化脓性脊柱炎患者病原菌培养结果的影响因素分析

doi:10.19723/j.issn.1671-167X.2019.06.011

摘要/Abstract

摘要：

目的研究不同因素对化脓性脊柱炎患者病原菌培养结果的影响,寻找临床可控因素,提高病原菌培养阳性率。方法回顾北京大学第一医院2011年1月至2017年7月期间收治的化脓性脊柱炎患者共40例,根据病原菌培养结果将患者分为培养阴性组和培养阳性组,分析临床可控因素和非可控因素对培养结果的影响。结果培养阳性的患者24例(60.00%),病原菌以革兰阳性球菌为主,共17例(68.00%)。对非可控因素分析显示,两组患者在年龄、性别、易感因素、脊柱外感染灶、视觉模拟评分(visual analogue score,VAS)、病程、脊柱受累部位、体温、全身炎症反应综合征发生率、白细胞计数、中性粒细胞百分比[(neutrophilic granulocyte)%,NE%]以及硬膜外脓肿的发生率上差异无统计学意义。培养阳性组患者的红细胞沉降率(erythrocyte sedimentation rate, ESR,Z=-2.269, P=0.023)、C-反应蛋白(C-reactive protein, CRP,Z=-2.058, P=0.040)、椎旁脓肿发生率[P ^a(Pearson Chi-square)=5.625,P=0.018]高于培养阴性组患者。对可控因素分析显示,培养前2周内应用抗生素(P=0.058, OR=4.030, 95%CI: 0.956~16.993)、组织匀浆(P=0.014, OR=0.171, 95%CI: 0.042~0.695)是影响培养结果的关键因素,不同术式对病原菌培养结果的影响差异无统计学意义。结论 ESR、CRP水平高,合并椎旁脓肿的化脓性脊柱炎患者病原菌培养阳性率高。培养前2周内应用抗生素的患者病原菌培养阳性率低,组织匀浆能够显著提高患者病原菌培养阳性率,尤其适用于ESR、CRP水平低,无椎旁脓肿且培养前2周内应用抗生素的患者。

关键词: 化脓性脊柱炎, 组织匀浆, 抗生素, 病原菌培养

Abstract:

Objective: To investigate the effect of clinical factors on the pathogen culture results in the patients with pyogenic spondylitis, and to find out clinical controllable factors which could increase the positive rate of the pathogen culture.Methods: A retrospective study reviewed 40 patients who were diagnosed with pyogenic spondylitis in Peking University First Hospital from January 2011 to July 2017. The patients were divided into two groups depending on the culture results, culture negative or culture positive. The influence of clinical uncontrollable factors [the patient’s age, gender, predisposing factors, infection site except spine, visual analogue score (VAS), course of disease, spinal segment, white blood cell (WBC), (neutrophilic granulocyte)% (NE%), the incidence of systemic inflammatory response syndrome (SIRS), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), the incidence of paravertebral abscess] and controllable factors (prior antibiotics exposure within 2 weeks, tissue homogenate, surgical approach) on pathogen culture results were analyzed.Results: Of the 40 patients, 18 patients were female and 22 patients were male. Causative germ was identified in 24/40 patients (60.00%) and dominant by gram positive cocci (68.00%). For clinical uncontrollable factors, there was no significant difference between the two groups in the patient’s age, gender, predisposing factors, infection site except spine, VAS, course of disease, spinal segment, WBC, NE% and the incidence of SIRS. ESR [(94.38±6.91) mm/h, P=0.023)], CRP [(64.74±13.51) mg/L, P=0.040], and the incidence of paravertebral abscess (75%, P=0.018) in culture negative group were lower in contrast to culture positive group. For clinical controllable factors, prior antibiotics exposure within 2 weeks (P=0.058, OR=4.030, 95%CI: 0.956-16.993) and tissue homogenate (P=0.014, OR=0.171, 95%CI: 0.042-0.695) were significantly associated with the pathogen culture result. Surgical approach was not significantly associated with pathogen culture result.Conclusion: Patients with high level of ESR, CRP, and paravertebral abscess, would have high positive rate of pathogenic culture. Prior antibiotics exposure was associated with lower positive pathogen culture rate. Culture with tissue homogenate was more likely to find the causative germ, especially for patients without paravertebral abscess who had low level of ESR, CRP and prior antibiotics exposure.

Key words: Pyogenic spondylitis, Tissue homogenate, Antibiotics, Pathogen culture

中图分类号:

R681.5

崔云鹏,米川,王冰,潘元星,林云飞,施学东. 化脓性脊柱炎患者病原菌培养结果的影响因素分析[J]. 北京大学学报（医学版）, 2019, 51(6): 1042-1047.

Yun-peng CUI,Chuan MI,Bing WANG,Yuan-xing PAN,Yun-fei LIN,Xue-dong SHI. Analysis of influencing factors for pathogen culture result in patients with pyogenic spondylitis[J]. Journal of Peking University(Health Sciences), 2019, 51(6): 1042-1047.

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Items	Culture - (n=16)	Culture + (n=24)	Statistic value	P
General
Age/years	55.81±3.95	59.13±2.22	t=0.786	0.436
Female, n	8	10	P^a=0.269	0.604
Infection site except spine, n	2	3	P^b<0.001	1.000
Predisposing factors (DM, oral immunosuppressive agents), n	4	9	P^a=0.684	0.408
Clinical manifestation
Course of disease/d	60 (7, 270)	50 (7, 240)	Z=-0.014	0.989
Temperature, n			Z=-0.144	0.902
<37.5 ℃	10	15
37.5-38.5 ℃	3	3
>38.5 ℃	3	6
SIRS, n	2	9	P^b=1.886	0.170
Laboratory examination
WBC/(×10⁹/L)	8.14±0.62	7.84±0.85	t=-0.258	0.798
NE%	67.06±3.26	74.30±2.55	t=1.765	0.086
CRP/(mg/L)	213.0 (93.1, 793.0)	410.0 (59.8, 2 060.0)	Z=-2.058	0.040
ESR/(mm/h)	65.00 (12.00, 124.00)	106.00 (36.00, 135.00)	Z=-2.269	0.023
Imaging examination, n
Spinal segment			P^a=0.269	0.182
Cervical and thoracic	8	7
Lumbar	8	17
Multiple segment involvement	2	5	P^b=0.065	0.799
Epidural abscess	4	4	P^b=0.059	0.809
Paravertebral abscess	6	18	P^a=5.625	0.018

Pathogen culture result (n)	Cipro	Moxi	Levo	Cef	R	Oxa	Vanco	Carba
CN-S (1)	-	-	-	-	-	-	-	-
S. warneri (2)	0	0	0	-	0	1/2	0	-
S. cohnii urealyticum (1)	0	0	0	-	0	1/1	0	-
S. caprae (1)	0	0	0	-	0	0	0	-
S. hominis (1)	0	0	0	-	0	1/1	0	-
S. aureus (7)	1/7	0	0	-	0	2/7	0	-
Streptococcus (1)	-	-	-	-	-	-	0	-
S. agalactiae B group (2)	-	1/2	1/2	-	-	-	0	-
E. gallinarum (1)	0	-	0	-	-	-	0	-
S. typhi (1)	0	-	0	0	-	-	-	-
E. coli (3)	3/3	-	2/3	1/3	-	-	-	0
P. aeruginosa (1)	0	-	0	0	-	-	-	1/1
A. Baumanii (1)	1/1	-	1/1	1/1	-	-	-	1/1
M. luteus (1)	-	-	-	-	-	-	-	-
F. nucleatum (1)	-	-	-	-	-	-	-	-

Items	Culture - (n=30)	Culture + (n=25)	Statistic value	P
Procedure			P^b=0.550	0.458
Debridement	15 (60.00%)	10 (40.00%)
Aspiration	15 (50.00%)	15 (50.00%)
Prior antibiotics history (within 2 weeks)			P^b=1.872	0.171
Yes	21 (61.76%)	13 (38.24%)
No	9 (42.86%)	12 (57.14%)
Tissue homogenate			P^b=3.669	0.055
Yes	7 (36.84%)	12 (63.16%)
No	23 (63.89%)	13 (36.11%)

Items	Univariate analysis			Multivariate analysis
Items	P	OR	95%CI	P	OR	95%CI
Aspiration	0.459	0.667	0.228-1.950	0.717	0.790	0.220-2.834
Prior antibiotics history (within 2 weeks)	0.174	2.154	0.712-6.516	0.058	4.030	0.956-16.993
Tissue homogenate	0.059	0.330	0.104-1.045	0.014	0.171	0.042-0.695