摘要
目的探讨急性髓系白血病(AML)患者在首次诱导化疗期间肺部感染的病原谱构成与耐药性特征,明确其独立危险因素,并评估以“早期预警—呼吸道管理—抗菌药物协同—导管护理—健康教育”为核心路径的综合护理干预对感染控制及短期临床结局的影响。方法采用单中心回顾性-准前瞻性队列研究设计,纳入2021年6月至2024年12月于福建医科大学附属龙岩第一医院接受首次诱导化疗的AML患者113例,依据是否接受标准化护理路径分为对照组(n=55)与干预组(n=58)。肺部感染的判定依据CDC/NHSN标准,病原菌采用MALDI-TOF质谱鉴定及VITEK2药敏分析,部分补充mNGS检测。观察指标包括肺部感染发生率、抗菌治疗达标时间、去梯度治疗比例、发热持续时间、住院时间、ICU转入率及30日感染相关死亡率。通过Logistic回归明确独立危险因素,并构建预测模型,结合ROC曲线、Hosmer-Lemeshow检验、Brier评分及决策曲线分析(DCA)评估其预测性能。结果肺部感染总发生率为36.28%(41/113),干预组为29.31%(17/58),对照组为43.64%(24/55)(P=0.093)。共分离病原菌41株,以革兰阴性杆菌为主(68.29%),其中铜绿假单胞菌(24.39%)、克雷伯菌属(21.95%)及大肠埃希菌(14.63%)最常见;革兰阳性菌占19.51%,真菌占12.20%。产ESBL菌占肠杆菌科细菌的41.18%,耐碳青霉烯肺炎克雷伯菌(CRKP)占克雷伯菌属的33.33%;铜绿假单胞菌对哌拉西林/他唑巴坦与阿米卡星的敏感率分别为66.67%和72.22%;MRSA占金黄色葡萄球菌的28.57%。Logistic回归分析显示,中性粒细胞绝对计数(ANC)低谷值<0.2×10^(9)/L(OR=2.47,95%CI:1.38-4.42,P=0.002)、粒细胞缺乏持续时间≥11 d(OR=2.13,95%CI:1.19-3.83,P=0.011)、化疗前喹诺酮暴露(OR=1.86,95%CI:1.05-3.30,P=0.034)、口腔黏膜炎≥2级(OR=2.21,95%CI:1.23-3.98,P=0.008)及白蛋白<32 g/L(OR=1.92,95%CI:1.08-3.41,P=0.026)为肺部感染的独立危险因素。构建的感染风险预测模型表现良好,AUC为0.812(95%CI:0.746-0.869),Hosmer-Lemeshow检验P=0.463,Brier评分为0.173,DCA分析提示在0.15-0.55风险阈值范围内具有较高净获益。干预组在抗菌治疗达标时间[18(13-27)h vs.27(19-38)h,P=0.009]、72 h内去梯度治疗比例(43.10%vs.27.08%,P=0.037)、发热持续时间(3.9±1.5 d vs.4.8±1.7 d,P=0.004)及住院时间(23.1±3.6 d vs.26.3±4.2 d,P=0.021)方面均优于对照组;30 d感染相关死亡率显著降低(6.90%vs.14.55%,P=0.048);ICU转入率亦呈下降趋势(8.62%vs.16.36%,P=0.098)。MDR首次检出率由对照组的45.83%下降至干预组的32.35%(P=0.204)。结论AML患者在诱导化疗期间肺部感染以革兰阴性菌为主,耐药水平较高。中性粒细胞显著减少、粒缺时间延长、低白蛋白水平、口腔黏膜损伤及既往喹诺酮暴露为主要危险因素。基于风险模型的早期识别联合路径化护理干预可有效提升感染控制效率、改善短期预后,具有一定临床推广价值。
Objective To investigate the pathogen spectrum and antimicrobial resistance profiles of pulmonary infections during the first induction chemotherapy in patients with acute myeloid leukemia(AML),to identify independent risk factors for infection,and to evaluate the impact of an integrated nursing intervention pathway-comprising"early warning,airway management,antimicrobial coordination,catheter care,and health education"-on infection control and short-term clinical outcomes.Methods A single-center retrospective-quasi-prospective cohort study was conducted,including 113 AML patients who received their first induction chemotherapy between June 2021 and December 2024 at Longyan First Hospital,Fujian Medical University.Patients were stratified into a control group(n=55)and an intervention group(n=58)based on whether they received a standardized nursing pathway.Pulmonary infections were diagnosed according to the CDC/NHSN criteria,with pathogen identification using MALDI-TOF mass spectrometry and VITEK2 antimicrobial susceptibility testing,supplemented by metagenomic next-generation sequencing(mNGS)in selected cases.Outcome measures included incidence of pulmonary infection,time to appropriate antimicrobial therapy,deescalation rate within 72 hours,duration of fever,length of hospital stay,ICU transfer rate,and 30-day infection-related mortality.Logistic regression analysis was used to identify independent risk factors and construct a predictive model.Model performance was evaluated using receiver operating characteristic(ROC)curve analysis,Hosmer-Lemeshow(HL)test,Brier score,and decision curve analysis(DCA).Results The overall incidence of pulmonary infection was 36.28%(41/113),with a lower rate in the intervention group(29.31%,17/58)compared to the control group(43.64%,24/55)(P=0.093).A total of 41 pathogens were isolated,with Gram-negative bacteria accounting for 68.29%,including Pseudomonas aeruginosa(24.39%),Klebsiella spp.(21.95%),and Escherichia coli(14.63%).Gram-positive bacteria accounted for 19.51%,and fungi for 12.20%.Extended-spectrum β-lactamase(ESBL)-producing Enterobacteriaceae accounted for 41.18%,and carbapenem-resistant Klebsiella pneumoniae(CRKP)represented 33.33% of Klebsiella spp.P.aeruginosa showed susceptibility rates of 66.67% to piperacillin/tazobactam and 72.22% to amikacin.Methicillinresistant Staphylococcus aureus(MRSA)accounted for 28.57% of S.aureus isolates.Logistic regression analysis identified the following independent risk factors for pulmonary infection:nadir absolute neutrophil count(ANC)<0.2×10^(9)/L(OR=2.47,95%CI:1.38-4.42,P=0.002),neutropenia duration≥11 days(OR=2.13,95%CI:1.19-3.83,P=0.011),prior fluoroquinolone exposure(OR=1.86,95%CI:1.05-3.30,P=0.034),grade≥2 oral mucositis(OR=2.21,95%CI:1.23-3.98,P=0.008),and serum albumin<32 g/L(OR=1.92,95%CI:1.08-3.41,P=0.026).The constructed infection risk prediction model showed good performance,with an AUC of 0.812(95%CI:0.746-0.869),Hosmer-Lemeshow test P=0.463,Brier score=0.173,and DCA analysis indicating a high net benefit within the 0.15-0.55 risk threshold range.The intervention group had significantly shorter time to appropriate antimicrobial therapy[18(13-27)hours vs.27(19-38)hours,P=0.009],higher de-escalation rate within 72 hours(43.10%vs.27.08%,P=0.037),reduced duration of fever(3.9±1.5 days vs.4.8±1.7 days,P=0.004),and shorter hospital stay(23.1±3.6 days vs.26.34.2 days,P=0.021).The 30-day infection-related mortality was significantly lower in the intervention group(6.90%vs.14.55%,P=0.048),and ICU transfer rate showed a downward trend(8.62%vs.16.36%,P=0.098).The initial detection rate of multidrug-resistant organisms(MDROs)decreased from 45.83% in the control group to 32.35% in the intervention group(P=0.204).Conclusion Pulmonary infections during induction chemotherapy in AML patients are predominantly caused by Gram-negative bacteria,with high levels of antimicrobial resistance.Severe neutropenia,prolonged neutropenia duration,hypoalbuminemia,oral mucosal injury,and prior fluoroquinolone exposure are major risk factors for infection.Early identification based on a risk model combined with a structured nursing intervention pathway significantly enhances infection control efficiency and improves short-term clinical outcomes,demonstrating clinical value for broader implementation.
作者
林艳红
邱红鑫
张扬
赖建连
廖芬芳
陈隆天
LIN Yanhong;QIU Hongxin;ZHANG Yang;LAI Jianlian;LIAO Fenfang;CHEN Longtian(School of Medicine and Nursing,Minzi Vocational and Technical College,Longyan 364000,China;Department of Hematology and Rheumatology,Longyan First Hospital Affiliated to Fujian Medical University)
出处
《中国病原生物学杂志》
北大核心
2025年第12期1556-1561,共6页
Journal of Pathogen Biology
基金
福建省终身教育促进委员会终身教育研究课题项目(No.ZS23040)
福建省中青年教师教育科研项目(No.JAT231278)
闽西职业技术学院校级课题(No.MXZY25XC15)。
关键词
急性髓系白血病
诱导化疗
肺部感染
病原菌谱
耐药性
护理干预
Acute myeloid leukemia
induction chemotherapy
pulmonary infection
pathogen spectrum
antimicrobial resistance
nursing intervention
