【摘要】目的探讨早期联合测定外周血降钙素原（PCT）、C反应蛋白（CRP）和内毒素对不同病原菌血流感染的脓毒症鉴别诊断的临床价值。方法回顾性分析2012年1月至2013年12月首都医科大学附属世纪坛医院ICU血培养阳性的脓毒症患者152例，根据血培养结果分革兰阴性杆菌与革兰阳性球菌及真菌血流感染组，分别观察患者入科后第1天的外周血PCT、CRP、内毒素和三者联合后的水平在早期诊断的价值。结果（1）共收集血流感染病例152例，革兰阴性菌共93例（61.18%），以肺炎克雷伯氏菌、鲍曼不动杆菌、大肠埃希氏菌、洋葱伯克霍尔德菌、铜绿假单胞菌为主;革兰阳性菌43例（28.29%），金黄色葡萄球菌13例（8.55%）;真菌16例（10.53%）。（2）对三组患者的炎症指标进行比较，革兰阴性菌组内毒素阳性60例（64.52%），革兰阳性菌及真菌组均未检测到内毒素阳性值。革兰阴性菌PCT为7.760 （3.365， 28.585）ng/mL，革兰阳性菌为0.705（0.265， 3.225） ng/mL，真菌为1.245（0.543， 1.998） ng/mL，三组间差异具有统计学意义;CRP在革兰阴性菌为（126.0166.53）mg/L，革兰阳性菌（77.5854.21）mg/L，真菌（140.1471.21）mg/L，血流感染真菌组升高更为明显。（3）比较各细菌组的受试者工作特征曲线（ROC曲线）的诊断效应，区分革兰阳性菌组和真菌组的ROC曲线显示，AUC PCT+CRP=0.791，PCT截点为0.92 ng/mL，CRP截点为68.00 mg/L，敏感性为50%，特异性为95.5%;区分革兰阴性菌组和真菌组的ROC曲线显示：AUCPCT+CRP+LPS=0.947， PCT截点为2.16 ng/mL，CRP截点为94.10 mg/L时，内毒素阳性为截点，敏感性为82.8%，特异性为100%;区分革兰阴性菌组和革兰阳性菌组的ROC曲线显示AUCPCT+CRP+LPS =90.2%， PCT截点为2.68 ng/mL，CRP截点为106.5 mg/L，内毒素阳性为截点，敏感性为74.2%，特异性为97.7 %。结论重症监护病房的血流感染仍以革兰阴性菌为主，早期联合外周血PCT、CRP、内毒素检测，与单一炎症因子相比，可明显提高对不同病原菌血流感染脓毒症患者早期诊断的敏感性和特异性。
【关键词】血流感染;脓毒症;革兰阴性菌;革兰阳性菌;真菌;降钙素原;C反应蛋白;内毒素
Early diagnostic value of combined inflammatory cytokines in bloodstream infection with different organisms
Chen Wei，Niu Suping， Zang Xuefeng， Zhao Lei， Sheng Bo.Department of Intensive Care Unit，Beijing Shijitan Hospital，Capital Medical University，Beijing 100038，China
Corresponding author：Chen Wei，Email：hanwa@aliyun.com
【Abstract】ObjectiveTo investigate the expression of procalcitonin（PCT） and C-reactive protein （CRP）， and endotoxin in bloodstream infection with different microorganisms， so as to assess the value of these inflammatory cytokines in early diagnosis of sepsis in bloodstream infections patients.Methods Data of 152 septic bloodstream infected patients with 90 male and 62 female aged from 62 to 102 years and 79.2 16.3 years in average admitted from January 2012 to December 2013 were analyzed retrospectively. According to the results of blood culture，the microorganisms [本文由wWw. 提供，毕业论文 网专业代写教育教学论文和本科毕业 论文以及发表论文服务，欢迎光临]could be categorized into gram-negative bacteria，gram-positive bacteria and fungus groups， and the levels of serum CRP， PCT， and endotoxin were compared among these groups of bloodstream infections patients within 24 hours after admission.Results （1）A total of 152 strains of microorganisms were surveyed including 92 gram-negative strains （ 61.18%） ，43 gram-positive strains （28.29%），and 16 fungal strains （10.53%）.In the gram-negative strains， Klebsiella pneumoniae （n=29），Acinetobacter baumannii （n=24），Escherichia coli （n=23），Burkholderia cepacia （n=9） and Pseudomonas aeruginosa （n=4） were the most common isolates. In the Gram-positive strains， 13 strains of Staphylococcus aureus were isolated. （2） In the gram-negative bacterial bloodstream infections group， there were 60 （64.52%） patients with endotoxin positive， and there were no endotoxin positive cases with detected gram-positive bacteria and fungal bloodstream infections. The median levels of PCT were significantly different among the three groups[gram-negative strains group： 7.760 （3.365， 28.585）ng/mL， gram-positive strains group： 0.705（0.265， 3.225）ng/mL，fungal infection group： 1.245（0.543， 1.998）ng/mL].In the fungal bloodstream infection group，the mean level of CRP was higher than that in other two groups[gram-negative strains group： （126.0166.53）mg/L， gram-positive strains group： （77.5854.21）mg/L ， fungal infection group： （140.1471.21）mg/L].（3） The receiver operating characteristic （ROC） curve of inflammatory cytokines was made for the diagnostic value in bloodstream infections. ROC curve used to distinguish between gram-positive bacterial bloodstream infections group and fungal group showed that AUCPCT+CRP=0.791. When PCT cut-off value was 0.92 ng/ mL，and CRP cut-off value was 68.00 mg/L ， the sensitivity was 50% and the specificity was 95.5%. ROC curve used to distinguish between the gram-negative bacterial bloodstream infections group and fungal group showed that AUCPCT+CRP+LPS=0.947. When PCT cut-off value was 2.16 ng/mL and CRP cut-off value was 94.10 mg/L， and endotoxin was positive， the sensitivity was 82.8% and the
发表于 2018-8-18 21:40:23