摘要
目的 探究重症急性胰腺炎(SAP)伴侵袭性肺真菌病(IPFD)的临床特点、真菌分布及影响因素。方法 回顾性分析2019年1月至2023年12月空军军医大学第一附属医院急诊科收治的26例经肺部真菌检测确诊的SAP合并IPFD患者作为观察组,并按1∶3比例通过倾向评分匹配同期收治的78例无真菌感染的SAP患者作为对照组。分析观察组SAP患者继发IPFD的临床特点、真菌分布状况,采用logistic回归模型分析SAP患者继发IPFD的危险因素;采用ROC曲线评估预测指标对SAP继发IPFD的预测价值。结果 26例SAP患者继发IPFD多发生于SAP病程3~4周(73.1%),多为院内感染(占81.4%),临床以咳嗽、咳痰(92.31%)、低氧血症(PaO_(2)/FiO_(2)≤200 mmHg:73.08%)及影像学新发浸润影(96.15%)为主要表现,血清学检查显示G试验阳性率为69.2%,GM试验阳性率为42.3%;共培养分离真菌26株,以白念珠菌(46.15%)及曲霉菌(23.08%)为主要病原体。多因素logistic回归显示:合并糖尿病(OR=10.576)、低蛋白血症(OR=8.060)、坏死型SAP(OR=20.527)、入院时APACHEⅡ评分> 15分(OR=5.215)、ICU入住时间长(OR=1.150)、侵入性操作史(OR=5.746)、使用全身糖皮质激素(OR=9.876)、广谱抗生素使用时间长(OR=1.237)是SAP继发IPFD的独立危险因素(P<0.05)。ROC分析显示:低蛋白血症、SAP分型、入院时APACHEⅡ评分、ICU入住时间、侵入性操作史、使用全身糖皮质激素、广谱抗生素使用时间及联合预测SAP继发IPFD差异均具有统计学意义(P<0.05);其中联合预测评估SAP继发IPFD的AUC=0.947,95%CI为0.906~0.987,灵敏度为0.923,特异度为0.846,预测价值较高。结论 SAP继发IPFD以白念珠菌和曲霉菌为主。合并糖尿病、低蛋白血症、坏死型SAP、APACHEⅡ评分>15分、ICU入住时间延长、侵入性操作史、使用全身糖皮质激素及广谱抗生素使用时间长是SAP继发IPFD的独立危险因素。
Objective To investigate the clinical features,fungal distribution and analysis of factors affecting severe acute pancreatitis(SAP)with invasive pulmonary fungal disease(IPFD).Methods Twenty-six patients with SAP combined with IPFD diagnosed by lung fungal testing admitted to the emergency department of the First Affiliated Hospital of Air Force Medical University from January 2019 to December 2023 were retrospectively analyzed as the observation group,and 78 SAP patients without fungal infection admitted during the same period were matched by propensity scoring in a 1∶3 ratio as the control group.The clinical characteristics and fungal distribution of secondary IPFD in SAP patients in the observation group were analyzed,and the logistic regression model was used to analyze the risk factors for secondary IPFD in SAP patients;ROC curves were used to assess the predictive value of predictive indicators for secondary IPFD in SAP.Results Secondary IPFD in 26 SAP patients mostly occurred in 3-4 weeks of SAP course(73.1%),mostly nosocomial infections(81.4%),clinical cough,sputum(92.31%),hypoxemia(PaO 2/FiO 2≤200 mmHg:73.08%)and imaging new infiltration shadows(96.15%)as the main manifestations,and the serological examination showed that the G test was positive in 69.2%,and the GM test was positive in 42.3%;a total of 26 fungal strains were cultured and isolated,with Candida albicans(46.15%)and Aspergillus(23.08%)as the main ones.Positive rate was 69.2%and GM test was 42.3%;a total of 26 fungal strains were cultured and isolated,with Candida albicans(46.15%)and Aspergillus(23.08%)as the main pathogens.Multifactorial logistic regression showed that:comorbid diabetes mellitus(OR=10.576),hypoproteinemia(OR=8.060),necrotizing SAP(OR=20.527),APACHEⅡscore>15 on admission(OR=5.215),long ICU stay(OR=1.150),history of invasive operations(OR=5.746),use of systemic glucocorticoids(OR=9.876),and prolonged use of broad-spectrum antibiotics(OR=1.237)were independent risk factors for IPFD secondary to SAP(p<0.05).ROC analysis showed that hypoproteinemia,SAP staging,APACHEⅡscore on admission,ICU stay,history of invasive operations,use of systemic glucocorticoids,broad-spectrum antibiotic use time and combined prediction of IPFD secondary to SAP were statistically significant differences(P<0.05);in which the combined prediction for assessing IPFD secondary to SAP had an AUC=0.947 with a 95%CI of 0.906 to 0.987,a sensitivity of 0.923,and a specificity of 0.846,which had a high predictive value.Conclusion IPFD secondary to SAP is dominated by Candida albicans and Aspergillus,and occurs as a result of a combination of host immunosuppression,pancreatic necrotic microenvironment and medical intervention.Comorbid diabetes mellitus,hypoproteinemia,necrotizing SAP,APACHEⅡscore>15,prolonged ICU stay,history of invasive maneuvers,use of systemic glucocorticoids,and prolonged use of broad-spectrum antibiotics are independent risk factors for IPFD secondary to SAP.
作者
朱传好
郭蕾
罗肖
魏利平
路伟
ZHU Chuanhao;GUO Lei;LUO Xiao;WEI Liping;LU Wei(Digestive Emergency Department of the First Affiliated Hospital of the PLA Air Force Military Medical University,Xi′an,710032,China)
出处
《现代消化及介入诊疗》
2025年第7期747-752,760,共7页
Modern Digestion & Intervention
基金
国家重点军事医学临床应用研究课题(JSYXM29)。
关键词
重症急性胰腺炎
侵袭性肺真菌病
临床特点
真菌分布
影响因素
重症监护
Severe acute pancreatitis
Invasive pulmonary fungal disease
Clinical characteristics
Distribution of fungi
Influencing factors
Intensive care
