肺炎克雷伯菌肝脓肿的临床特征及预后影响因素分析

丁蕊; 谢雯; 刘丽改; 王琦; 曹颖

doi:10.3969/j.issn.1001-5256.2022.07.023

肺炎克雷伯菌肝脓肿的临床特征及预后影响因素分析

DOI: 10.3969/j.issn.1001-5256.2022.07.023

首都医科大学附属北京地坛医院肝病一科，北京 100015

基金项目:

北京市科委科技计划重大项目 (D171100003117005);

北京市医院管理中心消化内科学科协同发展中心消化专项重点项 (XXZ0402);

北京市医院管理中心重点医学专业发展计划 (ZYLX201808)

伦理学声明：本研究方案于2021年3月2日经由首都医科大学附属北京地坛医院伦理委员会批准，批号：伦研字(2021)第(006)-01号。

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。

作者贡献声明：谢雯负责课题设计，拟定写作思路；丁蕊负责资料收集，文章撰写；王琦负责指导撰写文章；刘丽改、曹颖负责收集数据，资料分析。

详细信息

通信作者:
谢雯，xiewen6218@163.com

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出版历程
- 收稿日期: 2021-11-29
- 录用日期: 2022-03-08
- 出版日期: 2022-07-20

Clinical features of Klebsiella pneumoniae liver abscess and influencing factors for prognosis

Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China

Research funding:

Beijing Municipal Science and Technology Commission (D171100003117005);

Digestive Medical Coordinated Development Center of Beijing Municipal Administration (XXZ0402);

Beijing Hospitals Authority of Hospitals Clinical Medicine Development of Special Funding Support (ZYLX201808)

More Information

Corresponding author: XIE Wen, xiewen6218@163.com(ORCID: 0000-0002-7314-8175)

摘要

摘要: 目的探讨肺炎克雷伯菌肝脓肿的临床特点及预后影响因素。方法回顾性选取2010年1月— 2020年1月在首都医科大学附属北京地坛医院住院、并且血培养或脓液培养阳性的肝脓肿患者。根据病原学结果分为肺炎克雷伯菌组(KP组)与非肺炎克雷伯菌组(非KP组)。比较两组之间临床特点。计量资料两组间比较采用两独立样本t检验或Mann-Whitney U检验。计数资料两组间比较采用χ²检验。采用多因素logistic回归分析筛选预后不良的独立影响因素，建立Nomogram预测模型，通过C-index对模型进行内部验证，利用决策曲线对模型进行分析。结果共纳入89例有明确病原学结果的肝脓肿患者，KP组48例，非KP组41例。与非KP组患者比较，KP组患者合并2型糖尿病(χ²=12.508，P＜0.001)、高血压病(χ²=4.215，P=0.040)、脂肪性肝病(χ²=6.832，P=0.009)的比例较高，而合并恶性肿瘤病史(χ²=15.039，P＜0.001)、人类免疫缺陷病毒(HIV)感染(χ²=15.039，P＜0.001)、胆囊结石病史(χ²=5.834，P=0.016)的比例较低，KP组患者发生死亡结局的比例(χ²=4.115，P=0.042)亦较非KP组低。KP组白细胞计数(Z=-2.087，P=0.037)、血红蛋白(t=4.67，P＜0.001)、纤维蛋白原(Z=-3.300，P=0.001)、C反应蛋白(Z=-3.276，P=0.001)、降钙素原(Z=-0.361，P＜0.001)、ALT(Z=-2.436，P=0.015)水平较非KP组高。多因素logistic回归分析显示，合并脓毒症[比值比(OR)=9.110，95%CI: 1.268~65.443，P=0.028]、肺部感染(OR=17.720，95%CI: 2.661~118.010，P=0.003)、低白蛋白水平(OR=0.815，95%CI: 0.692~0.960，P=0.016)是肝脓肿预后不良危险因素，超声引导下脓腔穿刺治疗(OR=8.551，95%CI: 1.549~47.195，P=0. 014)为预后较好保护因素。结论 KP肝脓肿可能更易发生于糖尿病、高血压、脂肪性肝病人群。合并脓毒症、肺部感染、低白蛋白水平是肝脓肿预后不良危险因素，超声引导下脓腔穿刺治疗为较好预后保护因素。基于本研究构建的列线图预测模型对肝脓肿患者进行干预治疗可改善患者预后。
- 肝脓肿 /
- 肺炎克雷伯菌 /
- 列线图 /
- 预后
Abstract: Objective To investigate the clinical features of Klebsiella pneumoniae liver abscess and the influencing factors for prognosis. Methods A retrospective analysis was performed for the patients with liver abscess who were hospitalized and had positive blood culture or pus culture in Beijing Ditan Hospital, Capital Medical University, from January 2010 to January 2020, and according to the results of etiology, these patients were divided into Klebsiella pneumoniae group (KP group) and non-Klebsiella pneumoniae group (non-KP group). Clinical features were compared between the two groups. The two-independent-samples t test or the Mann-Whitney U test was used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups. A multivariate logistic regression analysis was used to identify independent influencing factors for poor prognosis, and a nomogram predictive model was established based on these factors. Index of concordance (C-index) was used for internal validation, and a decision curve analysis was also performed. Results A total of 89 patients with liver abscess were enrolled, with 48 patients in the KP group and 41 in the non-KP group. Compared with the non-KP group, the KP group had a significantly higher proportion of patients with type 2 diabetes mellitus (χ²=12.508, P < 0.001), hypertension (χ²=4.215, P=0.04), or fatty liver disease (χ²=6.832, P=0.009) and a significantly lower proportion of patients with a medical history of malignant tumor (χ²=15.039, P < 0.001), human immunodeficiency virus infection (χ²=15.039, P < 0.001), or a medical history of gallstones (χ²=5.834, P=0.016), as well as a significantly lower proportion of patients with the outcome of death (χ²=4.115, P=0.042). Compared with the non-KP group, the KP group had significantly higher levels of leukocyte count (Z=-2.087, P=0.037), hemoglobin (t=4.67, P < 0.001), fibrinogen (Z=-3.300, P=0.001), C-reactive protein (Z=-3.276, P=0.001), procalcitonin (Z=-0.361, P < 0.001), and alanine aminotransferase (Z=-2.436, P=0.015). The multivariate logistic regression analysis showed that sepsis (odds ratio [OR]=9.110, 95% confidence interval [CI]: 1.268-65.443, P=0.028), pulmonary infection (OR=17.720, 95%CI: 2.661-118.010, P=0.003), and low albumin level (OR=0.815, 95%CI: 0.692-0.960, P=0.016) were the risk factors for poor prognosis of liver abscess, while ultrasound-guided abscess puncture therapy (OR=8.551, 95%CI: 1.549-47.195, P=0.014) was a protective factor for relatively good prognosis of liver abscess. Conclusion KP liver abscess may be more likely to occur in patients with diabetes mellitus, hypertension, and fatty liver disease. Sepsis, pulmonary infection, and low albumin level are the risk factors for poor prognosis of liver abscess, while ultrasound-guided abscess puncture is a protective factor for relatively good prognosis. Intervention treatment based on the nomogram predictive model established in this study can effectively improve the prognosis of patients with liver abscess.
- Liver Abscess /
- Klebsiella Pneumonia /
- Nomograms /
- Prognosis

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图 1 89例病原学阳性肝脓肿患者病原学分布

Figure 1. Etiological distribution of 89 patients with positive pathogen

下载: 全尺寸图片幻灯片

图 2 基于logistics回归模型绘制的Nomogram列线图

Figure 2. The Nomogram based on logistic regression model

下载: 全尺寸图片幻灯片

图 3 Nomogram模型校准曲线

Figure 3. The calibration curves of the nomogram mode

下载: 全尺寸图片幻灯片

图 4 Nomogram模型DCA

Figure 4. The DCA of the nomogram model

下载: 全尺寸图片幻灯片

表 1 KP组与非KP组患者基本资料比较

Table 1. Comparison of basic characteristics between the KP and non-KP patients

指标	总例数(n=89)	KP组(n=48)	非KP组(n=41)	统计值	P值
年龄(岁)	54.4±13.0	55.2±12.7	53.5±13.4	t=0.610	0.541
性别(男/女，例)	61/28	30/18	31/10	χ²=1.762	0.184
基础疾病[例(%)]
2型糖尿病	35(39.3)	27(56.3)	8(19.5)	χ²=12.508	＜0.001
高血压	27(30.3)	19(39.6)	8(19.5)	χ²=4.215	0.040
脂肪性肝病	17(19.1)	14(29.2)	3(7.3)	χ²=6.832	0.009
HIV	17(19.1))	2(4.2)	15(36.6)	χ²=15.039	＜0.001
胆囊结石	13(14.6)	3(6.3)	10(24.4)	χ²=5.834	0.016
腹腔手术史	26(29.2)	11(22.9)	15(36.6)	χ²=1.998	0.158
肝硬化	9(10.1)	2(4.2)	7(17.1)	χ²=2.757	0.097
恶性肿瘤	17(19.1)	2(4.2)	15(36.6)	χ²=15.039	＜0.001
慢性肾病	3(3.4)	1(2.1)	2(4.9)	χ²=0.019	0.889
病死率[例(%)]	5(5.6)	0	5(12.2)	χ²= 4.115	0.042

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表 2 KP组与非KP组患者肝脓肿影像学资料及实验室指标比较

Table 2. Comparison of image and laboratory findings between the KP and non-KP patients

指标	总例数(n=89)	KP组(n=48)	非KP组(n=41)	统计值	P值
病灶个数[例(%)]				χ²=0.027	0.870
单发	60(67.4)	32(66.7)	28(68.3)
≥2个	29(32.6)	16(33.3)	13(31.7)
病灶位置[例(%)]				χ²=0.622	0.733
右叶	61(68.5)	33(68.8)	28(68.3)
左叶	15(16.9)	7(14.6)	8(19.5)
左右叶	13(14.6)	8(16.7)	5(12.2)
最大直径(cm)	7.6(4.9~9.9)	8.1(6.4~10.2)	7.0(4.5~8.4)	Z=-2.305	0.021
气腔形成[例(%)]	14(15.7)	9(18.8)	5(12.2)	χ²=0.717	0.397
腹腔积液[例(%)]	18(20.2)	6(12.5)	12(29.3)	χ²=3.854	0.050
脾肿大[例(%)]	28(31.5)	17(35.4)	11(26.8)	χ²=0.756	0.385
白细胞计数(×10⁹/L)	9.6(7.4~13.3)	10.6(8.5~14.0)	8.6(6.4~11.9)	Z=-2.087	0.037
中性粒细胞计数(×10⁹/L)	7.8(6.0~11.4)	8.7(6.9~11.5)	7.2(5.0~10.4)	Z=-1.885	0.060
血红蛋白(g/L)	114.3±21.5	123.1±18.5	103.9±20.2	t=4.670	＜0.001
ALT(U/L)	47.5(23.6~111.8)	66.8(28.7~125.7)	37.7(22.4~60.6)	Z=-2.436	0.015
总胆红素(μmol/L)	15.9(7.9~31.0)	16.2(7.9~33.5)	15.7(9.3~21.1)	Z=-0.638	0.526
碱性磷酸酶(U/L)	132.1(85.3~200.2)	154.8(101.2~198.0)	117.2(73.6~202.2)	Z=-1.000	0.319
白蛋白(g/L)	31.8±5.7	32.3±5.6	31.1±5.9	t=0.950	0.344
肌酐(μmol/L)	62.9(53.0~83.3)	62.9(53.0~103.2)	62.9(54.0~80.0)	Z=-0.560	0.578
INR	1.25(1.17~1.41)	1.3(1.2~1.4)	1.2(1.1~1.4)	Z=-0.758	0.451
纤维蛋白原(mg/dL)	487.0(379.0~591.5)	515.5(464.8~631.2)	455.0(365.0~487.0)	Z=-3.300	0.001
C反应蛋白(mg/L)	156.0(79.9~242.6)	185.4(116.4~293.1)	116.4(51.8~187.0)	Z=-3.276	0.001
降钙素原(ng/mL)	1.4(0.4~10.6)	2.4(0.9~26.6)	0.8(0.2~3.4)	Z=-0.361	＜0.001
住院费用(万元)	4.6(2.8~7.2)	4.0(2.8~5.7)	5.1(3.3~8.0)	Z=-1.465	0.144

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表 3 肝脓肿预后影响因素的多因素logistic回归分析

Table 3. Multivariate logistic regression analysis of prognostic factors in patients with liver abscess

变量	回归系数	SE	Wald	OR	95%CI	P值
脓毒症(有/无)	2.209	1.006	4.823	9.110	1.268~65.443	0.028
肺部感染(有/无)	2.875	0.967	8.830	17.720	2.661~118.010	0.003
超声穿刺(未做/做)	2.146	0.872	6.062	8.551	1.549~47.195	0.014
白蛋白	- 0.205	0.083	6.034	0.815	0.692~0.960	0.016
纤维蛋白原	- 0.005	0.003	3.131	0.995	0.990~1.001	0.077
高密度脂蛋白	2.341	1.726	1.839	10.388	0.353~33.285	0.175

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