病原学阴性肝脓肿的临床特征分析

郝建宏; 姚娜; 毕铭辕; 张谷芬; 王临旭; 连建奇; 汪春付

doi:10.3969/j.issn.1001-5256.2021.01.022

病原学阴性肝脓肿的临床特征分析

DOI: 10.3969/j.issn.1001-5256.2021.01.022

1.
内蒙古科技大学包头医学院第一附属医院全科医学科，内蒙古包头 014010
2.
空军军医大学第二附属医院传染科，西安 710038

基金项目:

十三五国家科技重大专项 (2017ZX10204401-002-005)

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突，特此声明。

作者贡献声明：郝建宏、姚娜负责撰写论文; 毕铭辕、张谷芬、王临旭参与收集数据，修改论文; 连建奇、汪春付负责课题设计，资料分析，指导撰写文章并最后定稿。

详细信息

作者简介:
郝建宏(1980—)，女，副主任医师，主要从事肝病、不明原因发热等感染性疾病研究

通信作者:
汪春付，wcf402@163.com

中图分类号: R575
计量
- 文章访问数: 680
- HTML全文浏览量: 87
- PDF下载量: 55
- 被引次数: 0
出版历程
- 收稿日期: 2020-06-18
- 录用日期: 2020-07-16
- 出版日期: 2021-01-20

Clinical features of culture-negative liver abscess

1.
Department of General Practice, The First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou, Inner Mongolia 014010, China
2.
Department of Infectious Diseases, The Second Affiliated Hospital of Air Force Medical University, Xi'an 710038, China

摘要

摘要: 目的对比病原学阴性肝脓肿(CNLA)与病原学阳性肝脓肿(CPLA)的临床特点及预后，为早期诊断及有效治疗提供参考。方法回顾性分析2005年—2018年空军军医大学第二附属医院收治的371例肝脓肿病例，其中病原学检查阳性(CPLA组)145例(39.1%)，病原学阴性(CNLA组)226例(60.9%)。比较CNLA组与CPLA组的临床特点、实验室检查、影像学资料及预后。满足正态分布或近似正态分布的计量资料两组间比较采用t检验; 非正态分布的计量资料两组间比较采用Mann-Whitney U检验。计数资料组间比较采用χ²或Fisher精确检验。结果与CNLA组比较，CPLA组患者年龄较大(t=-3.464，P=0.001)，多合并糖尿病(χ²=17.362，P＜0.001)、心血管疾病(χ²=10.827，P=0.001);CNLA组多合并AIDS(χ²=4.354，P=0.037)。与CNLA组比较，CPLA组白细胞计数及中性粒细胞百分比、ALP、GGT、TBil升高更明显(U值分别为20 393、19 711、18 586、19 349、18 496，P值均＜0.05)，白蛋白降低更显著(t=3.348，P=0.001)，基线APACHEⅡ评分≥16分占比更高(χ²=9.550，P=0.002)。CPLA组脓肿直径多大于5 cm，与CPLA组比较差异有统计学意义(χ²=53.61，P＜0.001)。CNLA组选用单纯抗感染治疗相对较多(19.9%)，但两组仍以抗感染联合B超或CT引导下脓肿穿刺引流为主要治疗方法。两组患者在住院天数、复发率及病死率方面差异均无统计学意义(P值均＞0.05)。结论 CNLA组患者年龄较小，不易出现较重的炎症反应和肝功能不全，脓肿直径小不易穿刺引流多见，但整体预后与CPLA无明显差异。常规覆盖肺炎克雷伯菌的经验性抗感染治疗对CNLA患者有效。
- 肝脓肿 /
- 细菌感染 /
- 体征和症状
Abstract: Objective To investigate the clinical features and prognosis of culture-negative liver abscess (CNLA) versus culture-positive liver abscess (CPLA), and to provide a reference for early diagnosis and effective treatment. Methods A retrospective analysis was performed for the clinical data of 371 patients with liver abscess who were admitted to The Second Affiliated Hospital of Air Force Medical University from 2005 to 2018, among whom 145 (39.1%) had positive results of pathogen test (CPLA group) and 226 (60.9%) had negative results (CNLA group). The two groups were compared in terms of clinical features, laboratory examination, imaging data, and prognosis. The t-test was used for comparison of normally distributed or approximately normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test or the Fisher's exact test was used for comparison of categorical data between two groups. Results Compared with the CNLA group, the CPLA group had a significantly older age (t=-3.464, P=0.001) and a significantly higher proportion of patients with diabetes (χ²=17.362, P < 0.001) or cardiovascular disease (χ²=10.827, P=0.001), and compared with the CPLA group, the CNLA group had a significantly higher proportion of patients with AIDS (χ²=4.354, P=0.037). Compared with the CNLA group, the CPLA group had significantly greater increases in leukocyte count, percentage of neutrophils, alkaline phosphatase, gamma-glutamyl transpeptidase, and total bilirubin (U=20393, 19711, 18586, 19349, and 18496, all P < 0.05), a significantly greater reduction in albumin (t=3.348, P=0.001), and a significantly higher proportion of patients with a baseline APACHE Ⅱ score of ≥16 (χ²=9.550, P=0.002). Compared with the CNLA group, the CPLA group had a significantly higher proportion of tumors with a diameter of > 5 cm (χ²=53.61, P < 0.001). In the CNLA group, 19.9% of the patients were treated with anti-infective therapy alone, while for both groups, anti-infective therapy combined with ultrasound- or CT-guided percutaneous drainage was the main treatment method. There were no significant differences in the length of hospital stay, recurrence rate, and mortality rate between the two groups (all P > 0.05). Conclusion Compared with CPLA patients, CNLA patients tend to have a younger age and are less likely to develop severe inflammatory response and liver insufficiency, with a smaller diameter of abscess which is less likely to be treated by percutaneous drainage, while there is no significant difference in prognosis between CPLA patients and CNLA patients.
- Liver Abscess /
- Bacterial Infections /
- Signs and Symptoms

HTML全文

表 1 两组患者基线情况比较

项目	CNLA组(n=226)	CPLA组(n=145)	统计值	P值
性别[例(%)]			χ²=0.094	0.759
男	154(68.1)	101(69.6)
女	72(21.9)	44(20.4)
年龄(岁)	53.4±15.1	58.1±13.0	t=-3.464	0.001
基础疾病[例(%)]
糖尿病	48(21.2)	60(41.4)	χ²=17.362	＜0.001
胆道病	50(22.1)	21(14.5)	χ²=3.333	0.068
肝硬化	14(6.2)	9(6.2)	χ²=0	0.996
手术史	35(15.5)	20(13.8)	χ²=0.201	0.645
心血管疾病	30(13.3)	39(26.9)	χ²=10.827	0.001
肿瘤	24(10.6)	10(6.9)	χ²=1.471	0.225
肾脏疾病	16(7.1)	8(5.5)	χ²=0.356	0.551
AIDS	13(5.8)	2(1.4)	χ²=4.354	0.037
隐源性肝脓肿	70(31.0)	53(36.5)	χ²=1.240	0.265
APACHEⅡ评分[例(%)]			χ²=9.550	0.002
＜16分	163(72.1)	82(56.5)
≥16分	63(27.9)	63(43.5)

下载: 导出CSV

表 2 两组患者临床表现、实验室检查及影像学检查比较

项目	CNLA组(n=226)	CPLA组(n=145)	统计值	P值
临床症状(例)
发热	189	130	χ²=2.662	0.103
腹痛	83	52	χ²=0.028	0.866
消化道症状	9	11	χ²=2.249	0.134
实验室检查
白细胞计数(×10⁹/L)	11.75(1.75~27.97)	14.25(1.16~46.60)	U=20 393	＜0.001
中性粒细胞百分比(%)	82.5(33.9~98.3)	85.7(67.4~98.9)	U=19 711	0.001
血红蛋白(g/L)	109.4±14.7	104.9±15.9	t=1.490	0.137
ALT(U/L)	78(9~679)	78(11~715)	U=17 027	0.524
ALP(U/L)	57(22~574)	127(6~1189)	U=18 586	0.029
GGT(U/L)	67(12~791)	164(4~1200)	U=19 349	0.003
TBil(μmol/L)	25.0(6.7~434.8)	26.0(6.1~309.1)	U=18 496	0.036
Alb(g/L)	33.2±4.6	31.0±5.3	t=3.348	0.001
影像学特点(例)
多个	65	54	χ²=2.916	0.080
双侧	65	45	χ²=0.037	0.847
直径＞5 cm	97	118	χ²=53.61	＜0.001
气腔形成	26	14	χ²=0.314	0.575
分隔形成	21	16	χ²=0.299	0.585
并发症(例)
肺炎	50	38	χ²=0.814	0.367
胸腔积液	29	11	χ²=2.527	0.112
感染性休克	7	3		0.746
其他部位脓肿	8	14	χ²=1.248	0.264

下载: 导出CSV

表 3 两组患者治疗方法及疾病转归情况比较

项目	CNLA组(n=226)	CPLA组(n=145)	统计值	P值
治疗方法[例(%)]				0.004
单纯抗生素	45(19.9)	12(8.3)
抗生素+穿刺引流	177(78.3)	131(90.3)
手术	2(0.8)	2(1.4)
住院天数(d)	17(3~35)	18(7~47)	U=17 716.5	0.185
复发[例(%)]	19(8.4)	15(10.3)	χ²=0.398	0.528
死亡[例(%)]	3(1.3)	2(1.4)	χ²=0.003	0.958

下载: 导出CSV

参考文献(16)

[1]	ZHANG SY, CHEN YX. Progress in diagnosis and treatment of pyogenic liver abscess[J]. J Clin Hepatol, 2018, 34(7): 1577-1580. (in Chinese) DOI: 10.3969/j.issn.1001-5256.2018.07.046 章顺轶, 陈岳祥. 细菌性肝脓肿诊治进展[J]. 临床肝胆病杂志, 2018, 34(7): 1577-1580. DOI: 10.3969/j.issn.1001-5256.2018.07.046
[2]	CHEMALY RF, HALL GS, KEYS TF, et al. Microbiology of liver abscesses and the predictive value of abscess gram stain and associated blood cultures[J]. Diagn Microbiol Infect Dis, 2003, 46(4): 245-248. DOI: 10.1016/S0732-8893(03)00088-9
[3]	CHEN F, ZHANG YT, QIAO HJ, et al. Clinical features of Klebsiella pneumoniae liver abscess[J]. J Clin Hepatol, 2016, 32(4): 764-768. (in Chinese) DOI: 10.3969/j.issn.1001-5256.2016.04.034 陈帆, 张艳亭, 乔慧捷, 等. 肺炎克雷伯菌肝脓肿的临床特征分析[J]. 临床肝胆病杂志, 2016, 32(4): 764-768. DOI: 10.3969/j.issn.1001-5256.2016.04.034
[4]	WU L, ZHANG J, SUN L, et al. Clinical characteristics of 70 cases of Klebsiella pneumoniae liver abscess[J]. Chin J Infect Chemother, 2018, 18(1): 11-17. (in Chinese) https://www.cnki.com.cn/Article/CJFDTOTAL-KGHL201801005.htm 吴柳, 张洁, 孙琳, 等. 肺炎克雷伯菌肝脓肿70例临床分析[J]. 中国感染与化疗杂志, 2018, 18(1): 11-17. https://www.cnki.com.cn/Article/CJFDTOTAL-KGHL201801005.htm
[5]	XIE N. Analysis of pathogenic bacteria in blood culture of 3905 AIDS patients[J]. Hainan Med J, 2012, 23(9): 89-91. (in Chinese) https://www.cnki.com.cn/Article/CJFDTOTAL-HAIN201209041.htm 谢宁. 3905例艾滋病患者血培养病原菌分布结果分析[J]. 海南医学, 2012, 23(9): 89-91. https://www.cnki.com.cn/Article/CJFDTOTAL-HAIN201209041.htm
[6]	CHEN SC, WU WY, YEH CH, et al. Comparison of Escherichia coli and Klebsiella pneumoniae liver abscesses[J]. Am J Med Sci, 2007, 334(2): 97-105. DOI: 10.1097/MAJ.0b013e31812f59c7
[7]	BELLMANN-WEILER R, WEISS G. Pitfalls in the diagnosis and therapy of infections in elderly patients-a mini-review[J]. Gerontology, 2009, 55(3): 241-249. DOI: 10.1159/000193996
[8]	YU YL, WANG JJ, WANG JY. Clinical significance of the combined detection of procalcitonin, fibrin and fibrinogen degradation products and C-reactive protein in children with sepsis[J]. J Clin Transfus Lab Med, 2018, 20(5): 521-524. (in Chinese) DOI: 10.3969/j.issn.1671-2587.2018.05.021 余艳丽, 汪建军, 王军阳. 联合检测PCT、FDP、CRP在儿童脓毒血症中的临床价值[J]. 临床输血与检验, 2018, 20(5): 521-524. DOI: 10.3969/j.issn.1671-2587.2018.05.021
[9]	KHAN R, HAMID S, ABID S, et al. Predictive factors for early aspiration in liver abscess[J]. World J Gastroenterol, 2008, 14(13): 2089-2093. DOI: 10.3748/wjg.14.2089
[10]	CERWENKA H. Pyogenic liver abscess: Differences in etiology and treatment in Southeast Asia and Central Europe[J]. World J Gastroenterol, 2010, 16(20): 2458-2462. DOI: 10.3748/wjg.v16.i20.2458
[11]	CHAN DS, ARCHULETA S, LLORIN RM, et al. Standardized outpatient management of Klebsiella pneumoniae liver abscesses[J]. Int J Infect Dis, 2013, 17(3): e185-e188. DOI: 10.1016/j.ijid.2012.10.002
[12]	LIN C, DONG GF, ZHANG SQ, et al. Clinical and microbiological characteristics of Klebsiella pneumoniae liver abscess[J]. Zhejiang Med J, 2019, 41(16): 1701-1705. (in Chinese) https://www.cnki.com.cn/Article/CJFDTOTAL-ZJYE201916007.htm 林超, 董郭枫, 张思琴, 等. 肺炎克雷伯菌致肝脓肿的临床和微生物学特征分析[J]. 浙江医学, 2019, 41(16): 1701-1705. https://www.cnki.com.cn/Article/CJFDTOTAL-ZJYE201916007.htm
[13]	SHELAT VG, WANG Q, CHIA CL, et al. Patients with culture negative pyogenic liver abscess have the same outcomes compared to those with Klebsiella pneumoniae pyogenic liver abscess[J]. Hepatobiliary Pancreat Dis Int, 2016, 15(5): 504-511. DOI: 10.1016/S1499-3872(16)60127-3
[14]	YOON JH, KIM YJ, KIM SI. Prognosis of liver abscess with no identified organism[J]. BMC Infect Dis, 2019, 19(1): 488. DOI: 10.1186/s12879-019-4131-z
[15]	ZENG DH, ZHANG DQ, LIANG YM, et al. Evaluation of the efficacy of percutaneous transhepatic catheter drainage guided by color Doppler ultrasound in the treatment of hepatic abscess[J]. J Prac Hepatol, 2013, 16(6): 561-562. (in Chinese) DOI: 10.3969/j.issn.1672-5069.2013.06.032 曾德辉, 张德强, 梁意敏, 等. 彩超引导下经皮经肝穿刺置管引流治疗肝脓肿的疗效评价[J]. 实用肝脏病杂志, 2013, 16(6): 561-562. DOI: 10.3969/j.issn.1672-5069.2013.06.032
[16]	YANG XP, ZHANG Y, WANG LS, et al. Evaluation on efficacy and safety of precise treatment guided by ultrasound for acquired immune deficiency syndrome patients with liver abscess[J/CD]. Chin J Exp Clin Infect Dis (Electronic Edition), 2017, 11(3): 277-281. (in Chinese) 杨学平, 张瑶, 王连双, 等. 超声引导精准治疗获得性免疫缺陷综合征合并肝脓肿的疗效及安全性评价[J/CD]. 中华实验和临床感染病杂志(电子版), 2017, 11(3): 277-281.