| Objective： This study was designed to investigate the status ofnosocomial infection, distribution of pathogenic bacteria and the clinicaloutcome in patients with hematologic malignancies from our hospital, so as toprovide some clues for optimizing the treatment effect of clinical anti-infection.Methods： A total of605cases with nosocomial infection inhematologic malignancies, including multiple myeloma (MM),myelodysplastic syndrome (MDS), acute leukemia (AL) and malignantlymphoma (ML), were collected with informed consent in the Second Hospitalof Hebei Medical University from2009to2013. We conducted the followingretrospective analysis:(1) the incidence of nosocomial infection, thedistribution of pathogenic bacteria types and the current situations ofmultidrug resistantce in patients with hematologic malignancies; the therapyregimens for patients who combined neutropenia with fever；the clinicaloutcomes of patients with bloodstream infection who have positive bloodcultures.（2）The risk factors of pulmonary fungal infections, consultation ofdiagnostic criteria， treatment strategies and efficacy analysis. Statisticalcomparisons between groups as well as two or more rates were conductedusing Chi-square test. Logistic regression was used to evaluate themultivariate analysis. All analyses were performed using SPSS17.0(SanDiego, CA, USA) and P<0.05was considered statistically significant.Results:1The incidence of nosocomial infection and distribution ofpathogens bacteria types in patients with hematologic malignanciesThe overall incidence of nosocomial infection in605patients withhematologic malignancies was18.63％. The infection rates in ANLL, ALL, MDS, ML, MM with a decreasing order (ANLL>ALL>MDS>ML>MM). Therespiratory tract is the most common site of infection. The rates of infectionwere58.35%in lung,26.28%in upper respiratory tract,6.94%in bloodstream,5.62%in perianal,4.96%in skin and soft tissue,3.8%in oral cavity,2.31%inurinary,1.49%in intestine,1.16%in sinuses,0.33%in abdominal,0.33%inacute appendicitis,0.17%in infective endocarditis,0.17%in liver abscesses,respectively. In addition, infection sites were uncertain in11.41%patients.Pathogens were detected out in123patients, which included70fungalstrains and224bacterial strains. Candida is the major infection fungus. Themajor infection bacterium included Escherichia coli (21.88%), Pseudomonasaeruginosa(15.63%), Klebsiella pneumoniae(11.61%), Maltophilia Aeromonas(10.27%), Feces Enterococci (10.27%), Acinetobacter baumannii (6.7%) andCoagulase-negative staphylococcus (4.91%). Bacterial strains ofMultidrug-resistant (MDR) accounted for16.52%of total bacterias.42patients were bloodstream infections with positive blood culture.Among them,16cases（38.10%） presented only fever without other focus ofinfection. The others were in combination with other site infection: includinglung (18cases), upper respiratory tract and oral (9cases), skin andsubcutaneous soft tissue (5cases), perianal(2cases), intestine(2cases),urinary(1case).No remission of primary disease, previous use history of antibioticwithin one month, agranulocytosis and combined with multiple organ failuremay be associated with a poor prognosis (P<0.05).2Agranulocytosis patients with feverThe patients with high-risk agranulocytosis was293cases, the patientswith low-risk agranulocytosis was86cases. Aggravation or mortality rate inhigh-risk group was higher than low-risk group, the difference was statisticallysignificant.The step-up anti-infection therapy have a lower efficacy than step-downtherapy (52.38%vs.81.82%), and the difference was statistically significant(P=0.039).3Clinical features, risk factors and treatment efficiency of pulmonary fungal infections226cases were diagnosed as pulmonary fungal infection, whichaccounted for64.02%in the lung infection. Among them,4cases were indeeddiagnosis,82cases were clinical diagnosis, and the other140cases werepreliminarily diagnosis.3.1Clinical symptoms, signs and imaging findingsClinical symptoms in the most of patients with pulmonary fungal infectionwere unspecific, and these symptoms included fever, cough and expectoration.73cases (32.3%) had positive signs, and the common sign was mainlypresented as wet and dry rales of lung. Imaging findings were diversity,including nonspecific patch shadow, multiple small nodules or nearly pleuralnodules, large nodules, hydrothorax or pleural thickening, ground-glasschanges, air bronchogram, halo sign, hollow,small airway inflammation,pulmonary consolidation, burr sign, mass shadow, cords shadow, crescent sign.Among them, large nodules, nearly pleural nodules, halo sign, hollow, burrsign,mass shadow and crescent sign may be the characteristic performance ofpulmonary fungal infection.3.2Analysis of risk factors for patients with pulmonary fungal infectionThe standard or high-dose chemotherapy (P=0.033, OR=2.042), noremission of primary disease (P=0.029, OR=2.209), duration ofagranulocytosis over7d (P=0.028, OR=1.039) and previous use history ofbroad-spectrum antibiotics (P=0.001, OR=3.286) were independent riskfactors for pulmonary fungal infections in patients with hematologicmalignancies by using Logistic regression analysis.3.3The strategies and efficacy of antifungal treatment2cases were treated with primary antifungal prophylaxis, andfluconazole was selected as therapeutic drugs. However, the patientsoccurred the breakthrough fungal infections and treatment failure.3caseswere treated with secondary antifungal prophylaxis, and fluconazole andvoriconazole were selected as therapeutic drugs, and these patients did notoccur breakthrough fungal infections. Empirical anti-fungal treatment was given124times. The efficiency in single drug group was less thancombination therapy group (73.15%vs.75%), but the difference was notstatistically significant (P≥0.05). Diagnosis driven treatment was given115times. The efficiency in single drug group was less than combination therapygroup (75.26%vs.88.89%), but the difference was not statistically significant(P≥0.05). The efficiency rates in empirical treatment group and diagnosisdriven treatment group were80.02%and84.89%, respectively. Thedifference was not statistically significant (P≥0.05）。Clinical diagnosis rateof fungal infection in empirical treatment group was lower than diagnosisdriven treatment group.There were14cases Aggravation of imaging findings not parallel to theseverity of infection.Conclusion:1The incidence of fungal infection in patients withhematologic malignancies was18.63％. The most common site of infectionis the respiratory tract. Multidrug-resistant (MDR) strains accounted for16.52%total bacteria.2High-risk agranulocytosis presented as a poor prognosis in patients withhematologic malignancies. The efficiency of step-down therapy is exceeded tostep-up therapy.3Some risk factors, including no rency betweemission of primary disease,previous use history of antibiotic within one month, agranulocytosis andcombined with multiple organ failure may be associated with a poor prognosis4There was not significantly statistical difference in efficien empiricaltreatment and diagnosis driven treatment. But diagnosis driven treatment wasmore targeted. Aggravation of imaging findings is usually not parallel to theseverity of infection. |
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