【作者】 李静；

【导师】 张颖；

【作者基本信息】 安徽医科大学 ， 老年医学， 2022， 硕士

【摘要】 目的1.探究超高龄肺部感染患者多重耐药菌感染的现状及危险因素;2.构建和验证超高龄肺部感染患者多重耐药菌感染风险Nomogram模型。方法采用回顾性调查方法,通过医院信息系统(Hospital information system,HIS)回顾性调查2017年1月-2019年12月我院659例超高龄(≥80岁)肺部感染痰培养阳性的住院患者的临床资料(包括年龄、性别、住院时长、吸烟史、药物过敏史、既往手术史,合并症等数据),原始数据中随机抽取150例作为验证集,其余509例作为训练集,使用SPSS20.0分别用单因素和Logistic回归多因素分析训练集中超高龄肺部感染住院患者感染多重耐药菌(MDRB)的独立危险因素。然后应用R 4.0.3软件进行统计分析,构建Nomogram预测模型,并对模型的预测性、准确度及获益性进行验证。结果1.将训练集中数据分为MDRB组和非MDRB组,MDRB组患者203例,其中男性150例,女性53例;年龄80~99岁,平均(86.00±4.46)岁;非MDRB组患者306例,其中男性200例,女性106例;年龄80~99岁,平均(85.85±4.07)岁。MDRB组和非MDRB组的年龄结构差异无统计学意义(P>0.05)。2.659例患者共检出感染病原菌830株,其中274例患者为MDRB感染,感染率为41.58%,检出MDRB菌株331株,占总菌株的39.88%。MDRB种类依次为鲍曼不动杆菌、铜绿假单胞菌、肺炎克雷伯菌、大肠埃希菌、金黄色葡萄球菌、粘质沙雷菌。3.训练集中MDRB组和非MDRB组两组一般临床资料比较发现,两组中长期卧床、呼吸衰竭、脑血管疾病、住院时长≥2周、抗菌药物使用种类≥2种、抗菌药物使用时长≥2周、治疗中吸痰、气管插管、留置胃管、留置尿管、深静脉置管、留置引流管、营养不良、红细胞数量等有统计学意义(P<0.05)。4.以感染多重耐药菌为因变量,单因素分析筛选出的危险因素为自变量进行logistic回归分析显示,超高龄患者肺部感染多重耐药菌与长期卧床、重症肺炎、住院时长≥2周、抗菌药物使用种类≥2种、治疗中吸痰、留置胃管、留置导尿管、深静脉置管、留置引流管等不相关,而抗生素使用时长≥2周(OR=1.852,95%CI:1.234~2.778)、气管插管(OR=3.194,95%CI:1.794~5.686)、呼吸衰竭(OR=2.102,95%CI:1.231~3.591)、脑血管疾病(OR=1.719,95%CI:1.135~2.602)、营养不良(OR=3.551,95%CI:1.391~9.067)为超高龄肺部感染患者感染多重耐药菌的独立危险因素(P<0.05),均与肺部感染MDRB高度相关。5.基于上述5项独立危险因素建立风险列线图模型,训练集和验证集AUC值分别为0.748、0.746,提示模型有良好的诊断能力;经Hosmer-Lemeshow检验(训练集P=0.991,验证集P=0.348),提示模型有良好的拟合优度;通过decision曲线分析显示,模型在较大的阈值内均有较高的获益性。结论1.我院超高龄患者肺部耐药菌感染分析结果与全国耐药菌调查结果存在一定差异,当临床工作中遇到多重耐药菌感染时,应根据本院超高龄肺部感染患者自身的耐药菌分布规律及对各种抗生素的耐药率,慎重选择符合自身规律的抗生素。2.对于超高龄肺部感染患者应注意关注抗生素使用时长、气管插管等危险因素,利用列线图模型个体化评估超高龄肺部感染患者发生多重耐药菌感染的可能性,综合考虑各项指标,制定相应的干预措施。更多还原

【Abstract】 Objective1.To explore the status quo and risk factors of multi-drug resistant bacteria infection in ultra-old patients with pulmonary infection;2.To establishment and validation of Nomogram model for the risk of multi-drug resistant bacteria infection in ultra-old patients with pulmonary infection.MethodsThe clinical data(including age,gender,length of stay,smoking history,drug allergy history,previous surgery history,complications,etc.)of 659 hospitalized patients with positive sputum culture of pulmonary infection in our hospital from January 2017 to December 2019 were retrospectively investigated by using the Hospital Information System(HIS).150 patients were randomly selected from the original data as the verification set,and the remaining 509 patients were used as the training set.SPSS20.0was used to analyze the independent risk factors of infection with multidrug-resistant bacteria in extremely elderly inpatients with pulmonary infection in the training set by univariate and Logistic multivariate regression,respectively.Then,R 4.0.3 software was used for statistical analysis to build Nomogram prediction model,and verified its prediction,accuracy and benefit.Results1.Data from the training set were divided into MDRB group and non-MDRB group.There were 203 patients in the MDRB group,including 150 males and 53 females.The average age was(86.00 ± 4.46)between 80 and 99 years old.There were 306 patients in the non-MDRB group,including 200 males and 106 females.The average age was(85.85 ± 4.07)years old.There was no significant difference in age structure between the MDR group and the non-mdr group(P > 0.05).2.830 strains pathogenic bacteria infection were detected in 659 patients,274 patients for MDRB infection,infection rate is 41.58%,check out the MDRB strains in 331 strains,the total strain of 39.88%.In order,the multidrug-resistant strains were Acinetobacter baumannii,Pseudomonas aeruginosa,Klebsiella pneumoniae,Escherichia coli,Staphylococcus aureus,and Sartorius mucilatus.3.Comparison of general clinical data between the multi-drug resistant bacteria group and the non-multi-drug resistant bacteria group showed that there were statistically significant differences in long-term bed rest,respiratory failure,cerebrovascular disease,length of hospitalization ≥ 2 weeks,types of antibacterial drug use ≥ 2 weeks,duration of antibacterial drug use ≥ 2 weeks,sputum aspiration during treatment,endotracheal intubation,indwelling gastric tube,indwelling urinary tube,deep vein indwelling tube,indwelling drainage tube,malnutrition,and number of red blood cells(P < 0.05).4.Logistic regression analysis showed that infection with multidrug-resistant bacteria was not correlated with long-term bed rest,severe pneumonia,hospitalization duration≥ 2 weeks,antibiotic use ≥ 2 types,sputum aspiration during treatment,indwelling gastric tube,indwelling urethral catheter,deep vein indwelling tube,indwelling drainage tube,etc.However,antibiotic use duration ≥ 2 weeks(OR=1.852,95%CI:1.234～ 2.778),endotracheal intubation(OR=3.194,95%CI:1.794 ～ 5.686),respiratory failure(OR=2.102,95%CI:1.231 ～ 3.591),cerebrovascular disease(OR=1.719,95%CI:1.135 ～2.602),and malnutrition(OR=3.551,95%CI:1.391-9.067)were independent risk factors for multi-drug resistant bacteria infection in ultra-old patients with pulmonary infection(P < 0.05),both highly correlated with pulmonary infection with multidrug-resistant bacteria.5.The risk nomogram model was established based on the above five risk factors.The AUC values of the modeling group and the verification group were 0.748 and 0.746 respectively,indicating that the model had good diagnostic ability.Hosmer-lemeshow test(P=0.991 for the modeling group and P=0.348 for the validation group)indicated that the model had a good goodness of fit.The decision curve analysis shows that the model has a higher benefit within a larger threshold.Conclusion1.There are some differences between the analysis results of pulmonary drug-resistant bacterial infection of the super-aged patients in our hospital and the national drug-resistant bacterial survey results.When multi-drug-resistant bacterial infection is encountered in clinical work,we should carefully choose antibiotics in line with our own rules according to the distribution rules of drug-resistant bacteria and drug resistance rates of various antibiotics of ultra-elderly pulmonary infection patients in our hospital.2.For ultra-old patients with pulmonary infection,attention should be paid to the duration of antibiotic use,endotracheal intubation and other risk factors,and the possibility of multi-drug-resistant bacterial infection in ultra-elderly patients with pulmonary infection should be evaluated individually by using the nomogram model,and the corresponding intervention measures should be developed after comprehensive consideration of various indicators.更多还原