創傷弧菌感染病患的死亡率預後因子

Prognostic Factors of Mortality in Vibrio Vulnificus Infected Patients

郭周彩濃(Tsai-Nung Kuo Chou)

指導教授 ： 翁瑞宏

中山醫學大學/醫學院/醫學研究所/博士(2010年)

https://doi.org/10.6834/CSMU.2010.00072

摘要

創傷弧菌感染 (Vibrio vulnificus) 是非常具有侵犯性的，即使立即的診斷與積極的治療，病例致死率仍是相當高。因此，辨識出創傷弧菌感染病患的預後因子是相當重要的。
首先，我們探討創傷弧菌所導致的原發性敗血症 (primary septicemia) 或傷口感染 (wound infection) 的死亡率之預後因子。在2000年1月至2006年12月期間，90名18歲以上因創傷弧菌感染而住院之患者被納入此回溯性研究。從病歷所記載的資料包括臨床特徵、實驗室檢驗、治療及預後結果皆被收集。在90名確診為創傷弧菌感染的患者中，39名具有原發性敗血症，並且51名具有傷口感染。到院時急性生理及慢性健康評估 (Acute Physiology and Chronic Health Evaluation [APACHE II]) 以及急診部門敗血症死亡率 (Mortality in Emergency Department Sepsis [MEDS]) 分數之平均值分別為11.1 ± 4.9和5.5 ± 3.8；其中，有15名病患死亡，住院期間死亡率 (in-hospital mortality rate) 為17%。多變項分析顯示於到院時具有較高APACHE II (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.2-1.8) 以及MEDS (OR = 1.3; 95% CI = 1.1-1.6) 分數是顯著相關於死亡率。APACHE II和MEDS分數對於預測住院期間死亡率的接受者操作特徵曲線 (receiver operating characteristic curve [ROC curve]) 下面積分別是0.928 (95% CI = 0.854-0.972) 以及0.830 (95% CI = 0.736-0.901)。
創傷弧菌感染在皮膚或軟組織能夠迅速地進展，並且可能會危害到生命；因此，我們收集了更多的研究對象，接續對於皮膚或軟組織受到創傷弧菌感染的患者，探討其死亡率的預測因子。在2000年1月至2007年12月間，119名年齡在18歲以上並且皮膚或軟組織受到創傷弧菌感染而住院的病患其醫療記錄被審查。24名病患死亡，產生總病例致死率 (overall case-fatality rate) 為20%。在24名死亡者中，20 (83%) 名病患是到院後72小時之內死亡。多變項分析顯示具有出血性水皰的皮膚損傷 (hemorrhagic bullous skin lesions) 與壞死性筋膜炎 (necrotizing fasciitis) 的呈現 (P = 0.003)、原發性敗血症 (P = 0.042)、較高的器官失能和/或感染的分數 (P = 0.005)、白血球增多症的缺乏 (absence of leukocytosis) (P = 0.0001) 和低白蛋白血症 (hypoalbuminemia) (P = 0.003) 與死亡率具有相關。手術介入合併抗生素治療 (P = 0.038) 與到院後24小時內進行手術治療 (P = 0.017)，是保護因子。
我們的結果顯示，到院時的APACHE II以及MEDS分數是創傷弧菌所導致的原發性敗血症或傷口感染的顯著預後指標。此外，出血性水皰的皮膚損傷與壞死性筋膜炎的呈現、原發性敗血症、較高的疾病嚴重度、白血球增多症缺乏、以及低白蛋白血症在創傷弧菌感染病患中是死亡率的顯著危險因子。更進一步地，接受手術合併抗生素治療的病患，特別是到院後24小時內即時地接受手術評估者，可能具有較好的預後。然而，一項進一步的追蹤研究來強化我們的結果是需要的。

關鍵字

海洋弧菌 ； 死亡率 ； 預後因子

並列摘要

Vibrio vulnificus infection is extremely invasive. Even with prompt diagnosis and aggressive therapy, the case-fatality rate is still very high. Therefore, it is important to identify the prognostic factors for V. vulnificus infected patients.
Initially, we investigated the predictive factors for mortality in primary septicemia or wound infections caused by V. vulnificus. A retrospective review of 90 patients 18 years and older who were hospitalized due to V. vulnificus infection between January 2000 and December 2006 was performed. Clinical characteristics, laboratory studies, treatments, and outcomes retrieved from medical records were analyzed. Of 90 patients identified as V. vulnificus infections, 39 had primary septicemia and 51 had wound infection. The mean Acute Physiology and Chronic Health Evaluation (APACHE II) and Mortality in Emergency Department Sepsis (MEDS) scores on admission were 11.1 ± 4.9 and 5.5 ± 3.8, respectively. Fifteen patients died, yielding an in-hospital mortality rate of 17%. Multivariate analysis revealed that higher APACHE II (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.2-1.8) and MEDS (OR = 1.3; 95% CI = 1.1-1.6) scores on admission were significantly associated with mortality. The area under the receiver operating characteristic curves values for APACHE II and MEDS in predicting in-hospital mortality were 0.928 (95% CI = 0.854-0.972) and 0.830 (95% CI = 0.736-0.901), respectively.
Vibrio vulnificus infection can progress rapidly in skin or soft tissue, and it is potentially life-threatening. Therefore, we collected more study subjects, and subsequently explored the predictors of mortality in patients with V. vulnificus infections of skin or soft tissue. The medical records of 119 consecutive patients aged 18 years and older, hospitalized for V. vulnificus infections of skin or soft tissue between January 2000 and December 2007 were reviewed. Twenty-four patients died, yielding an overall case fatality rate of 20%. Of the 24 deaths, 20 (83%) occurred within 72 h after hospital admission. Multivariate analysis revealed that hemorrhagic bullous skin lesions/necrotizing fasciitis (P = 0.003), primary septicemia (P = 0.042), a greater organ dysfunction and/or infection score (P = 0.005), absence of leukocytosis (P = 0.0001), and hypoalbuminemia (P = 0.003) were associated with mortality. Treatment with surgical intervention plus antibiotics (P = 0.038) and surgical intervention within 24 h after admission (P = 0.017) were protective factors.
Our results showed that the APACHE II and MEDS scores on admission are significant prognostic indicators in primary septicemia or wound infections caused by V vulnificus. In addition, the presence of hemorrhagic bullous skin lesions/necrotizing fasciitis, primary septicemia, a greater severity-of-illness, absence of leukocytosis, and hypoalbuminemia were the significant risk factors for mortality in V vulnificus infected patients. Moreover, patients treated with surgery plus antibiotics, especially those receiving a prompt surgical evaluation within 24 h after hospital admission, may have a better prognosis. However, a further prospective study to strengthen our findings is required.

並列關鍵字

Vibrio Vulnificus ； Mortality ； Prognostic Factor

參考文獻

2.Shapiro RL, Altekruse S, Hutwagner L, et al. for the Vibrio Working Group. The role of Gulf Coast oysters harvested in warmer months in Vibrio vulnificus infections in the United States, 1988-1996. J Infect Dis 1998;178:752-9.

3.Hsueh PR, Lin CY, Tang HJ, et al. Vibrio vulnificus in Taiwan. Emerg Infect Dis 2004;10:1363-8.

4.Centers for Disease Control and Prevention (CDC). Vibrio vulnificus infections associated with eating raw oysters-Los Angeles, 1996. MMWR Morb Mortal Wkly Rep 1996;45:621-4.

5.Centers for Disease Control and Prevention (CDC). Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food-10 states, United States, 2005. MMWR Morb Mortal Wkly Rep 2006;55:392-5.

6.Hor LI, Chang TT, Wang ST. Survival of Vibrio vulnificus in whole blood from patients with chronic liver diseases: association with phagocytosis by neutrophils and serum ferritin levels. J Infect Dis 1999;179:275-8.