探讨肝移植术后耐碳青霉烯肺炎克雷伯菌(CRKP)感染危险因素。

回顾性分析2018年1月至2020年1月在北京佑安医院肝移植中心接受肝移植手术并随访超过3个月的186例受者临床资料。按术后是否出现CRKP感染分为无感染组(n＝63)、非CRKP感染组(n＝102)和CRKP感染组(n＝21)。观察受者年龄、性别、终末期肝病模型(MELD)评分和Child-Pugh分级等术前指标，手术时间、无肝期时间、失血量和输血量等术中指标，气管插管和ICU停留时间、并发症发生率和连续性肾脏替代治疗(CRRT)等术后指标。非正态分布计量资料采用Kruskal-Wallis检验进行比较，组间比较采用Dunn检验。计数资料采用χ²检验及Bonferroni校正进行比较。采用多分类logistic回归分析CRKP感染发生的危险因素。P<0.05为差异有统计学意义。

无感染组、非CRKP感染组和CRKP感染组受者术前MELD评分、Child-Pugh分级、原发性肝癌、肝衰竭、术前感染、术前1个月内碳青霉烯类抗菌药物使用超过7 d以及术前气管插管比例差异均有统计学意义(χ²＝9.03、22.67、3.80、3.15、13.67、8.52和7.29，P均<0.05)。三组受者术中失血量、术中输血量差异均有统计学意义(χ²＝15.60、23.08，P均<0.05)。截至2020年4月1日，所有受者随访时间均超过3个月。无感染组受者未发生死亡；非CRKP感染组和CRKP感染组受者分别死亡17、14例(均于住院期间死亡)，病死率分别为17%和67%，差异有统计学意义(χ²＝23.09，P<0.05)。3组受者气管插管时间、ICU停留时间以及并发症、CRRT、移植术后早期肝功能不全和合并感染比例差异均有统计学意义(χ²＝22.92、14.46、30.34、21.91、5.74、77.21，P均<0.05)。与无感染组比较，CRKP感染发生的危险因素分别为：受者性别、MELD评分、术前1个月内碳青霉烯类抗菌药物使用超过7 d、术前感染以及原发病为肝衰竭和原发性肝癌(OR＝0.25、1.09、7.14、7.17、8.70和0.22，P均<0.05)。

受者性别、MELD评分、术前1个月内碳青霉烯类抗菌药物使用超过7天、术前感染以及原发病诊断肝衰竭和原发性肝癌是肝移植术后CRKP感染的危险因素，对术前指导抗菌药物合理使用、降低耐药菌感染风险以及术后准确、有针对性抗感染治疗具有重要临床意义。

To investigate the risk factors of carbapenem-resistant Klebsiella pneumoniae (CRKP) infection after liver transplantation.

The clinical data of 186 patients who underwent liver transplantation in the Liver Transplantation Center of Beijing You′an Hospital from January 2018 to January 2020 were retrospectively analyzed. The patients were divided into non-infected group (n=63), non-CRKP-infected group (n=102) and CRKP-infected group (n=21). The preoperative indexes such as age, gender, modle for end-stage liver disease (MELD) score and Child-Pugh grade, the intraoperative indexes such as operation time, anhepatic period, blood loss and blood transfusion, the time of endotracheal intubation and ICU stay, the incidence of complications and continuous renal replacement therapy (CRRT) were observed. Abnormal distribution data were compared by Kruskal-Wallis test, and Dunn test was used for inter-group comparison. The counting data were compared by Chi-square test and Bonferroni correction. The risk factors of CRKP infection in perioperative period were analyzed by multiple logistic regression. A P<0.05 was considered statistically significant.

There were significant differences in preoperative MELD score, Child-Pugh grade, primary liver cancer, liver failure, preoperative infection, use of carbapenem antibiotics for more than 7 days in one month before operation and the proportion of preoperative endotracheal intubation among non-infected group, non-CRKP-infected group and CRKP-infected group (χ²= 9.03, 22.67, 3.80, 3.15, 13.67, 8.52 and 7.29, all P<0.05). There were significant differences in intraoperative blood loss and transfusion among three groups (χ²=15.60, 23.08, all P<0.05). As of April 1, 2020, all subjects had been followed up for more than 3 months. There was no death in the non-infected group; 17 and 14 patients in non-CRKP-infected group and CRKP-infected group died respectively (all died during hospitalization). The mortality rates were 17% and 67%, respectively (χ²= 23.09, P<0.05). There were significant differences in intubation time, ICU stay, complications, CRRT, early liver dysfunction and the proportion of co-infection among the three groups (χ²= 22.92, 14.46, 30.34, 21.91, 5.74 and 77.21, all P<0.05). Compared with the non-infected group, the risk factors of CRKP infection were recipient gender, MELD score, use of carbapenem antibiotics for more than 7 days in one month before operation, preoperative infection and preoperative diagnosis of liver failure and liver cancer (OR= 0.25, 1.09, 7.14, 7.17, 8.70 and 0.22, all P<0.05).

Recipient gender, MELD score, carbapenem antibiotics used for more than 7 days within one month before operation, preoperative infection and preoperative diagnosis of liver failure and liver cancer are high risk factors for CRKP infection after liver transplantation, which has important clinical significance for guiding rational use of antibiotics before operation, reducing the risk of infection caused by drug-resistant bacteria and accurate and targeted anti-infection treatment after operation.