The Epidemiological Investigation On Nosocomial Infection In Patients With Rheumatic Deseases In Hanghai

Rheumatic diseases are multi-system involvement, multiple immune abnormalities existing in vivo. Often treated with long-term glucocorticoids and immunosuppressive agents to control the progression of the disease, rheumatic patients are vulnerable to infection. Patients complicated with nephritis, interstitial pneumonia, pulmonary hypertension caused by systemic lupus erythematosus (SLE), polymyositis / dermatomyositis (PM / DM), systemic sclerosis (ssc) and so on, are about 30-50% died of infection. Thus, the majority of scholars believe that the infections have become an important factor for increased rheumatic diseases mortality.1 ObjectiveTo investigate the nosocomial infection risk factors and etiological characteristics of pathogenes of patients with rheumatic diseases in Shanghai city.2 Material and methods2.1 Study population Patients with rheumatic diseases who were admitted to Changhai hospital, Changzheng hospital, Renji hospital, Huashan hospital, Zhongshan hospital, Longhua hospital, Yueyang hospital, Shanghai traditional medical hospital, The 1st. City hospital, The 6th city hospital and Baogang hospital in 2008.3 ~ 2009.2 were prospectively studied. 2.2 Observation items2.2.1 Items were included patient's name, sex, age, admission date, time of disease onset, length of stay in hospital, the system damage (such as kidney, nerve system, blood, heart, lungs and pleura, the digestive system), corticosteroid dose, immunosuppressant treatment, blood leukocyte count, lymphocyte count, ESR, CRP, liver function, biochemistry, chest X-ray, nosocomial infection date, site of infection and so on. Microbial culture results combined with clinical symptoms, signs, test results and imaging data were listed and unified for analysis.2.2.2 Diagnostic criteria A variety of rheumatic diseases fulfilled the Chinese Medical Association Rheumatology Society "Guide to the diagnosis of rheumatic diseases" in the diagnostic criteria. Diagnosis of nosocomial infection with reference to the Ministry of Health criteria, the patients were admitted to hospital 48 hours after the onset of infection, the doctor designated by hospital filled out each infection in registration form. Original deseases were confirmed by the first admission diagnosis.2.2.3 Cases grouping Original patients are divided into the following 5 groups: (1) rheumatoid arthritis (RA) group; (2) systemic lupus erythematosus (SLE) group; (3) Ankylosing Spondylitis Yan (AS) group; (4) other diffuse connective tissue disease (OCTD) group, including Behcet's disease (BS), mixed connective tissue disease (MCTD), multiple polymyositis/dermatomyositis (PM/DM), polymyalgia rheumatic (PMR), Sjogren's syndrome (SS) and systemic sclerosis (SSc), etc.; (5) bone and joint diseases(BJD) group, including gout, osteoarthritis, osteoporosis and so on.2.2.4 Statistical methods For counting data, chi-square test was used and P <0.05 as significant cutoff. For measurement data normally distributed, T test was used. For measurement data non-normally distributed, rank sum test was used. SPSS11.0 was applied for descriptive statistical analysis. The single factors will be analyzed with a statistical significance of the variables as independent variables. Infection or non-infection as a dependent variable was carried out in multi-factor non-conditional Logistic regression analysis in patients with rheumatism nosocomial infection as risk factors.3 Results3.1 Nosocomial infection incidence and clinical features3.1.1 A total of 1880 patients were investigated, of which 477 cases of male, female 1403 cases, age 3 ~ 95 years old, on average 51.8±5 years old, duration 2d ~ 50 years, an average of 95.6 months, the average length of stay 12.8±5.1 d, the average occupancy 7.38±2.1 days after the infection. For 1880 cases of rheumatic patients with 338 cases of nosocomial infection, the infection rate was 17.69%. Among 477 cases of men, 60 cases were infected (the infection rate, 12.58%) and 1403 cases of women, 276 cases were infected (19.67%). Concurrent infection rate for women was significantly higher than males,χ2 = 12.373, P <0.005. For infection group, the average length of stay was 17.21d, the average length of stay of non-infection group 12.07d. Among 727 cases of RA patients, 150 cases occurred nosocomial infection, and the infection rate was 20.63%. Among 328 cases of SLE, 63 cases of patients occurred nosocomial infection, and the infection rate was 19.21%. For 296 cases of AS patients with 19 cases of nosocomial infections, the infection rate was 6.42%. For 434 cases of patients with OCTD with 93 cases of nosocomial infections, the infection rate was 21.43%. For 95 cases of BJD with 11 cases of nosocomial infections, the infection rate was 11.58%.3.1.2 Sites of infection122 cases of infection were two sites, 36 cases for the three parts of infection. Among 338 cases of patients with infection, upper respiratory tract infection was 62 cases, and 142 cases were lower respiratory tract infection, 101 cases of urinary tract infection, oral infection 36 cases, 39 cases of reproductive tract infections, 23 cases of gastrointestinal tract infections, 8 cases of blood infections, 46 cases of skin and soft tissue infections, 4 cases of infection in the nervous system, the others 33 cases. 3.1.3 Dual infection and prognosisDual infections occurred in 170 cases, and the infection rate was 8.91 percent, accounting for 49.97% in patients with nosocomial infection. Double infection occurred mainly in the respiratory tract, urinary tract and mouth, and mainly caused by Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae and mixed with Candida albicans. 11 cases of infection were dead and the mortality rate was 3.01%. 1544 cases of non-infection group, five cases of death, the mortality rate was 0.033%. Among 11 cases of infection, one kinds of infection was three cases, eight cases of double infection and double infection deaths rate was significantly higher than a simple infection (χ2 = 47, P <0. 05). Persistent infection for more than a month was 44 cases. The nosocomial infection rates between groups and the significant difference in infection rates (χ2 = 36.9094, P <0.0001), were significantly different.3.2 Risk factors for nosocomial infectionSingle-factor analysis showed that rheumatism, gender, age, duration of hospitalization, primary disease, the affected organ (lung, kidney, blood vessels and joints and other target organs), the number of involved sites, the number of species of antibiotics for prevention, glucocorticoid dose, the number of antibody-positive and the level of peripheral blood leukocytes count, plasma hemoglobin, plasma albumin, immunoglobulin G, serum creatinine, and blood urea nitrogen were risk factors related to nosocomial infection(P <0.05). C-reactive protein was the detective and predictive indicators for RA, AS and OCTD patients. The use of immunosuppressive agents, the application of CTX and biological agents such as etanercept had no correlations with nosocomial infection in patients with rheumatism (P> 0.05).Multi-factor regression analysis showed that the original situation, the involvement of organs (lung, kidney, blood vessels and joints and other target organs), the patient's sex, age, duration of hospitalization, preventive use of broad-spectrum antibiotics (more than 7 days) and blood leukocyte count, hemoglobin, C-reactive protein and r-globulin in patients with rheumatism were the risk factors for nosocomial infection, and was closely related to the occurrence of infection (P <0.05).3.3 Etiological characteristics of nosocomial infection pathogens3.3.1 Pathogens distributionFive handrand and ten pathogens were isolated, of which Gram-positive bacteria were 134, accounting for 26.54%. Enterococcus faecalis were 60 strains, enterococci feces (VER not detected) 12, Staphylococcus aureus 24 (MRSA 8 strains, accounting for 30.0%), Staphylococcus epidermidis 22, Staphylococcus saprophytic 8, hemolytic streptococcus 6. Gram-negative bacteria were 210 strains, accounting for 41.67%: 104 strains of Escherichia coli (ESBLS+ 12 strains, accounting for 11.50%), 22 strains of Pseudomonas aeruginosa, 24 of Acinetobacter baumannii, 20 strains of Klebsiella pneumoniae Strain (ESBLS+ not detected), 6 of Enterobacter cloacae, 6 strains of Pseudomonas maltophilia strains, 6 strains of Enterobacter cloacae, 6 strains of Proteus mirabilis and others such as: Acinetobacter, Enterobacter sakazakii, Pseudomonas onion, Pseudomonas sp, mandrax citrobacter moving, etc. Fungi were 86 strains, accounting for 16.86%, and 50 strains of Candida albicans mainly, 8 strains of Candida parapsilosis, 8 strains of Candida tropicalis, 4 strains of Candida krusei, 2 strains of Cryptococcus. Mycoplasmas were 62 strains, accounting for 12.00%: 36 strains of Ureaplasma urealyticum, 22 strains of Mycoplasma hominis, a small amount for Mycoplasma pneumoniae and Chlamydia. mycobacterium tuberculosis were 4 strains, accounting for 0.08% and herpes virus were 8 strains (the skin of herpes zoster).3.3.2 Relation of infection site and pathogenic speciesAt different sites of infection, the distributions of strains were different. In 142 cases of lower respiratory tract infection, 8 pathogens were detected. They were Staphylococcus aureus, Klebsiella pneumoniae Bacillus, Pseudomonas aeruginosa, Candida, Candida albicans, Mycobacterium tuberculosis, etc. In 101 cases of urinary tract infection, nine kinds of pathogens (162 strains) were detected, mainly of E. Coli, Proteus mirabilis, Pseudomonas aeruginosa, epidermal grapes cocci, enterococci feces, Ureaplasma urealyticum and Mycoplasma hominis, Candida albicans, yeast, etc. 23 cases of gastrointestinal tract infections were detected for 4 kinds of pathogenes (32 strains) for Candida, Candida albicans, Escherichia coli and Enterococcus feces. 8 cases of blood infections were detected for 4 kinds of pathogens: Staphylococcus aureus, Green Streptococcus, Staphylococcus epidermidis and Candida. In 46 cases of skin and soft tissue infection, six kinds of pathogens were detectived, mainly of Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus Green, Morgan's Morgan bacteria, Candida krusei parent enzyme. In 4 cases of cerebrospinal fluid, three kinds of pathogenes, mainly Cryptococcus, mycobacterium tuberculosis, maltophilia Pseudomonas were detected. 36 cases of oral infection were detected for 4 kinds of pathogens, mainly of Staphylococcus aureus, Streptococcus, Candida, Candida albicans, etc. Double infection was mainly of Klebsiella pneumoniae, Escherichia coli and Candida albicans and mixed with beads.3.3.3 Drugs sensitivity of pathogens 13 kinds of antibiotics against gram-positive bacteria had been applied for sensitivity test and found that the drug resistant rate of penicillin, erythromycin, gentamicin-resistant was high and to norvancomycin was low. The MRSA proportion was slightly lower than the general level and vancomycin-resistant strains were not finded. All Enterococcus faecalis were sensitive to glycopeptide (vancomycin), drug-resistant strains were not detected and the sensitive rate to ampicillin was 88%, penicillin G-sensitive rate 72.1%. Feces intestinal bacteria sensitive to vancomycin was 98.2%, to linezolid-sensitive was 96.8%, tetracycline-sensitive was 68.6%, Nitrofurantoin-sensitive was 51%, and the rests of antibiotics sensitive rates were less than 15%. 16 kinds of antibiotics on Gram-negative bacteria had been applied for sensitivity test and found that Gram-negative bacteria resistant to ampicillin were serious. Drug-resistant rate of less than 20% of the antibiotics, only was imipenem / cilastatin (imipenem), ceftazidime (Tatsu new complex), and amikacin. Escherichia coli producing ESBLs accounted for 18%. The sensitivity of third-generation cephalosporin ceftriaxone was only 3.6% (ESBls-, about 67.5 percent), and fluoroquinolones (ciprofloxacin gatifloxacin) sensitive rate was only 7% around (ESBLs-, about 32.1%), but aminoglycoside (amikacin) sensitivity rate was as high as 89%, cefoperazone / sulbactam sensitive rate was 82%. In addition to hydrocarbon vinyl antimicrobial enzyme, the Klebsiella pneumoniae to ceftazidime, cefepime, cefoperazone / tazobactam and amikacin sensitivity rate was more than 70%, other antibacterial drug-sensitive rates were at 50%. For Pseudomonas aeruginosa, resistant strains accounted for 35.3%. In addition the sensitivity rate of amikacin was 87%, cefoperazone / tazobactam-sensitive rate was 89.4%, the sensitivity rate of cefepime was 78%. Other anti-bacterial drugs sensitive rate was less than 70%. Especially the sensitive rate of meropenem was 88.5%, while imipenem was only 79.6%. For Acinetobacter baumannii, the resistant strains accounted for 41.6%. The amikacin sensitive rate was 96.5%, cefoperazone / tazobactam ketone was 76.4%, for meropenem 76.7%, imipenem 56.8%, and the rest were less than 40%.4. Conclusion4.1 The nosocomial infection rate in rheumatic patients was higher than the average level, and women were higher then men. OCTD hospital patients were of the highest infection rate, followed by RA, SLE, BJD, AS. Dual infections often occurred in rheumatic patients and the mortality was high.4.2 The common sites of nosocomial infections in patients with rheumatic diseases were as followed: upper respiratory tract, lower respiratory tract, urinary tract, oral cavity, reproductive tract, gastrointestinal tract, blood, skin and soft tissue and the nervous system. Double infections often occurred in the respiratory tract, urinary tract and oral.4.3 Risk factors of nosocomial infection4.3.1 Primary disease, organ involvement, the patient's sex, age, duration of hospitalization, preventive use of broad-spectrum antibiotics and blood leukocyte count, hemoglobin, C-reactive protein and r-globulin were risk factors for nosocomial infection.4.3.2 For RA, AS and OCTD patients, C-reactive protein levels were detective and predictive indicators.4.3.3 For rheumatic disease patients, the use of immunosuppressive agents, CTX and biological agents had no correlation to nosocomial infection.4.4 Etiology of nosocomial infections4.4.1 Distribution of pathogenic species Mainly pathogens were as followed: Gram-positive organisms was enterococci, mainly Staphylococcus aureus. Gram-negative bacteria were Escherichia coli, Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, Candida albicans.4.4.2 Drug susceptibility Staphylococcus aureus bacterial were resistant to penicillin, oxacillin, ampicillin, and the vancomycin-resistant strains were not found, and enterococci were sensitive to vancomycin, linezolid, tetracycline and nitrofurantoin. For Pseudomonas aeruginosa, amikacin, ciprofloxacin, cefoperazone / tazobactam and cefepime were sensitive, but the sensitivity of Pseudomonas aeruginosa to carbon Catalase viny antimicrobial drug began to decline. Klebsiella pneumoniae was sensitive to ceftazidime, cefepime, cephalosporin cefoperazone / tazobactam and amikacin.