艰难梭菌毒素阳性延长急诊重症患者住院时间并增加费用

doi:10.16138/j.1673-6087.2025.03.06

摘要/Abstract

摘要：

目的：研究重症监护室患者中粪便艰难梭菌毒素检测阳性对临床预后的影响及危险因素。 方法：方法：回顾性分析2013—2022年间上海交通大学医学院附属瑞金医院急诊重症监护室收治的2 036例患者，比较粪便艰难梭菌毒素检测阳性组（n=225）与阴性组（n=1 811）的临床预后。采用多因素Logistic回归分析艰难梭菌毒素阳性的危险及保护因素。 结果：粪便检测艰难梭菌毒素检测阳性组患者住院时间显著延长（B=18.734 d，95%CI：14.683~22.785），治疗费用明显升高（B=68 854.912元， 95%CI ：46 579.159~91 130.665），但2组死亡率差异无统计学意义。多因素分析显示，碳青霉烯类抗菌药物（OR=1.58，95%CI：1.16~2.15），血流感染（OR=1.77，95%CI： 1.17~2.66）和胆道感染（OR=1.79，95%CI ：1.03 ~3.10）与粪便艰难梭菌毒素检测阳性率升高呈相关性，而甲硝唑使用（OR=0.58，95%CI ：0.40~0.84）、头孢菌素抗菌药物使用（OR=0.54，95%CI： 0.39~0.74）以及女性（OR=0.60，95%CI ：0.44~0.83）是保护因素。 结论：危重症患者粪便中艰难梭菌毒素检测阳性不增加患者死亡率，但会延长住院时间，增加住院费用。

关键词: 艰难梭菌, 重症监护室, 抗菌药物管理, 感染预防

Abstract:

Objective To explore the influence of Clostridioides difficile (C. difficile)positivity on clinical outcomes and identify associated risk factors in intensive care unit（ICU） patients. Methods A retrospective analysis was conducted on 2 036 patients admitted to the emergency ICU of Ruijin Hospital from 2013 to 2022, comparing outcomes between C. difficile-positive (n=225) and C. difficile negative (n=1 811) groups. Multivariate regression analysis was used to identify risk and protective factors. Results Significantly prolonged hospital stays (B=18.734 d, 95% CI: 14.683-22.785) and higher treatment costs (B=68 854.912, 95% CI: 46 579.159-91 130.665) in the C. difficile-positive group, with no statistically significant difference in mortality between groups. Multivariate analysis identified carbapenem use (OR=1.58, 95% CI: 1.16-2.15), bloodstream infection (OR=1.77, 95% CI: 1.17-2.66), and biliary tract infection (OR=1.79, 95% CI: 1.03-3.10) as risk factors for C. difficile positivity. Protective factors included metronidazole use (OR=0.58, 95% CI: 0.40-0.84), cephalosporin use (OR=0.54, 95% CI: 0.39-0.74), and female sex (OR=0.60, 95% CI： 0.44-0.83). Conclusions C. difficile positivity in critically ill patients did not affect mortality but prolonged hospitalization and increased costs. Both risk and protect factors for C. difficile are identified.

Key words: Clostridioides difficile, Intensive care unit, Antimicrobial stewardship, Infection prevention

中图分类号:

R515

虞美玲, 李娇琰, 黎健, 陈影, 赵冰, 毛恩强, 杨之涛. 艰难梭菌毒素阳性延长急诊重症患者住院时间并增加费用[J]. 内科理论与实践, 2025, 20(03): 216-223.

YU Meiling, LI Jiaoyan, LI Jian, CHEN Ying, ZHAO Bing, MAO Enqiang, YANG Zhitao. Clostridioides difficile toxin positivity prolongs hospital stay and increases costs for critically ill patients in emergency patients[J]. Journal of Internal Medicine Concepts & Practice, 2025, 20(03): 216-223.

图/表 5

图1

表1

CDP组和CDN组患者基线特征[n(%)/M(P25,P75)]

项目	CDN组(n=1 811)	CDP组(n=225)	χ²/Z	P
年龄（岁）	55 (39, 69)	56 (39, 69)	-0.38	0.701
女性[n(%)]	664 (36.66)	58 (25.78)	10.36	0.001
APACHE Ⅱ	11.00 (7.00, 16.00)	11.00 (7.00, 17.00)	-1.24	0.217
既往病史[n(%)]
冠心病	126 (6.96)	19 (8.44)	0.67	0.415
脑卒中	118 (6.52)	18 (8.00)	0.70	0.402
急性胰腺炎	150 (8.29)	27 (12.00)	3.47	0.062
消化道溃疡	48 (2.65)	5 (2.22)	0.15	0.703
实验室指标
白细胞计数(×10⁹)	10.90 (7.67, 14.71)	11.23 (7.60, 15.93)	-1.26	0.207
C反应蛋白（mg/L）	106.00(23.00,201.70)	83.00 (16.00, 194.00)	-1.56	0.120
肌酐(μmol/L)	73.00 (54.00, 119.00)	77.00 (58.00, 132.00)	-1.28	0.201
白蛋白(g/L)	30.00 (26.00, 34.00)	30.00 (26.00, 34.00)	-1.20	0.229
血流感染[n(%)]	155 (8.56)	36 (16.00)	13.04	<0.001
中心静脉导管感染[n(%)]	140 (7.73)	25 (11.11)	3.07	0.080
胆道感染[n(%)]	84 (4.64)	19 (8.44)	6.04	0.014
住院治疗[n(%)]
禁食	1 389 (76.70)	168 (74.67)	0.46	0.498
肠内营养	1 291 (71.29)	163 (72.44)	0.13	0.717
生长抑素	534 (29.49)	63 (28.00)	0.21	0.644
质子泵抑制剂	1 445(79.79)	180(80.00)	0.05	0.941
免疫球蛋白	137 (7.56)	24 (10.67)	2.64	0.104
胸腺肽	97 (5.36)	10 (4.44)	0.33	0.563
SAID	751 (41.47)	102 (45.33)	1.23	0.268
NSAID	651 (35.95)	79 (35.11)	0.06	0.805
去甲肾上腺素	404 (22.31)	52 (23.11)	0.07	0.785
多巴胺	318 (17.56)	28 (12.44)	3.71	0.054
阿片类药物	425 (23.47)	57 (25.33)	0.39	0.535
CRRT	285 (15.74)	36 (16.00)	0.01	0.919
机械通气	537 (29.65)	76 (33.78)	1.62	0.203
抗菌药物
种类（种）	2 (2,3)	2 (1,4)	-1.41	0.160
青霉素[n(%)]	107 (5.91)	19 (8.44)	2.22	0.136
喹诺酮[n(%)]	493 (27.22)	48 (21.33)	3.56	0.059
碳青霉烯类[n(%)]	1 034 (57.10)	155 (68.89)	11.46	<0.001
万古霉素[n(%)]	516 (28.49)	86 (38.22)	9.10	0.003
利奈唑胺[n(%)]	304 (16.79)	31 (13.78)	1.32	0.251
阿米卡星[n(%)]	91 (5.02)	12 (5.33)	0.04	0.842
甲硝唑[n(%)]	692 (38.21)	50 (22.22)	22.09	<.001
磺胺甲𫫇唑[n(%)]	92 (5.08)	13 (5.78)	0.20	0.655
第1代头孢菌素[n(%)]	6(0.33)	0(0)	0.748	0.387
第2代头孢菌素[n(%)]	195 (10.77)	20(8.89)	0.748	0.387
第3代头孢菌素[n(%)]	1 150(63.50)	106(47.11)	22.75	<0.001
第4代头孢菌素[n(%)]	40(2.21)	14(6.22)	12.49	<0.001
替加环素[n(%)]	135 (7.45)	15 (6.67)	0.18	0.670
预后
住院时长 (d)	23.00 (15.00, 37.00)	39.00 (23.00, 66.00)	-8.88	<0.001
住院费用（元）	73 009.11 (41 605.92, 147 581.23)	127 163.58 (74 607.01, 262 362.70)	-8.24	<0.001
死亡[n(%)]	265 (14.63)	41 (18.22)	2.02	0.155

表1

表2

表3

表4

参考文献 33

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变量	未标准化系数		标准化系数	t	P	B的95%CI		共线性统计
变量	B	SE	β	t	P	下限	上限	容差	VIF
回归方程截距	26.570	2.639		10.069	0.000	21.395	31.745
年龄	-0.051	0.037	-0.032	-1.396	0.163	-0.123	0.021	0.896	1.116
CDP	18.734	2.066	0.196	9.069	0.000	14.683	22.785	0.998	1.003
冠心病	6.396	2.603	0.055	2.457	0.014	1.290	11.501	0.933	1.072
白细胞计数	0.305	0.108	0.062	2.822	0.005	0.093	0.517	0.973	1.027
C反应蛋白	0.028	0.006	0.101	4.525	0.000	0.016	0.040	0.931	1.075
R²	0.058
调整后 R²	0.056
F	F(5，2 030)=25.115, P<0.001

变量	未标准化系数		标准化系数	t	P	B的95%CI		共线性统计
变量	B	SE	β	t	P	下限	上限	容差	VIF
回归方程截距	59 006.872	22 748.351		2.594	0.010	14 394.192	103 619.552
APACHE Ⅱ	3 994.021	577.936	0.164	6.911	0.000	2 860.608	5 127.434	0.807	1.239
CDP	68 854.912	11 358.579	0.130	6.062	0.000	46 579.159	91 130.665	0.994	1.006
急性胰腺炎	-26 425.580	13 032.176	-0.045	-2.028	0.043	-51 983.489	-867.671	0.935	1.069
白细胞计数	722.038	601.734	0.026	1.200	0.230	-458.047	1 902.123	0.948	1.055
C反应蛋白	157.321	33.133	0.103	4.748	0.000	92.342	222.299	0.968	1.033
肌酐	78.469	21.622	0.082	3.629	0.000	36.066	120.872	0.883	1.133
白蛋白	-497.693	625.675	-0.018	-0.795	0.426	-1 724.728	729.343	0.900	1.111
R²	0.080
调整后 R²	0.077
F	F(7，2 028)=25.211, P<0.001

变量	变量水平	β	多因素回归分析OR(95% CI)	P
性别	女性	-0.500	0.60 (0.44 ~ 0.83)	0.002
	男性	对照
血流感染	阳性	0.570	1.77 (1.17 ~ 2.66)	0.007
	阴性	对照
胆道感染	阳性	0.580	1.79 (1.03 ~ 3.10)	0.039
	阴性	对照
碳青霉烯	使用	0.460	1.58 (1.16 ~ 2.15)	0.003
	未使用	对照
甲硝唑静脉注射	使用	-0.540	0.58 (0.40 ~ 0.84)	0.004
	未使用	对照
头孢菌素	使用	-0.620	0.54 (0.39 ~ 0.74)	<.001
	未使用	对照