| Part I The risk factors for 28-day mortality with carbapenem-resistant Klebsiella pneumoniae in critically ill patientsObjective: To evaluate the risk factors of 28-day mortality for CRKP patients in the Department of Intensive Medicine.Methods: This is a retrospective case-control study.To record and to analyze the clinical data of CRKP patients who infectedcarbapenem-resistant Klebsiella pneumoniae who were treated in the Department of Intensive Medicine of Shenzhen Second People’s Hospital from January 2013 to October 2019 and met the selection criteria: including basic information(age,gender,underlying disease,source of infection),the day when the bacterial culture specimen was submitted for inspection(D0),the day when the result of the bacterial culture and drug sensitivity test report came out(D4),biochemical indicators on the fourth day(D8)after the drug sensitivity test reported(blood routine,liver and kidney function,blood coagulation function,blood gas analysis index,myocardial injury index),clinical treatment plan,acute physiology and chronic health score(APACHE Ⅱ),sequential irrigation Organ Failure score(SOFA score),Charlson Comorbidity Index(CCI score),etc.According to the28-day mortalityfor patients,they were divided into a survival group and death group.T-test,χ2 test,adjusted χ2 test,or Fisher’s exact probability method were used for comparison between groups,and univariate and multivariate logistic regression were used to analyze the risk factors of 28-day mortality for CRKP patients.Draw the Receiver operating characteristic curve(ROC curve)and calculate the area under the curve(AUC).The De.Long method was used to test whether the difference between the area under the ROC curve of the combined risk factor equation and each independent risk factor was statistically different.The two-way repeated-measures ANOVA analysis of variance was used to analyze the characteristics of independent risk factors over time(D0,D4,D8).Results:1.A total of 147 CRKP patients were included in this study.According to the inclusioncriteria and exclusion criteria,89 CRKP patients were finally included.Aged between 19-95 years,with a median age of 64.0(48.0-77.0)years,including 66 males(74.15%)and 23 females(25.84%);It divided into two group:survival groups(51cases,57.30%)and death group(38 cases,42.70%).2.Comparison of clinical data between the two groups: death combined with cardiovascular disease,chronic renal insufficiency,PCT,total bilirubin,non-tuberculous bilirubin,aspartate aminotransferase,urea nitrogen,prothrombin time,international standardized ratio,lactate,Troponin,myoglobin,creatine kinase isoenzyme,N-terminal brain natriuretic peptide precursor,APACHE Ⅱ score,SOFA score,number of endotracheal intubation cases and blood purification cases were higher than the survival group,with statistics Significance(P <0.05).The platelet count,hemoglobin,albumin,and tigecycline combined with fosfomycin in the death group were all less than those in the survival group,which was statistically significant(P <0.05).3.The univariate and multivariate logistic regression analysis showed that lactic acid,APACHE Ⅱ score,tigecycline combined with fosfomycin anti-infection program are independent risk factors for 28-day mortality of CRKP patients,the difference is statistically significant(P <0.05).4.The ROC curve showed that the 28-day mortality AUC value of lactic acid in CRKP patients was 80.3%(95% CI,0.71-0.88,P <0.001),and the optimal cutoff point was 3.15 mmol / L.The APACHE Ⅱ score predicts the AUC value of 28-day mortality of CRKP patients is 88.4%(95% CI,0.799-0.942 P <0.001),and the best cut-off point is 21.5 points.Lactate combined with APACHE Ⅱ score predicts the28-day mortality prediction model of CRKP patients: PS = 0.204 * APACHE Ⅱ score+ 1.035 * LACT-7.086.The ROC curve shows that the AUC value of the prediction model is 91.6%(95% CI,0.847-0.985,sensitivity: 0.763;specificity: 0.98).Comparison of the area under the ROC curve: The difference between the combined risk factor equation and the area under the lactic acid ROC curve using the De.long method of Med Calc software is statistically significant.The combined risk factor equation predicts that the 28-day mortality rate of CRKP patients is stronger than lactic acid.The difference between the risk factor combination equation and the area under the ROC curve of the APACHE Ⅱ score was not statistically different,proving that lactic acid has a weak predictive power for 28-day mortality in CRKP patients.5.The two-way repeated-measures ANOVA analysis of variance showed that the difference between the APACHE Ⅱ scores of the death group and the survival group at different times was statistically significant(P <0.05),and the APACHE Ⅱ score level of the death group at three-time points(D0,D4,and D8).It was higher than the survival group and showed an upward trend with time.The APACHE Ⅱ score level had an interactive effect with time;the survival group APACHE Ⅱ score level did not increase significantly at three-time points,D0,D4,and D8.The difference of lactic acid between the death group and the surviving group at different times was statistically significant(P <0.05).The lactic acid level of the death group was higher than that of the surviving group at D0,D4,and D8 time points,and showed a downward trend with time.There was an interactive effect with time;the lactic acid level in the survival group did not increase significantly at D0,D4,and D8.Conclusion: Blood lactate and APACHEⅡ score prediction are independent risk factors for the 28-day mortality of CRKP patients.The combined model is used to predict the 28-day mortality of patients with high sensitivity and specificity.The anti-infection therapy of tigecycline combined with fosfomycin may reduce the28-day mortality of CRKP patients.Part Ⅱ Correlative study on tigecycline combined with fosfomycin for 28-day mortality in CRKP patientsObjective: To evaluate the effect of tigecycline combined with fosfomycin on the 28-day mortality of CRKP patients.Methods: This is a retrospective case-control study.To record and to analyze the clinical data of CRKP patients who infectedcarbapenem-resistant Klebsiella pneumoniae who were treated in the Department of Intensive Medicine of Shenzhen Second People’s Hospital from January 2013 to October 2019 and met the selection criteria:including basic information(age,gender,underlying disease,source of infection),the day when the bacterial culture specimen was submitted for inspection(D0),the day when the result of the bacterial culture and drug sensitivity test report came out(D4),biochemical indicators on the fourth day(D8)after the drug sensitivity test reported(blood routine,liver and kidney function,blood coagulation function,blood gas analysis index,myocardial injury index),clinical treatment plan,acute physiology and chronic health score(APACHE Ⅱ),sequential irrigation Organ Failure score(SOFA score),Charlson Comorbidity Index(CCI score),etc.Those patients who used tigecycline combined with fosfomycin anti-infection therapy were included in the treatment group(33 cases),and patients who without used tigecycline combined with fosfomycin anti-infection therapy were included in the control group(56 cases).T-test,χ2 test,corrected χ2 test,or Fisher’s exact probability method was used for comparison between groups.The 1: 1 propensity score match was used for matching.A total of 44 patients were included in the analysis.Univariate and multivariate logistic regression analysis was used to analyze the correlation between tigecycline combined with fosfomycin anti-infection regimen and 28-day mortality of CRKP patients.A Kaplan-Meier survival curve was drawn to compare the difference in survival curves between the two groups.Perform subgroup analysis according to the infection site,and calculate the odds ratio(OR)of tigecycline combined with fosfomycin in each subgroup.Results:1.A total of 147 CRKP patients were included in this study.According to the inclusion and exclusion criteria,89 CRKP patients were finally included.Aged between 19-95 years,with a median age of 64.0(48.0-77.0)years,including 66 males(74.15%)and 23 females(25.84%);depending on whether tigecycline combined with fosfomycin is used for anti-infection The treatment was divided into 33 cases(37.10%)in the treatment group and 56 cases(62.90%)in the control group.Compared with the control group,the 28-day mortality rate of patients in the treatment group was lower(86.8% VS 13.2%).2.Comparison of clinical data between the two groups: SOFA score,APACHE Ⅱ score,prothrombin time,total bilirubin and unconjugated bilirubin in the control group were all higher than the treatment group,and there was a statistical difference between the groups(P <0.05).A total of 44 CRKP patients were included in the study after matching using the PSM method(22 cases in the treatment group and 22 cases in the control group).After the PSM method was matched,there was no statistically significant difference between the factors.Compared with the control group,the 28-day mortality rate of the patients in the treatment group was lower(50% vs 18.2%).3.The univariate and multivariate logistic analysis showed that after adjusting the CRKP patient’s gender,age,SOFA score,CCI score and other indicators that may affect the patient’s mortality,the treatment group reduced the risk of death at 28 days relative to the control group(OR = 0.22,95% CI: 0.057-0.87,P = 0.031).4.Subgroup analysis showed that the 28-day mortality of CRKP patients with lung infection in the treatment group was better,with an odds ratio of 0.12(95% CI: 0.042-0.37).There was no statistically significant difference between CRKP subgroup,intraperitoneal infection subgroup,central infection subgroup,urinary tract infection,skin,and soft tissue infection subgroup,and mixed infection subgroup(P> 0.05).5.The Kaplan-Meier method: the average survival time of the treatment group and the control group was estimated to be 25.51 days and 18.29 days,and the comparison between the groups was statistically significant(Log Rank P = 0.021).The program can reduce the 28-day mortality of CRKP patients.Conclusions:Tigecycline combined with fosfomycin can reduce the 28-day mortality of CRKP patients.Subgroup analysis of anti-infection treatment with tigecycline combined with fosfomycin in patients with pulmonary infection CRKP can reduce the 28-day mortality rate of patients. |
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