏自治区人民医院重症医学科诊治的全部成人重症患者。根据其送检标本真菌检出结果，分为真菌检出阳性组、真菌检出阴性组。通过电子病历系统收集两组患者的临床资料及其检出真菌的菌株分布情况。采用多因素Logistic回归法分析真菌检出的影响因素。结果 共755例符合纳入和排除标准的成人重症患者(送检标本4917份)纳入本研究，其中真菌检出阳性组142例、真菌检出阴性组613例。共检出真菌192株，其中念珠菌183株(95.3%)、曲霉7株(3.7%)、其他真菌2株(1.0%)。念珠菌中，白色念珠菌164株(89.6%)、光滑念珠菌9株(4.9%)、近平滑念珠菌7株(3.8%)、克柔念珠菌2株(1.1%)、热带念珠菌1株(0.6%)。曲霉中，烟曲霉3株(42.8%)、黑曲霉2株(28.6%)、黄曲霉2株(28.6%)。多因素Logistic回归分析结果显示，高序贯性器官衰竭评分(OR=1.402, 95% CI: 1.277~1.538, P＜0.001)、消化系统重症(OR=2.671, 95% CI: 1.465~4.872, P=0.001)、气管插管时间≥48 h(OR=2.661, 95% CI: 1.611~4.397, P=0.000)、碳青霉烯类药物使用时间≥24 h(OR=2.825, 95% CI: 1.522~5.245, P=0.001)、头孢菌素类+β-内酰胺酶抑制剂类药物使用时间≥24 h(OR=2.678, 95% CI: 1.679~ 4.272, P=0.000)、长ICU住院时间(OR=1.043, 95% CI: 1.011~1.076, P=0.008)是成人重症患者真菌检出的独立危险因素，高居住地海拔(OR=0.999, 95% CI: 0.999~1.000, P=0.040)、高血红蛋白水平(OR=0.994, 95% CI: 0.988~0.999, P=0.020)是其保护因素。结论 西藏地区成人重症患者真菌检出现象并非少见，白色念珠菌是检出的主要菌株。影响真菌检出的因素涉及多个方面，应基于西藏地区特征，针对危险因素采取相应的预防措施。Abstract:Objective To explore the situation of fungal detection in adult patients with severe diseases in Tibet region, and further analyze the influencing factors of fungal detection.Methods All patients admitted to the Department of Critical Care Medicine Tibet Autonomous Region People's Hospital from January 1, 2018 to December 31, 2019 were retrospectively analyzed. According to the results of fungal detection, the patients were then divided into the positive group and the negative group. The distribution of fungal strains detected and clinical data of the two groups were collected by the electronic medical record system. Multivariate Logistic regression was used to analyze the influencing factors of fungal detection.Results A total of 755 severe patients (4917 specimens were submitted) were enrolled, including 142 patients with positive fungal detection and 613 patients with negative fungal detection.Of which, 192 fungal strains were detected, including 183(95.3%) Candida strains, 7(3.7%) Aspergillus strains and 2(1.0%) other fungi strains. Among Candida genus, there were 164 strains (89.6%) of Candida albicans, 9 strains (4.9%) of Candida glabrata, 7 strains (3.8%) of Candida parapsilosis, 2 strains (1.1%) of Candida krusei, and 1 strain (0.6%) of Candida tropicalis. Among Aspergillus, there were 3 strains (42.8%) of Aspergillus fumigatus, 2 strains (28.6%) of Aspergillus niger, and 2 strains (28.6%) of Aspergillus flavus. Multivariate Logistic regression analysis showed that, high sequential organ failure assessment score (OR=1.402, 95% CI: 1.277-1.538, P < 0.001), severe digestive diseases (OR=2.671, 95% CI: 1.465-4.872, P=0.001), the duration of tracheal intubation ≥48 h(OR=2.661, 95% CI: 1.611-4.397, P=0.000), the use of carbapenemes ≥24 h (OR=2.825, 95% CI: 1.522-5.245, P=0.001), the use of cephalosporins plus beta lactamase inhibitor ≥24 h (OR=2.678, 95% CI: 1.679-4.272, P=0.000), and the long ICU stay (OR=1.043, 95% CI: 1.011-1.076, P=0.008) were independent risk factors for fungal detection in adult patients with severe diseases. High altitude of residence (OR=0.999, 95% CI: 0.999-1.000, P=0.040) and the high hemoglobin level (OR=0.994, 95% CI: 0.988-0.999, P=0.020) were protective factors.Conclusions Positive fungal detection in adult patients with severe diseases in the Tibet area is not uncommon, and Candida albicans is the main strain detected. The factors affecting the detection of fungi involve many aspects. Corresponding preventive measures should be taken according to the characteristics of Tibet.
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Key words:
- Tibet region /
- fungus /
- patients with severe diseases /
- influencing factor
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表 1 真菌检出阳性组与真菌检出阴性组患者临床资料比较
指标 真菌检出阳性组(n=142) 真菌检出阴性组(n=613) P值 年龄(x±s, 岁) 53.59±15.24 51.03±15.48 0.073 男性[n(%)] 96(67.6) 390(63.6) 0.372 居住地海拔[M(P25, P75), m] 3680(3650, 3992) 3680(3680, 4020) 0.026 疾病严重程度 APACHE Ⅱ评分(x±s, 分) 16.55±5.83 15.75±5.69 0.133 SOFA评分[M(P25, P75), 分] 10(7, 11) 7(6, 9) ＜0.001 患者来源[n(%)] 0.216 急诊转入 45(31.7) 159(26.0) 0.164 院内其他科室转入ICU 93(65.5) 444(72.4) 0.100 院外转入 4(2.8) 10(1.6) 0.345# 合并疾病[n(%)] 糖尿病 14(9.9) 27(4.4) 0.010 慢性阻塞性肺疾病 7(4.9) 11(1.8) 0.027 慢性消化系统疾病 30(21.1) 79(12.9) 0.012 高血压 54(38.0) 188(30.7) 0.098 冠状动脉粥样硬化性心脏病 14(9.9) 37(6.0) 0.032 实体肿瘤 10(7.0) 35(5.7) 0.972 入院前14 d内使用广谱抗菌药物[n(%)] 2(1.4) 5(0.8) 0.859# 入院前14 d内使用免疫抑制剂[n(%)] 3(2.1) 5(0.8) 0.365# 住院原因[n(%)] 0.013 休克 10(7.0) 36(5.9) 0.600 呼吸系统重症 21(14.8) 52(8.5) 0.022 神经系统重症 65(45.8) 336(54.8) 0.600 消化系统重症 30(21.1) 83(13.6) 0.022 妇产科重症 2(1.4) 34(5.5) 0.037# 多发伤 6(4.2) 38(6.2) 0.366 其他 8(5.7) 34(5.5) 0.967 实验室检测指标 总胆红素[M(P25, P75), μmol/L] 19.70(11.70, 34.42) 17.90(11.10, 28.21) 0.171 血肌酐[M(P25, P75), μmol/L] 77.25(56.00, 118.00) 64.00(48.70, 88.50) ＜0.001 血红蛋白(x±s, g/L) 128.83±42.02 143.38±39.63 ＜0.001 白细胞减少*[n(%)] 8(5.6) 12(2.0) 0.014 APACHE Ⅱ：急性生理学和慢性健康状况评价Ⅱ；SOFA：序贯性器官衰竭评分；*ICU血常规检查白细胞计数低于4.0×109/L；#采用Fisher精确概率法 
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表 2 真菌检出阳性组与真菌检出阴性组患者入院后主要干预措施及ICU住院时间比较
指标 真菌检出阳性组(n=142) 真菌检出阴性组(n=613) P值 手术[n(%)] 腹腔手术 22(15.5) 115(18.8) 0.363 胸腔手术 5(3.5) 37(6.0) 0.239 颅脑手术 52(36.6) 232(37.9) 0.786 其他部位手术 5(3.5) 37(6.0) 0.239 未行手术 58(40.9) 192(31.3) 0.103 管路植入[n(%)] 中心静脉置管留置时间≥24 h 111(78.2) 405(66.1) 0.014 尿管植入时间≥48 h 134(94.4) 555(90.5) 0.146 气管插管时间≥48 h 109(76.8) 328(53.5) 0.000 住院期间抗生素使用情况[n(%)] 碳青霉烯类药物使用时间≥24 h 68(47.9) 112(18.3) 0.000 糖肽类药物使用时间≥24 h 52(36.6) 88(14.4) 0.000 头孢菌素类+β-内酰胺酶抑制剂药物使用时间≥24 h 75(52.8) 170(27.7) 0.000 青霉素类+β-内酰胺酶抑制剂药物使用时间≥24 h 72(50.7) 308(50.2) 0.921 喹诺酮类药物使用时间≥24 h 13(9.2) 39(6.4) 0.236 糖肽类+碳青霉烯类药物使用时间≥24 h 40(28.2) 52(8.5) 0.000 ICU住院时间[M(P25, P75), d] 9(4, 13) 6(3, 11) 0.000
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表 3 真菌检出影响因素的多因素Logistic回归分析结果
指标 β值 SE Wald χ2 OR(95% CI) P值 年龄 0.005 0.007 0.417 1.005(0.990~1.019) 0.518 居住地海拔1 0.000 0.000 4.227 0.999(0.999~1.000) 0.040 居住地海拔2 -0.560 0.027 4.227 0.946(0.897~0.997) 0.040 居住地海拔3 -0.279 0.136 4.227 0.756(0.580~0.987) 0.040 SOFA评分 0.338 0.047 50.826 1.402(1.277~1.538) ＜0.001 合并疾病 糖尿病 0.748 0.480 2.431 2.113(0.825~5.413) 0.119 慢性阻塞性肺疾病 0.274 0.620 0.196 1.315(0.390~4.433) 0.658 慢性消化系统疾病 -0.096 0.300 0.102 0.909(0.505~1.634) 0.749 冠状动脉粥样硬化性心脏病 0.719 0.483 2.220 2.053(0.797~5.288) 0.136 住院原因 呼吸系统重症 0.384 0.369 1.087 1.469(0.713~3.025) 0.297 消化系统重症 0.983 0.307 10.270 2.671(1.465~4.872) 0.001 妇产科重症 -1.369 0.860 2.534 0.254(0.047~1.372) 0.111 入院时实验室检测指标 白细胞减少 0.940 0.594 2.499 2.559(0.798~8.204) 0.114 血肌酐 0.001 0.001 1.475 1.001(0.999~1.002) 0.225 血红蛋白 -0.006 0.003 5.412 0.994(0.988~0.999) 0.020 入院后主要治疗措施 中心静脉置管留置时间≥24 h 0.458 0.269 2.909 1.581(0.934~2.677) 0.088 气管插管时间≥48 h 0.979 0.256 14.609 2.661(1.611~4.397) 0.000 碳青霉烯类药物使用时间≥24 h 1.039 0.316 10.828 2.825(1.522~5.245) 0.001 糖肽类药物使用时间≥24 h 0.363 0.440 0.680 1.437(0.607~3.404) 0.410 头孢菌素类+β-内酰胺酶抑制剂药物使用时间≥24 h 0.985 0.238 17.105 2.678(1.679~4.272) 0.000 糖肽类+碳青霉烯类药物使用时间≥24 h 0.023 0.571 0.002 0.978(0.319~2.996) 0.969 ICU住院时间 0.042 0.016 7.031 1.043(1.011~1.076) 0.008 SOFA：同表 1；居住地海拔1：回归分析时以“m”为单位；居住地海拔2：回归分析时以“100 m”为单位；居住地海拔3：回归分析时以“500 m”为单位
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