Analysis Of Risk Factors And Clinical Characteristics Of Secondary Infection In Severe Acute Pancreatitis

Objective:This article explored the risk factors and clinical characteristics of secondary infection in severe acute pancreatitis.Methods:Retrospecting study 360 patients diagnosed with SAP who were hospitalized in the First Affiliated Hospital of Kunming Medical University from August 1,2014 to August 31,2019.Patients were divided into the infected group and non-infected group according to whether the infection complications occurred.Then the infected group was divided into four subgroups:lung infection group,urinary tract infection group,pancreas and peripancreatic infection group,multiple organ infection group(2 or more organs)according to the infected area.Explore the clinical characteristics and risk factors of secondary infection and secondary multiple organ infection of SAP,and the prognosis differences among subgroupsResults:1 General information1.1 Incidence,distribution of secondary infection and etiological characteristics of infection A total of 360 cases of SAP patients were included,186 cases(51.67%)of the infected group,and 174 cases(48.33%)of the non-infected group.There were 120 cases(33.33%)in the pulmonary infection group,12 cases(3.33%)in the urinary tract infection group,12 cases(3.33%)in the pancreas and peripancreatic infection group,and 42 cases(11.67%)in the multi-organ infection group(2 or more organs).There were 45 positive cases of pathogenic bacteria in culture(blood/body fluid/drainage fluid/secretion,etc.),according to the amount of the pathogenic bacteria,the results are 35 cases(77.78%)of gram-negative bacilli in culture:14 cases of klebsiella pneumoniae,8 cases of escherichia coli,5 cases of pseudomonas aeruginosa and 4 cases of acinetobacter baumannii.4 other cases(burkholderia onionis:2;Acid producing klebsiella:1 case;Enterobacter cloacae:1 case);gram-positive cocci:5 cases(11.11%):enterobacter feces:2 cases;streptococcus grass green 2 cases;staphylococcus human subspecies 1 case;fungus 4 cases(8.89%);gram positive bacilli(2.22%):corynebacterixun 1 case.1.2 Gender There were 130 cases(69.89%)of male and 56 cases(30.11%)of female in the infected group,124 cases(71.26%)of male and 50 cases(28.74%)of female in the non-infected group,there was no significant difference(P>0.05).1.3 Age The difference in the age between the infected group(47(20)years old)and the non-infected group(44(20)years old)was statistically significant(p<0.05 or p<0.01).1.4 BMI BMI 24.39(5.43)(kg/m2)of the infected group was not significantly different from that of the non-infected group 24.44(5.16)(kg/m2)(P>0.05).1.5 Previous history and personal history The previous history of hyperlipidemia(13.44%)of infected group was higher than that of non-infected group(6.90%),and the difference was statistically significant(P<0.05 or P<0.01).The previous history of diabetes(18.82%),alcohol consumption(33.87%)of the infected group was higher than that of non-infected group(14.37%,27.59%),pancreatitis(28.49%),fatty liver(11.80%),and smoking history(38.71%)of the infected group was lower than that of non-infected group(33.33%,18.97%,43.68%),and there were no significant differences(P>0.05).1.6 Causes The causes of disease of infected group were:biliary(23.66%),alcoholic(20.43%),dietary(17.74%)hyperlipidemia(14.52%),multifactorial(12.37%),idiopathic(5.38%),pancreatic stone(3.76%),drug(1.61%)and autoimmune(0.54%)in turn.As for non-infection group:alcohol(24.14%),dietary(23.56%),biliary(21.26%),hyperlipidemia(13.79%),polygenic(6.32%),idiopathic(5.75%),pancreatic stone(4.60%),and autoimmune(0.57%).Comparison of each factors between two groups had no statistical significance(P>0.05).2 The complications2.1 Systemic complications Systemic complications of infected group(100%)was higher than that of the non-infected group(97.70%),including hypoalbuminemia(66.67%vs 43.68%),abdominal cavity effusion(76.88%vs 42.53%),pleural effusion(39.78%vs 13.22%),renal insufficiency(23.66%vs 10.92%),hypoxemia(20.97%vs 5.75%),and the difference was statistically significant(P<0.05 or P<0.01).As for hyperglycemia,hepatic insufficiency,hyperlipidaemia,pancreatic encephalopathy,hemorrhage of upper gastrointestinal tract,there was no statistically significant difference(P>0.05).2.2 Local complications The incidence of local complications of infected group(87.10%)was higher than that of non-infected group(69.54%).Including APFC(77.42%vs 62.64%),PPC(16.77%vs 9.20%),ANC(22.04%vs 12.64%),and WON(4.84%vs 1.14%).The difference was statistically significant(P<0.05 or P<0.01).3 Laboratory examination The level of RDW-CV,CRP,PCT,PT,FDP,D-dimer of infected group was higher,while the level of RBC,Hb,HCT,ALB,serum calcium was lower than that of non-infected group,and difference was statistically significant(P<0.05 or P<0.01).WBC,BUN,Glu,LDH and FIB in the infected group were higher than those in the non-infected group,while AMY,LIP and TG were lower than those in the non-infected group,the difference was not statistically significant(P>0.05).4 Scoring system There was no statistically significant difference in MCTSI score?BISAP score and Ranson score(P>0.05)between two groups.5 Treatment methods The artificial mechanical ventilation rate(10.75%vs 0.57%),CRRT(7.53%vs 0.00%),fasting time[7(7)(d)vs 6(5)(d)],abdominal puncture rate(13.98%vs 1.15%)between two groups were significantly different(P<0.05 or P<0.01),which were higher in the infected group.While the differences in penicillium preventive carbon alkene antibiotics,PPI,anticoagulants,prokinetics,glucocorticoid,probiotics,gastrointestinal decompression between two groups were not statistically significante(P>0.05).The EN group were divided into 3 subgroups according to the starting time:24 hours,48 hours and 72 hours.The statistically significant cut-off points were 24 hours and 48 hours(P<0.05 or P<0.01).6 Prognosis6.1 Outcome 13 cases in infected group died(6.99%)while 0 died case in non-infected group,the difference was statistically significant(p<0.05 or p<0.01).Among 13 died cases,10 cases(76.92%)of multiple organ infection group,2 cases(15.38%)of lung infection group and 1 case(7.69%)of pancreas and peripancreatic infection group.Difference between multiple organ infection and pulmonary infection group was statistically significant(p<0.05 or p<0.01).6.2 Length of hospital stay Length of hospital stay 13(10)(days)in the infected group was higher than that in the non-infected group 9(5)(days),there was statistically significant difference(p<0.05 or p<0.01).Lung infection group 11(6)(days),urinary tract infection group 9.5(10)(days),pancreas and peripancreatic infection group 12.5(9)(days),multi-organ infection group 24.5(39)(days).The difference between single organ infection groups respectively and multiple organ infection group were statistically significant(P<0.05 or P<0.01),but the differences between each single organ infection group were not statistically significant(P>0.05).6.3 Hospitalization expenses The hospitalization expenses of the infected group were 26056.81(28322.85)(RMB),higher than that of the non-infected group 16760.40(14072.59)(RMB),there was significant diffence(p<0.05 or p<0.01).Lung infection group 22944.31(19330.27)(RMB),urinary tract infection group 18016.36(21436.57)(RMB),pancreas and peripancreatic infection group 19098.31(14292.52)(RMB),multiple organ infection group 79139.09(180499.39)(RMB).The difference between single organ infection groups respectively and multiple organ infection group were statistically significant(P<0.05 or P<0.01),but the differences between each single organ infection group were not statistically significant(P>0.05).7.Independent risk factors of secondary infection in SAP Multivariate logistic regression analysis showed regression(OR=1.025,95%CI=1.007-1.043,P=0.005).Pleural effusion(OR=2.144,95%CI=1.215-3.784,P=0.008),abdominal effusion(OR=2.302,95%CI=1.214-4.368,P=0.011),history of hyperlipidemia(OR=2.510,95%CI=1.051-5.994,P=0.038),ALB(OR=0.863,95%CI=0.863-0.941,P<0.001)and abdominal puncture(OR=0.863,95%CI=0.863-0.941,P<0.001)were independent risk factors of secondary infection in SAP.8.Influence factors of multiple organ infection RDW-CV,BUN,CRP,PCT,PT,FDP,LDH,D-dimer,artificial mechanical ventilation rate and CRRT,gastrointestinal decompression,penicillium carbon alkene preventive antibiotics,probiotics,abdominal puncture,fasting time is significantly higher than that of uninfected group,while the RBC,Hb,HCT,ALB,Ca2+ is lower than that of uninfected group,the differences were statistically significant(P<0.05 or P<0.01).9.Risk factors of secondary multi-organ infection of SAP Multivariate logistic regression analysis showed that Hb(OR=0.945,95%CI=0.921-0.969,P<0.001),PCT(OR=1.092,95%CI=1.024-1.166,P=0.008),peritoneal puncture(OR=0.009,95%CI=0.001-0.084,P<0.001),and artificial mechanical ventilation(OR=0.005,95%CI=0.000-0.080,P<0.001)were independent risk factors of secondary multi-organ infection of SAP.Conclusion1.The incidence of secondary infection of SAP was 51.67%,and the most common area of secondary infection was pulmonary>multi-organ>urinary tract=pancreas and peripancreatic infection.The most common pathogenic bacteria:G-bacilli>G+cocci>fungal>G+bacilli.2.The prognosis of patients with secondary infection,especially those with multi-organ infection was poor,and the mortality,hospital stay and expenses were significantly higher than those of non-infected patients.3.Age,previous history of hyperlipidemia,complications like pleural effusion,peritoneal effusion,ALB and peritoneal puncture are risk factors of secondary infection in SAP.4.Hb,PCT,abdominal puncture and artificial mechanical ventilation are risk factors of secondary multi-organ infection in SAP.5.There is no significant difference about conventional medical treatment between infected group and non-infected group.Invasive operation,prolonged fasting,prophylactic carbapenem antibiotics and probiotics may increase the risk of secondary infection or even multi-organ infection in SAP patients.The timing of the initiation of EN depends on patient's actual situation.6.For the elderly,patients with previous hyperlipidemia,chest/abdominal effusion,anemia tendency and hypoproteinemia,they should be alert to the possibility of secondary infection and early intervention should be performed in time.Meanwhile,the indications and timing of antibiotics and invasive operation should be strictly controlled.