胰十二指肠切除术后复杂腹腔感染的危险因素分析及病原菌构成

doi:10.3877/cma.j.issn.1674-0793.2022.06.007

目的

通过探讨胰十二指肠切除术（PD）后发生复杂腹腔感染（cIAI）的相关影响因素及病原菌构成，为PD后cIAI的预防提供一定的依据。

方法

回顾性分析2010年1月至2020年1月于宁夏医科大学总医院行PD患者病例资料，按照纳入标准收集发生cIAI 89例为感染组；从360余例未发生cIAI患者中按照约1∶1的比例等距随机抽样91例为对照组。收集感染组术后引流液的细菌培养情况，统计描述病原菌构成；单因素和多因素Logistic回归分析PD后发生cIAI的危险因素。

结果

术前减黄（OR=6.569，95% CI：1.178~14.630）、手术时间≥6 h（OR=6.872，95% CI：2.258~20.913）和术后胰瘘（OR=3.426，95% CI：1.219~9.631）是PD后发生cIAI的危险因素（均P<0.05）。培养菌株28种，革兰阴性菌以大肠埃希菌、阴沟肠杆菌、肺炎克雷伯菌居多（总构成比为50.00%），革兰阳性菌以屎肠球菌居多（构成比为52.17%），真菌中以白色念珠菌居多（构成比为92.86%）。

结论

PD后发生cIAI病情危重，合理的术前减黄及缩短手术时间对于cIAI的预防尤为重要，应及时合理应用抗生素进行综合治疗。

关键词: 胰十二指肠切除术, 复杂腹腔感染, 危险因素, 病原菌

Objective

To explore the related factors and pathogen composition of complicated intra-abdominal infection (cIAI) after pancreaticoduodenectomy (PD), providing evidence for the prevention of cIAI after PD.

Methods

From January 2010 to January 2020, 89 patients with cIAI after PD were retrospectively collected as the infectious group in General Hospital of Ningxia Medical University. According to the inclusion criteria, 91 patients without cIAI after PD were collected as the control group by equidistant random sampling at a ratio of about 1∶1. The pathogen composition was described statistically according to the results of bacterial culture of the drainage fluid in the infection group. The risk factors of cIAI after PD were analyzed by single- and multi-variate Logistic regression analysis. Preoperative biliary drainage (OR=6.569, 95% CI: 1.178-14.630), operation time ≥ 6 h (OR=6.872, 95% CI: 2.258-20.913) and pancreatic fistula (OR=3.426, 95% CI: 1.219-9.631) were the risk factors for cIAI after PD (all P<0.05). There were 28 varieties of cultivated strains. The majority of gram-negative bacteria were Escherichia coli, Enterobacter cloacae and Klebsiella pneumoniae, the total composition ratio was 50.00%. Enterococcus faecium was the major Gram-positive bacteria, with a composition ratio of 52.17%; and Candida albicans is the most common fungus (92.86%).

Conclusions

The occurrence of cIAI after PD is critical. Rational preoperative biliary drainage and shortening surgery time are particularly vital for the prevention of cIAI. Comprehensive treatment with antibiotics should be carried out in a timely and reasonable manner.

Key words: Pancreaticoduodenectomy, Complicated intra-abdominal infection, Risk factors, Pathogens

表1 两组胰十二指肠切除术患者一般资料的比较

组别	例数	年龄(岁)^a	性别^b		高血压^b		糖尿病^b		冠心病^b		腹部手术史^b		病灶性质^b
组别	例数	年龄(岁)^a	男	女	无	有	无	有	无	有	无	有	良性	恶性
感染组	89	60.09±10.08	47(52.80)	42(47.20)	62(69.70)	27(30.30)	77(86.50)	12(13.50)	83(93.30)	6(6.70)	49(55.10)	40(44.90)	3(3.40)	86(96.60)
对照组	91	58.38±9.58	47(51.60)	44(48.40)	66(72.50)	25(27.50)	72(79.10)	19(20.90)	87(95.60)	4(4.40)	59(64.80)	32(35.20)	5(5.50)	86(94.50)
统计值		0.352	0.024		0.180		1.762		0.472		1.793		0.478
P值		0.554	0.876		0.672		0.189		0.534		0.181		0.720

表1 两组胰十二指肠切除术患者一般资料的比较

组别	例数	年龄(岁)^a	性别^b		高血压^b		糖尿病^b		冠心病^b		腹部手术史^b		病灶性质^b
组别	例数	年龄(岁)^a	男	女	无	有	无	有	无	有	无	有	良性	恶性
感染组	89	60.09±10.08	47(52.80)	42(47.20)	62(69.70)	27(30.30)	77(86.50)	12(13.50)	83(93.30)	6(6.70)	49(55.10)	40(44.90)	3(3.40)	86(96.60)
对照组	91	58.38±9.58	47(51.60)	44(48.40)	66(72.50)	25(27.50)	72(79.10)	19(20.90)	87(95.60)	4(4.40)	59(64.80)	32(35.20)	5(5.50)	86(94.50)
统计值		0.352	0.024		0.180		1.762		0.472		1.793		0.478
P值		0.554	0.876		0.672		0.189		0.534		0.181		0.720

表2 胰十二指肠术后发生复杂腹腔感染术前和术后危险因素的单因素分析

变量		对照组	感染组	统计值	P值
例数		91	89
白细胞(×10⁹/L)
	术前^a	5.76±1.74	6.29±1.99	-1.896	0.065
	术后^b	9.95(7.84,11.75)	12.41(8.56,15.32)	-3.136	0.002^e
NLR^b
	术前	4.00(1.86,4.29)	3.45(2.08,4.31)	-1.538	0.124
	术后	11.23(6.48,13.53)	11.75(6.64,14.32)	-0.044	0.965
PLR^b
	术前	192.90(165.39, 220.40)	196.27(166.77, 225.78)	-0.512	0.398
	术后	224.01(154.90, 288.88)	254.89(149.15, 325.30)	-1.124	0.261
血红蛋白(g/L)^b
	术前	129.00(120.00, 138.00)	131.00(117.00, 140.00)	-0.572	0.567
	术后	96.91(87.00, 108.00)	100.10(90.50, 108.00)	-1.576	0.115
血小板(×10⁹/L)^b
	术前	217.70(175.00, 255.00)	252.69(119.00, 305.00)	-1.628	0.129
	术后	169.71(130.00, 210.00)	226.45(163.00, 291.50)	-4.595	<0.001^e
总胆红素(μmol/L)^b
	术前	82.20(16.40, 204.60)	149.40(26.75, 257.65)	-2.282	0.023^d
	术后	78.21(18.50, 126.50)	122.21(34.25, 188.05)	-3.008	0.003^e
非结合胆红素(μmol/L)^b
	术前	29.16(9.90, 35.30)	34.74(12.59, 38.40)	-1.561	0.119
	术后	22.28(10.40, 28.80)	28.57(12.45, 40.15)	-1.898	0.058
白蛋白(g/L)^b
	术前	36.17(33.80, 38.40)	34.78(31.95, 38.09)	-1.671	0.095
	术后	29.56(27.00, 32.30)	30.13(27.55, 32.20)	-0.856	0.392
丙氨酸转氨酶(U/L)^c
	术前	203.60(45.10, 307.50)	175.13(47.40, 229.45)	-1.036	0.300
	术后	80.54(41.30, 101.20)	91.06(35.25, 79.30)	-0.303	0.762
天冬氨酸转氨酶(U/L)^c
	术前	148.24(28.00, 224.00)	114.12(34.65, 162.70)	-0.239	0.811
	术后	44.12(23.20, 49.30)	50.43(35.25, 79.30)	-1.604	0.109
CA19-9(kU/L)^c				1.858	0.173
	阴性	27(29.70)	35(39.30)
	阳性	64(70.30)	54(60.70)
癌胚抗原(μg/L)^c				1.285	0.257
	阴性	73(80.20)	77(86.50)
	阳性	18(19.80)	12(13.50)
术前减黄				26.479	<0.001^e
	无	50(54.90)	16(18.00)
	有	41(45.10)	73(82.00)
术后入住ICU^c				3.630	0.057
	有	52(57.10)	63(70.80)
	无	39(42.90)	26(36.10)
术后肺部感染^c				4.981	0.260
	有	34(37.40)	48(53.90)
	无	57(62.60)	41(46.10)
术后胰瘘^c				34.032	<0.001^e
	有	21(23.10)	30(33.70)
	无	70(76.90)	59(66.30)

表2 胰十二指肠术后发生复杂腹腔感染术前和术后危险因素的单因素分析

变量		对照组	感染组	统计值	P值
例数		91	89
白细胞(×10⁹/L)
	术前^a	5.76±1.74	6.29±1.99	-1.896	0.065
	术后^b	9.95(7.84,11.75)	12.41(8.56,15.32)	-3.136	0.002^e
NLR^b
	术前	4.00(1.86,4.29)	3.45(2.08,4.31)	-1.538	0.124
	术后	11.23(6.48,13.53)	11.75(6.64,14.32)	-0.044	0.965
PLR^b
	术前	192.90(165.39, 220.40)	196.27(166.77, 225.78)	-0.512	0.398
	术后	224.01(154.90, 288.88)	254.89(149.15, 325.30)	-1.124	0.261
血红蛋白(g/L)^b
	术前	129.00(120.00, 138.00)	131.00(117.00, 140.00)	-0.572	0.567
	术后	96.91(87.00, 108.00)	100.10(90.50, 108.00)	-1.576	0.115
血小板(×10⁹/L)^b
	术前	217.70(175.00, 255.00)	252.69(119.00, 305.00)	-1.628	0.129
	术后	169.71(130.00, 210.00)	226.45(163.00, 291.50)	-4.595	<0.001^e
总胆红素(μmol/L)^b
	术前	82.20(16.40, 204.60)	149.40(26.75, 257.65)	-2.282	0.023^d
	术后	78.21(18.50, 126.50)	122.21(34.25, 188.05)	-3.008	0.003^e
非结合胆红素(μmol/L)^b
	术前	29.16(9.90, 35.30)	34.74(12.59, 38.40)	-1.561	0.119
	术后	22.28(10.40, 28.80)	28.57(12.45, 40.15)	-1.898	0.058
白蛋白(g/L)^b
	术前	36.17(33.80, 38.40)	34.78(31.95, 38.09)	-1.671	0.095
	术后	29.56(27.00, 32.30)	30.13(27.55, 32.20)	-0.856	0.392
丙氨酸转氨酶(U/L)^c
	术前	203.60(45.10, 307.50)	175.13(47.40, 229.45)	-1.036	0.300
	术后	80.54(41.30, 101.20)	91.06(35.25, 79.30)	-0.303	0.762
天冬氨酸转氨酶(U/L)^c
	术前	148.24(28.00, 224.00)	114.12(34.65, 162.70)	-0.239	0.811
	术后	44.12(23.20, 49.30)	50.43(35.25, 79.30)	-1.604	0.109
CA19-9(kU/L)^c				1.858	0.173
	阴性	27(29.70)	35(39.30)
	阳性	64(70.30)	54(60.70)
癌胚抗原(μg/L)^c				1.285	0.257
	阴性	73(80.20)	77(86.50)
	阳性	18(19.80)	12(13.50)
术前减黄				26.479	<0.001^e
	无	50(54.90)	16(18.00)
	有	41(45.10)	73(82.00)
术后入住ICU^c				3.630	0.057
	有	52(57.10)	63(70.80)
	无	39(42.90)	26(36.10)
术后肺部感染^c				4.981	0.260
	有	34(37.40)	48(53.90)
	无	57(62.60)	41(46.10)
术后胰瘘^c				34.032	<0.001^e
	有	21(23.10)	30(33.70)
	无	70(76.90)	59(66.30)

表3 胰十二指肠术后发生复杂腹腔感染术中指标的单因素分析

组别	例数	手术时间(h)^a		输血量(ml)^a		淋巴结转移^a		病灶直径(cm)^b
组别	例数	≥6	<6	≥800	<800	未转移	转移	病灶直径(cm)^b
对照组	91	38.0(41.8)	53.0(58.2)	40.0(44.0)	51.0(56.0)	65.0(71.4)	26.0(28.6)	3.0(1.6,4.0)
感染组	89	55.0(61.8)	34.0(38.2)	55.0(61.8)	34.0(38.2)	73.0(82.0)	16.0(18.0)	3.3(2.0,4.0)
统计值		7.236		5.747		2.823		-0.580
P值		0.007^c		0.017^c		0.093		0.562

表3 胰十二指肠术后发生复杂腹腔感染术中指标的单因素分析

组别	例数	手术时间(h)^a		输血量(ml)^a		淋巴结转移^a		病灶直径(cm)^b
组别	例数	≥6	<6	≥800	<800	未转移	转移	病灶直径(cm)^b
对照组	91	38.0(41.8)	53.0(58.2)	40.0(44.0)	51.0(56.0)	65.0(71.4)	26.0(28.6)	3.0(1.6,4.0)
感染组	89	55.0(61.8)	34.0(38.2)	55.0(61.8)	34.0(38.2)	73.0(82.0)	16.0(18.0)	3.3(2.0,4.0)
统计值		7.236		5.747		2.823		-0.580
P值		0.007^c		0.017^c		0.093		0.562

表4 胰十二指肠术后发生复杂腹腔感染的多因素Logistic回归分析

变量	β	SE	Wald	df	P值	OR	95% CI
变量	β	SE	Wald	df	P值	OR	下限	上限
术前减黄	1.882	0.651	8.371	1	0.004	6.569	1.178	14.630
手术时间	1.928	0.568	11.524	1	0.001	6.872	2.258	20.913
术后胰瘘	1.231	0.527	5.452	1	0.020	3.426	1.219	9.631
输血量	0.606	0.543	1.245	1	0.264	1.832	0.633	5.308
术后第3天白细胞	0.113	0.072	2.468	1	0.116	1.097	0.972	1.290
术后第3天血小板	0.007	0.004	3.081	1	0.079	1.007	0.995	1.017
术前总胆红素	0.001	0.003	0.002	1	0.963	1.000	0.995	1.009
术后第3天总胆红素	0.004	0.003	1.522	1	0.217	1.004	0.998	1.068

表4 胰十二指肠术后发生复杂腹腔感染的多因素Logistic回归分析

变量	β	SE	Wald	df	P值	OR	95% CI
变量	β	SE	Wald	df	P值	OR	下限	上限
术前减黄	1.882	0.651	8.371	1	0.004	6.569	1.178	14.630
手术时间	1.928	0.568	11.524	1	0.001	6.872	2.258	20.913
术后胰瘘	1.231	0.527	5.452	1	0.020	3.426	1.219	9.631
输血量	0.606	0.543	1.245	1	0.264	1.832	0.633	5.308
术后第3天白细胞	0.113	0.072	2.468	1	0.116	1.097	0.972	1.290
术后第3天血小板	0.007	0.004	3.081	1	0.079	1.007	0.995	1.017
术前总胆红素	0.001	0.003	0.002	1	0.963	1.000	0.995	1.009
术后第3天总胆红素	0.004	0.003	1.522	1	0.217	1.004	0.998	1.068

[1]	Cameron JL, Jin He J. Two thousand consecutive pancreaticoduodenectomies[J]. J Am Coll Surg, 2015, 220(4): 530-536.
[2]	Sartelli M, Abu-Zidan FM, Catena F, et al. Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: A prospective multicentre study (WISS Study)[J]. World J Emerg Surg, 2015, 10: 61.
[3]	Leone S, Damiani G, Pezone I, et al. New antimicrobial options for the management of complicated intra-abdominal infections[J]. Eur J Clin Microbiol Infect Dis, 2019, 38(5): 819-827.
[4]	Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America[J]. Surg Infect (Larchmt), 2010, 11(1): 79-109.
[5]	Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after[J]. Surgery, 2017, 161(3): 584-591.
[6]	Limongelli P, Pai M, Bansi D, et al. Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery[J]. Surgery, 2007, 142(3): 313-318.
[7]	Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society Revised Guidelines on the management of intra-abdominal infection[J]. Surg Infect (Larchmt), 2017, 18(1): 1-76.
[8]	Tu RH, Lin JX, Desiderio J, et al. Does intra-abdominal infection after curative gastrectomy affect patients’ long-term prognosis? A multi-center study based on a large sample size[J]. Surg Infect (Larchmt), 2019, 20(4): 271-277.
[9]	张芬菊，胡国妃，徐灵剑, 等. 气管插管患者术后下呼吸道感染的危险因素及病原菌分析[J]. 中国消毒学杂志, 2021, 38(11): 850-852.
[10]	Wu JM, Ho TW, Yen HH, et al. Endoscopic retrograde biliary drainage causes intra-abdominal abscess in pancreaticoduodenectomy patients: An important but neglected risk factor[J]. Ann Surg Oncol, 2019, 26(4): 1086-1092.
[11]	van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cancer of the head of the pancreas[J]. N Engl J Med, 2010, 362(2): 129-137.
[12]	Shen Z, Chen H, Wang W, et al. Machine learning algorithms as early diagnostic tools for pancreatic fistula following pancreaticoduodenectomy and guide drain removal: A retrospective cohort study[J]. Int J Surg, 2022, 102: 106638.
[13]	薛鸿，陈江明，谢胜学, 等. 胰十二指肠切除术后发生胰瘘的危险因素分析[J]. 中华胰腺病杂志, 2020, 20(4): 259-264.
[14]	缪琦，杜华劲，高学键, 等. 普外科患者复杂腹腔感染的病原菌分布及药敏分析[J]. 中国病原生物学杂志, 2021, 16(9): 1064-1068.

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Risk factors and pathogen composition of complicated intra-abdominal infection after pancreaticoduodenectomy

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Risk factors and pathogen composition of complicated intra-abdominal infection after pancreaticoduodenectomy