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慢性肾功能衰竭是肾内科常见的疾病,多种原因可导致肾实质损伤,并呈进行性发展,引起氮质代谢产物失调,水、电解质及酸碱平衡紊乱,对病人的生活质量和日常生活造成影响[1]。随着医疗技术的不断发展,透析治疗成为肾脏替代疗法之一,腹膜透析(PD)具有设备简单、便于操作以及费用较低等优点,逐渐受到临床的采纳,并取得了显著的治疗效果[2]。然而PD治疗可引起机体免疫力下降,肾功能衰竭病人需要长期住院行PD治疗,且多伴随严重贫血、低蛋白血症及营养不良等症状,这导致医院感染发生率一直持续在较高水平,成为影响病人生存率和预后的重要并发症[3-4]。尽管临床文献对于PD医院感染的高危因素进行了深入研究,但不同地区因医疗条件、基础设施配备及医疗水平有所差异,常用的高危因素难以完全适用于本地区。鉴于此,为提高对慢性肾衰竭PD医院感染病原菌及影响因素的认识及诊治水平,本研究对PD病人资料进行了回顾性分析,以便有针对性提出控制管理措施。现作报道。
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PD病人中发生医院感染42例,感染发生率为21.76%。以呼吸道感染为主,17例(8.81%),其次为泌尿道10例(5.18%)、皮肤黏膜7例(3.63%)、腹膜5例(2.59%)、胃肠道2例(1.04%)、血液1例(0.52%)。
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42例发生医院感染病人送检标本检出病原菌56株,革兰阴性菌44株,占78.57%,革兰阳性菌5株,占8.93%,真菌4株,占7.14%,其他3株,占5.36%(见表 1)。
病原菌 株数 百分率/% 革兰阴性菌 肺炎克雷伯菌 17 30.36 铜绿假单胞菌 11 19.64 大肠埃希菌 9 16.07 阴沟肠杆菌 7 12.50 革兰阳性菌 金黄色葡萄球菌 5 8.93 真菌 白色假丝酵母菌 4 7.14 其他 3 5.36 总计 56 100.00 表 1 PD感染病人病原菌分布情况
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感染组与未感染组年龄、住院时间、透析时间、低蛋白血症、BMI、贫血、心功能不全、血液透析充分、应用PICC差异均有统计学意义(P < 0.05~P < 0.01)(见表 2)。
临床资料 感染组(n=42) 未感染组(n=151) χ2 P 性别 男 25 84 0.20 >0.05 女 17 67 年龄/岁 ≥50 30 52 18.40 < 0.01 < 50 12 99 住院时间/d ≥30 29 67 8.00 < 0.01 < 30 13 84 透析时间/d >25 24 40 11~25 12 77 13.97 < 0.01 < 11 6 34 CRP/(mg/L) ≥10 16 52 0.19 >0.05 < 10 26 99 低蛋白血症 有 27 62 7.13 < 0.01 无 15 89 血清肌酐/(μmol/L) ≥707 25 95 0.14 >0.05 < 707 17 56 BMI/(kg/m2) ≥24 31 49 23.16 < 0.01 < 24 11 102 原发病 慢性肾小球肾炎 14 51 高血压肾损害 9 31 糖尿病肾病 7 24 0.05 >0.05 狼疮性肾炎 5 19 其他 7 26 贫血 是 35 72 16.91 < 0.01 否 7 79 心功能不全 是 27 57 9.41 < 0.01 否 15 94 血液透析充分 是 26 64 5.03 < 0.05 否 16 87 应用PICC 是 22 52 4.48 < 0.05 否 20 99 表 2 不同临床资料病人感染发生情况比较(n)
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以2组之间差异具有统计学意义的年龄、住院时间、透析时间、低蛋白血症、BMI、贫血、心功能不全、血液透析充分、应用PICC为自变量,赋值“1”表示发生,“0”表示未发生,以发生医院感染为应变量进行多因素logistic回归分析,结果显示年龄、住院时间、透析时间、低蛋白血症、BMI、贫血、心功能不全、血液透析充分、应用PICC是PD病人发生医院感染的独立危险因素(P < 0.01)(见表 3)。
变量 B SE Waldχ2 P OR(95%Cl) 年龄(≥50岁=1 vs < 50岁=0) 0.813 0.128 4.52 < 0.01 1.562(1.024~3.267) 住院时间(≥30 d=1 vs < 30 d=0) 0.952 0.056 2.70 < 0.01 1.294(1.132~2.965) 透析时间(≥25个月=1 vs < 25个月=0) 0.630 0.187 3.15 < 0.01 1.34(1.058~3.564) 低蛋白血症(是=1 vs否=0) 1.081 0.150 4.11 < 0.01 1.287(1.521~3.287) BMI(kg/m2) 0.494 0.244 4.05 < 0.01 1.824(1.113~3.562) 贫血(是=1 vs否=0) 0.685 0.326 3.56 < 0.01 1.356(1.054~2.682) 心功能不全(是=1vs否=0) 0.832 0.312 2.83 < 0.01 1.627(0.890~3.162) 血液透析充分(是=1vs否=0) 0.947 0.281 3.26 < 0.01 1.175(1.451~2.893) 应用PICC(是=1 vs否=0) 1.113 0.160 4.53 < 0.01 1.284(1.320~2.941) 表 3 PD病人发生医院感染的logistic回归分析
慢性肾功能衰竭行腹膜透析病人医院感染因素分析
Analysis of the risk factors of nosocomial infection in peritoneal dialysis patients with chronic renal failure
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摘要:
目的探讨慢性肾功能衰竭行腹膜透析(PD)病人发生医院感染的危险因素。 方法回顾性分析行PD的慢性肾功能衰竭病人193例临床资料,按照是否发生医院感染分为感染组与非感染组,分析医院感染情况及病原菌分布情况,比较2组的临床资料,采用多因素logistic分析PD病人发生医院感染的危险因素。 结果42例(21.76%)发生医院感染,其中呼吸道感染17例(8.81%),泌尿道感染10例(5.18%);共培养出病原菌56株,其中革兰阴性菌44株(78.57%),革兰阳性菌5株(8.93%)。感染组与未感染组年龄、住院时间、透析时间、低蛋白血症、体质量指数(BMI)、贫血、心功能不全、血液透析充分、应用中心静脉导管差异均有统计学意义(P < 0.05~P < 0.01);年龄、住院时间、透析时间、低蛋白血症、BMI、贫血、心功能不全、血液透析充分、应用中心静脉导管是引起病人发生医院感染的独立危险因素(P < 0.01)。 结论慢性肾功能衰竭行PD病人医院感染以呼吸道感染和肺炎克雷伯菌较为常见,临床需要警惕高龄、长时间住院和透析、低蛋白血症、贫血、心功能不全的PD病人,预防医院感染的发生。 Abstract:ObjectiveTo investigate the risk factors of nosocomial infection in peritoneal dialysis(PD) patients with chronic renal failure. MethodsThe clinical data of 193 PD patients with chronic renal failure were retrospectively analyzed, and divided into the infection group and non-infection group according to whether occurrence of nosocomial infection.The nosocomial infection situation and distribution of pathogenic bacteria in two groups were analyzed.The clinical data were compared between two groups, and the risk factors of nosocomial infection in PD patients were analyzed using multivariate logistic analysis. ResultsFifty-two PD patients(21.76%) with nosocomial infection were found, which included 17 cases with respiratory tract infections(8.81%) and 10 cases with urinary tract infections(5.18%).A total of 56 strains pathogenic bacteria were cultured, which included 44 strains of gram-negative strains(78.57%) and 5 strains of gram-positive strains(8.93%).The differences of the age, length of hospital stay, dialysis duration, hypoproteinemia, body mass index(BMI), anemia, cardiac insufficiency, full hemodialysis and central venous catheter application between two groups group were statistically significant(P < 0.05 to P < 0.01).The age, length of hospital stay, length of dialysis, hypoproteinemia, BMI, anemia, cardiac insufficiency, adequate hemodialysis and use of central venous catheter were the independent risk factors of nosocomial infection(P < 0.01). ConclusionsThe respiratory tract infection and Klebsiella pneumoniae are the most common nosocomial infections in PD patients with chronic renal failure.Clinical attention should be paid to PD patients with advanced age, long hospitalization, dialysis, hypoproteinemia, anemia and cardiac insufficiency to prevent nosocomial infections. -
Key words:
- renal failure /
- peritoneal dialysis /
- nosocomial infection
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表 1 PD感染病人病原菌分布情况
病原菌 株数 百分率/% 革兰阴性菌 肺炎克雷伯菌 17 30.36 铜绿假单胞菌 11 19.64 大肠埃希菌 9 16.07 阴沟肠杆菌 7 12.50 革兰阳性菌 金黄色葡萄球菌 5 8.93 真菌 白色假丝酵母菌 4 7.14 其他 3 5.36 总计 56 100.00 表 2 不同临床资料病人感染发生情况比较(n)
临床资料 感染组(n=42) 未感染组(n=151) χ2 P 性别 男 25 84 0.20 >0.05 女 17 67 年龄/岁 ≥50 30 52 18.40 < 0.01 < 50 12 99 住院时间/d ≥30 29 67 8.00 < 0.01 < 30 13 84 透析时间/d >25 24 40 11~25 12 77 13.97 < 0.01 < 11 6 34 CRP/(mg/L) ≥10 16 52 0.19 >0.05 < 10 26 99 低蛋白血症 有 27 62 7.13 < 0.01 无 15 89 血清肌酐/(μmol/L) ≥707 25 95 0.14 >0.05 < 707 17 56 BMI/(kg/m2) ≥24 31 49 23.16 < 0.01 < 24 11 102 原发病 慢性肾小球肾炎 14 51 高血压肾损害 9 31 糖尿病肾病 7 24 0.05 >0.05 狼疮性肾炎 5 19 其他 7 26 贫血 是 35 72 16.91 < 0.01 否 7 79 心功能不全 是 27 57 9.41 < 0.01 否 15 94 血液透析充分 是 26 64 5.03 < 0.05 否 16 87 应用PICC 是 22 52 4.48 < 0.05 否 20 99 表 3 PD病人发生医院感染的logistic回归分析
变量 B SE Waldχ2 P OR(95%Cl) 年龄(≥50岁=1 vs < 50岁=0) 0.813 0.128 4.52 < 0.01 1.562(1.024~3.267) 住院时间(≥30 d=1 vs < 30 d=0) 0.952 0.056 2.70 < 0.01 1.294(1.132~2.965) 透析时间(≥25个月=1 vs < 25个月=0) 0.630 0.187 3.15 < 0.01 1.34(1.058~3.564) 低蛋白血症(是=1 vs否=0) 1.081 0.150 4.11 < 0.01 1.287(1.521~3.287) BMI(kg/m2) 0.494 0.244 4.05 < 0.01 1.824(1.113~3.562) 贫血(是=1 vs否=0) 0.685 0.326 3.56 < 0.01 1.356(1.054~2.682) 心功能不全(是=1vs否=0) 0.832 0.312 2.83 < 0.01 1.627(0.890~3.162) 血液透析充分(是=1vs否=0) 0.947 0.281 3.26 < 0.01 1.175(1.451~2.893) 应用PICC(是=1 vs否=0) 1.113 0.160 4.53 < 0.01 1.284(1.320~2.941) -
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