背景:先前的研究表明,合并感染侵袭性肺曲霉病(IPA)的严重流感患者的死亡率高于未合并感染的患者;尽管如此,无流感危重患者的IPA临床结局尚不清楚.
方法:这项回顾性研究在三个研究所进行。从2016年至2018年,确定了所有在重症监护病房(ICU)诊断为IPA的成年患者。logistic回归用于确定与非流感IPA患者住院死亡率相关的潜在危险因素。还对有和没有抗真菌治疗的IPA患者进行了分层分析。最终的模型是使用正向方法建立的,选择p值小于0.05的变量。
结果:研究期间纳入了90例患者,63(70%)是男性。最常见的合并症是糖尿病(n=24,27%),其次是实体癌(n=22,24%)。对50例(56%)患者进行了抗真菌治疗,主要是伏立康唑(n=44)。住院死亡率为49%(n=44)。单因素分析显示,死亡的危险因素包括每日类固醇剂量,APACHEII得分,SOFA得分,C反应蛋白(CRP)水平,碳青霉烯的使用,抗真菌治疗,和卡泊芬净使用。多元回归分析确定了死亡的四个独立危险因素:年龄(赔率比[OR],1.052,p=0.013),每日类固醇剂量(OR,1.057,p=0.002),APACHEII得分(或,1.094,p=0.012),和CRP水平(或,1.007,p=0.008)。此外,多变量分析发现,对于长期使用类固醇的患者,更多的医生会开始抗真菌治疗(p=0.001),较低的白细胞计数(p=0.021),和更高的SOFA评分(p=0.048)。因此,在选择偏差下,抗真菌治疗亚组死亡的独立危险因素是每日类固醇剂量(OR,1.046,p=0.001)和CRP(OR,1.006,p=0.018),而未治疗组死亡的独立危险因素为APACHEII评分(OR,1.232,p=0.007)。
结论:IPA患者的死亡率相当高。总的来说,年龄,使用类固醇,APACHEII得分,和CRP水平被确定为ICU患者死亡的独立危险因素。
BACKGROUND: Previous studies have revealed higher mortality rates in patients of severe influenza coinfected with invasive pulmonary aspergillosis (IPA) than in those without the coinfection; nonetheless, the clinical outcome of IPA in critically ill patients without influenza remains unclear.
METHODS: This retrospective
study was conducted in three institutes. From 2016-2018, all adult patients diagnosed with IPA in the intensive care units (ICUs) were identified. The logistic regression was used to identify the potential risk factors associated with in-hospital mortality in patients with non-influenza IPA. The stratified analysis of IPA patients with and without antifungal therapy was also performed. The final model was established using a forward approach, selecting variables with p-values less than 0.05.
RESULTS: Ninety patients were included during the
study period, and 63 (70%) were men. The most common comorbidity was diabetes mellitus (n = 24, 27%), followed by solid cancers (n = 22, 24%). Antifungal therapy was administered to 50 (56%) patients, mostly voriconazole (n = 44). The in-hospital mortality rate was 49% (n = 44). Univariate analysis revealed that the risk factors for mortality included daily steroid dose, APACHE II score, SOFA score, C-reactive protein (CRP) level, carbapenem use, antifungal therapy, and caspofungin use. Multiple regression analysis identified four independent risk factors for mortality: age (Odds ratio [OR], 1.052, p = 0.013), daily steroid dose (OR, 1.057, p = 0.002), APACHE II score (OR, 1.094, p = 0.012), and CRP level (OR, 1.007, p = 0.008). Furthermore, the multivariable analysis identified that more physicians would initiate antifungal therapy for patients with prolonged steroid use (p = 0.001), lower white blood cell count (p = 0.021), and higher SOFA score (p = 0.048). Thus, under the selection bias, the independent risk factors for mortality in the antifungal treatment subgroup were daily steroid dose (OR, 1.046, p = 0.001) and CRP (OR, 1.006, p = 0.018), whereas the independent risk factor for mortality in the untreated group became APACHE II score (OR, 1.232, p = 0.007).
CONCLUSIONS: Patients with IPA had a substantially high mortality. Overall, age, steroid use, APACHE II score, and CRP level were identified as the independent risk factors for mortality in patients in the ICU.