40歲以上成年人發生醫療照護相關血流感染之預後因子

Prognostic Factors of Healthcare Associated Bloodstream Infection in Adult Patients Older Than 40 Years

馬瑄吟(Hsuan-Yin Ma)

指導教授 ： 季瑋珠

共同指導教授 ： 盛望徽

國立臺灣大學/公共衛生學院/公共衛生碩士學位學程/碩士(2016年)

https://doi.org/10.6342/NTU201600899

摘要

前言背景
醫療照護相關感染是醫療品質重要指標，其中血流感染佔醫療照護相關感染的比例最高且預後較差。台灣社會高齡化而老年族群比例增加，老年族群被視為較脆弱的族群，容易發生感染以及死亡。然而過去關於醫療照護相關血流感染的研究較少比較老年和中年族群的異同，特別在預後以及預後因子部分。本研究為公共衛生學位學程於臺大醫院感控中心之實習報告，旨在提供台灣本土關於中老年族群醫療照護相關血流感染的共病及基本資料、預後及預後因子的分析。
研究方法
本研究是回溯性、觀察性、世代研究，利用臺大醫院感控中心關於醫療照護相關感染之疫情調查資料，配合病人病歷資料，分析發生醫療照護相關血流感染成年人所具有的人口學與共病特性以及預後因子。特別著重於65歲以上老年人，比較其和40到64歲的中年人之間的差異。
本研究收集2014年1月1日至2014年07月31日間，於臺大醫院一般病房住院患者中，發生醫療照護相關血流感染的40歲以上成年人。將患者分成40至64歲中年族群以及65歲以上老年族群，計算兩族群的人口學特性、共病特性、感染菌種與病房、實驗室數據以及預後情形差異，並且分析兩族群患者發生醫療照護相關感染的預後因子。
針對類別型和連續型變項，分別使用卡方檢定和獨立樣本T檢定，來比較中年族群和老年族群的基本特性和死亡率。以醫療照護相關感染發生後30天內的存活情形為依變項，感控中心收案資料及病歷資料等為自變項，選取粗略勝算比中達統計顯著的變項，利用多變項羅吉斯回歸分析(Multivariable Logistic Regression)，找出相關獨立預後危險因子。最後以年齡分層，進行預後相關危險因子的分層分析。使用SAS 9.3軟體進行資料統計分析，當p value< 0.05表有統計上的顯著差異。
研究結果
老年族群的疾病嚴重度較中年族群高，然而中年病患族群中罹患血液惡性疾病(37%)的比例較老年患者族群(14%)高(P<0.001)，老年族群則較多具有慢性疾病診斷，如：腎臟疾病(29% v.s 13%, p<0.001)、糖尿病(42% v.s 13%, p<0.001)、惡性固體腫瘤(63% v.s 53%, p=0.02)、鬱血性心衰竭(16% v.s 5%, p<0.001)、腦血管意外(13% v.s 6.6%, p<0.001)，老年族群的血清白蛋白數值亦顯著較中年族群低(3.39 v.s 3.78, p<0.001)。老年族群和中年族群在感染菌種和預後方面都沒有統計上顯著差異。經由多因子迴歸分析調整後，高Charlson分數 (OR 1.30, 95% CI 1.10-1.53)、抗藥性金黃色葡萄球菌感染(OR 13.22, 95% CI 1.25-140.19)、抗藥性腸球菌感染(OR 13.86, 95% CI 2.10-91.59)以及高C-反應蛋白數值(C-reative protein, OR 1.08, 95% CI 1.02-1.14)是達到統計上顯著差異的獨立不良預後因子，至於入院時的血清白蛋白指數則為統計顯著的保護因子(OR 0.48, 95% CI 0.27-0.85)。Charlson 分數在老年族群為獨立不良預後因子(OR 1.28, 95% CI 1.05-1.56)，在中年族群，抗藥性金黃色葡萄球菌感染(OR 15.58, 95%CI 1.37-177.30)以及C反應蛋白(OR 1.10, 95%CI 1.03-1.18)為獨立不良預後因子，血清白蛋白指數為獨立保護因子(OR 0.27, 95%CI 0.13-0.58)。
結論
本研究以觀察性、世代研究方式分析醫療照護相關血流感染的預後因子，特別著重於老年族群和中年族群的異同。結果顯示老年族群的疾病嚴重度較群中年族群高，且以慢性疾病居多。疾病嚴重度、血清白蛋白指數以及感染當下的發炎情形和預後較為相關，疾病嚴重度在老年族群特別重要，血清白蛋白指數及感染當下的情況則在中年族群較重要。

關鍵字

醫療照護相關血流感染 ； 老年族群 ； 預後因子

並列摘要

Background:
Healthcare-associated bloodstream infection (HABSI) is an important indicator for healthcare quality, since it may complicate clinical course and worsen outcomes. Geriatric patients are considered to have more vulnerable risk and mortality to infections compared with middle-aged patients. However, the differences in patient characteristics, HABSI outcomes and prognostic factors between geriatric and middle-aged population are scarcely reported. Our study, as a Practicum Report of Master of Public Health Program at Infection Control Center, National Taiwan university Hospital, aims to provide Taiwanese data about the characteristics, outcomes and prognostic factors of HABSI.
Material and Methods:
This is a retrospective cohort study. During the annual surveillance at National Taiwan University Hospital, we systematically reviewed the demographic characteristics, comorbidities, laboratory data and 30-day mortality after HABSI from electronic chart records between January 2014 and July 2014. We are interested in the differences in the clinical characteristics, HABSI-associated outcomes and prognostic factors between geriatric patients (≧65 years) and middle-aged patients (40-64 years). The basic characteristics and mortality of middle-aged patients and geriatric patients were compared using Chi square for categorical variables and t test for continuous variables. We set HABSI-associated 30-day mortality as outcome and use univariable logistic regression and cross table to calculate crude odds ratio. We included the factors with significant crude odds ratio in the multivariable logistic regression to find independent prognostic factors. All statistical analysis was performed using SAS 9.3 with a significance level of 0.05.
Results:
Totally 258 middle-aged patients and 228 geriatric patients were included. Geriatric patients had higher disease severity then middle-aged patients (Charlson score, 5.5 versus 4.6; p<0.001). Higher percentage of middle-aged patients had hematological malignancy (37% versus 14%, p<0.001), while most geriatric patients had chronic comorbidities, such as renal diseases (29% v.s 13%, p<0.001), diabetes mellitus (42% versus 13%, p<0.001), solid cancer (63% v.s 53%, p=0.02), congestive heart failure (16% versus 5%, p<0.001) and cerebral vascular accident (13% versus 6.6%, p<0.001). Geriatric patients also had lower albumin level than middle-aged patients (3.39 v.s 3.78, p<0.001). There were no significant differences of causative pathogens and outcomes between these two groups. High Charlson score (OR 1.30, 95% CI 1.10-1.53), methicillin-resistant Staphylococcus aureus infection (OR 13.22, 95% CI 1.25-140.19), vancomycin-resistant enterococcus species infection (OR 13.86, 95% CI 2.10-91.59) and high C-reactive protein (OR 1.08, 95% CI 1.02-1.14) are statistically significant independent risk factors. High albumin level is independent protective factor (OR 0.48, 95% CI 0.27-0.85).
Conclusion:
Geriatric patients had higher disease severity and more chronic comorbidities compared with middle-aged patients. Higher disease severity, lower serum albumin level and severe inflammation during infection were poor prognostic factors for healthcare-associated bloodstream infection related 30-day mortality. Disease severity had a special role in geriatric patients while serum albumin and inflammation during infection were more important for middle-aged patients.

並列關鍵字

Healthcare-associated bloodstream infection ； Geriatric patients ； Prognostic factors

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