11例创伤弧菌感染患者的临床特征及该病快速诊断流程的建立

林伟鹏; 穆旭; 陈胜华; 何春景; 李汉华; 孙传伟; 卞徽宁; 赖文; 黄志锋

doi:10.3760/cma.j.cn501225-20230803-00036

11例创伤弧菌感染患者的临床特征及该病快速诊断流程的建立

doi: 10.3760/cma.j.cn501225-20230803-00036

1.
广东药科大学附属第一医院普外一科，广州　　510062
2.
广东省心血管病研究所，广东省人民医院，广东省医学科学院，广州　　510080
3.
深圳市人民医院（暨南大学第二临床医学院，南方科技大学第一附属医院）烧伤与创面修复科，深圳　　518020
4.
南方医科大学附属广东省人民医院（广东省医学科学院）烧伤与创面修复科，广州　　510080

基金项目:

广东省基础与应用基础研究区域联合基金重点项目 2020B151520088

详细信息

通讯作者:
黄志锋，Email：13802938068@139.com

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出版历程
- 收稿日期: 2023-08-03

Clinical characteristics of 11 patients with Vibrio vulnificus infection and the establishment of a rapid diagnosis procedure for this disease

1.
The First Department of General Surgery, the First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou 510062, China
2.
Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
3.
Department of Burns and Wound Repair, Shenzhen People's Hospital, the First Affiliated Hospital of Southern University of Science and Technology, the Second Clinical Medicine College of Jinan University, Shenzhen 518020, China
4.
Department of Burns and Wound Repair, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China

Funds:

Key Project of Guangdong Province Basic and Applied Basic Research Regional Joint Fund 2020B151520088

More Information

Corresponding author: Huang Zhifeng, Email: 13802938068@139.com

摘要

摘要: 目的分析创伤弧菌感染患者的临床特征，分享诊疗经验，建立该病的快速诊断流程。方法该研究为回顾性病例系列研究。2009年1月—2022年11月，南方医科大学附属广东省人民医院烧伤与创面修复科收治11例符合入选标准的创伤弧菌感染患者。统计所有患者的性别，年龄，发病时间，入院时间，确诊时间，感染途径，基础疾病，受累肢体，入院时的临床表现及体征，入院时的白细胞计数、血红蛋白、血小板计数、C反应蛋白（CRP）、丙氨酸转氨酶（ALT）、天冬氨酸转氨酶（AST）、肌酐、降钙素原、白蛋白、N端-B型钠尿肽前体（NT-proBNP）、血钠水平，住院期间的病原菌培养结果与宏基因组二代测序（mNGS）结果及创伤弧菌药物敏感试验结果，治疗方式，住院时间，转归。对比分析有、无海水/海产品接触史患者的入院时间和确诊时间，是、否早期接受足量抗生素治疗患者的病死比和截肢/指比。对存活的手部受累患者，统计末次随访时使用Brunnstrom分期评定的手功能情况。综合患者临床特征和救治情况，建立创伤弧菌感染的快速诊断流程。结果患者中男7例、女4例，年龄（56±17）岁，多在夏、秋季发病，入院时间为发病后3.00（1.00，4.00）d，确诊时间为发病后4.00（2.00，8.00）d。有、无海水/海产品接触史患者分别有7、4例，这2类患者的入院时间相近（ P>0.05）；有海水/海产品接触史患者确诊时间为发病后2.00（2.00，5.00）d，明显短于无海水/海产品接触史患者的发病后9.00（4.25，13.00）d（ Z=-2.01， P<0.05）。10例患者有基础疾病。患肢为右手者8例、左手者1例、下肢者2例。入院时，发热患者共9例；11例患者感染部位均伴疼痛、患肢红肿，有瘀斑/坏死、水疱/血疱的患者各9例；6例患者发生休克，2例患者发生多器官功能障碍综合征。入院时，白细胞计数、血红蛋白、白蛋白水平异常的患者数均为8例，CRP、降钙素原、NT-proBNP水平异常的患者数均为10例，肌酐、血钠水平异常的患者数均为5例，血小板计数、ALT、AST水平异常者少。住院期间，11份创面组织/分泌物标本的病原菌培养结果中4份阳性，结果回报时间为5.00（5.00，5.00）d；9份血液标本的病原菌培养结果中4份阳性，结果回报时间为3.50（1.25，5.00）d；7份创面组织/分泌物或血液标本的mNGS结果均为阳性，结果回报时间为1.00（1.00，2.00）d。3株检测出的创伤弧菌对环丙沙星、左氧氟沙星、阿米卡星等10种临床常用抗生素敏感。共10例患者接受了手术治疗，其中4例患者截肢/指；所有患者均接受了抗感染治疗。11例患者住院时间为（26±11）d，其中9例患者治愈，2例患者死亡。与未早期接受足量抗生素治疗的6例患者比较，早期接受足量抗生素治疗的5例患者的病死比、截肢/指比均无明显变化（ P>0.05）。术后3个月~2年，对8例患者进行了手功能评定，结果为残废手者4例、不完全残废手者2例、功能恢复手者2例。当患者临床表现有肢体红肿且有海水/海产品接触史或创伤弧菌脓毒症预检分诊RiCH评分≥1分时，应立即启动病原学检测，从而快速诊断创伤弧菌感染。结论创伤弧菌感染在夏、秋季多发，临床表现及实验室检测结果有明显感染特征，可伴有多器官功能损害；病死比及致残比均较高，对患肢功能影响大；早期诊断困难，易延误治疗，mNGS有助于快速检测。对于有肢体红肿伴海水/海产品接触史或创伤弧菌脓毒症预检分诊RiCH评分≥1分的患者，应立即启动病原学检测以快速诊断创伤弧菌感染。
- 创伤弧菌 /
- 感染 /
- 临床特征 /
- 手功能 /
- 快速诊断 /
- 流程
Abstract: Objective To analyze the clinical characteristics of patients with Vibrio vulnificus infection, share diagnosis and treatment experience, and establish a rapid diagnosis procedure for this disease. Methods This study was a retrospective case series study. From January 2009 to November 2022, 11 patients with Vibrio vulnificus infection who met the inclusion criteria were admitted to the Department of Burns and Wound Repair of Guangdong Provincial People's Hospital Affiliated to Southern Medical University. The gender, age, time of onset of illness, time of admission, time of diagnosis, route of infection, underlying diseases, affected limbs, clinical manifestations and signs on admission, white blood cell count, hemoglobin, platelet count, C-reactive protein (CRP), alanine transaminase (ALT), aspartate transaminase (AST), creatinine, procalcitonin, albumin, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and blood sodium levels on admission, culture results and metagenomic next-generation sequencing (mNGS) results of pathogenic bacteria and the Vibrio vulnificus drug susceptibility test results during hospitalization, treatment methods, length of hospital stay, and outcomes of all patients were recorded. Comparative analysis was conducted on the admission time and diagnosis time of patients with and without a history of exposure to seawater/marine products, as well as the fatality ratio and amputation of limbs/digits ratio of patients with and without early adequate antibiotic treatment. For the survived patients with hand involvement, the hand function was assessed using Brunnstrom staging at the last follow-up. Based on patients' clinical characteristics and treatment conditions, a rapid diagnosis procedure for Vibrio vulnificus infection was established. Results There were 7 males and 4 females among the patients, aged (56±17) years. Most of the patients developed symptoms in summer and autumn. The admission time was 3.00 (1.00, 4.00) d after the onset of illness, and the diagnosis time was 4.00 (2.00, 8.00) d after the onset of illness. There were 7 and 4 patients with and without a history of contact with seawater/marine products, respectively, and the admission time of these two types of patients was similar ( P>0.05). The diagnosis time of patients with a history of contact with seawater/marine products was 2.00 (2.00, 5.00) d after the onset of illness, which was significantly shorter than 9.00 (4.25, 13.00) d after the onset of illness for patients without a history of contact with seawater/marine products ( Z=-2.01, P<0.05). Totally 10 patients had underlying diseases. The affected limbs were right-hand in 8 cases, left-hand in 1 case, and lower limb in 2 cases. On admission, a total of 9 patients had fever; 11 patients had pain at the infected site, and redness and swelling of the affected limb, and 9 patients each had ecchymosis/necrosis and blisters/blood blisters; 6 patients suffered from shock, and 2 patients developed multiple organ dysfunction syndrome. On admission, there were 8 patients with abnormal white blood cell count, hemoglobin, and albumin levels, 10 patients with abnormal CRP, procalcitonin, and NT-proBNP levels, 5 patients with abnormal creatinine and blood sodium levels, and fewer patients with abnormal platelet count, ALT, and AST levels. During hospitalization, 4 of the 11 wound tissue/exudation samples had positive pathogenic bacterial culture results, and the result reporting time was 5.00 (5.00, 5.00) d; 4 of the 9 blood specimens had positive pathogenic bacterial culture results, and the result reporting time was 3.50 (1.25, 5.00) d; the mNGS results of 7 wound tissue/exudation or blood samples were all positive, and the result reporting time was 1.00 (1.00, 2.00) d. The three strains of Vibrio vulnificus detected were sensitive to 10 commonly used clinical antibiotics, including ciprofloxacin, levofloxacin, and amikacin, etc. A total of 10 patients received surgical treatment, 4 of whom had amputation of limbs/digits; all patients received anti-infection treatment. The length of hospital stay of 11 patients was (26±11) d, of whom 9 patients were cured and 2 patients died. Compared with that of the 6 patients who did not receive early adequate antibiotic treatment, the 5 patients who received early adequate antibiotic treatment had no significant changes in the fatality ratio or amputation of limbs/digits ratio ( P>0.05). In 3 months to 2 years after surgery, the hand function of 8 patients was assessed, with results showing 4 cases of disabled hands, 2 cases of incompletely disabled hands, and 2 cases of recovered hands. When a patient had clinical symptoms of limb redness and swelling and a history of contact with seawater/marine products or a pre-examination triage RiCH score of Vibrio vulnificus sepsis ≥1, the etiological testing should be initiated immediately to quickly diagnose Vibrio vulnificus infection. Conclusions Vibrio vulnificus infection occurs most frequently in summer and autumn, with clinical manifestations and laboratory test results showing obvious infection characteristics, and may be accompanied by damage to multiple organ functions. Both the fatality and disability ratios are high and have a great impact on the function of the affected limbs. Early diagnosis is difficult and treatment is easily delayed, but mNGS could facilitate rapid detection. For patients with red and swollen limbs accompanied by a history of contact with seawater/marine products or with a pre-examination triage RiCH score of Vibrio vulnificus sepsis ≥1, the etiological testing should be initiated immediately to quickly diagnose Vibrio vulnificus infection.
- Vibrio vulnificus /
- Infection /
- Clinical characteristics /
- Hand function /
- Rapid diagnosis /
- Procedure
林伟鹏：整理数据、统计分析以及撰写论文；穆旭、陈胜华、何春景：数据整理与统计分析；李汉华、孙传伟、卞徽宁、赖文：研究指导、论文修改；黄志锋：研究指导、论文修改、经费支持

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1 2例创伤弧菌感染患者创面情况及处理方法。1A.入院时，患肢可见水疱、瘀斑并伴红肿；1B.入院第2天行切开清创手术，可见深层筋膜、肌肉坏死；1C.入院第7天，因红肿扩散未能控制，将肢体全长切开减压；1D.入院第20天，感染得到控制，行缝合+左侧腹股沟区刃厚皮片移植修复创面；1E.末次术后1个月，手指仍肿胀，伸展动作受限；1F.入院时，患肢侧面见皮肤溃烂、有水疱，将手背局部切开；1G.入院时，患肢掌面见局部指端坏死，有不规则的小切口；1H.入院第1天，行切开清创手术，清除坏死皮肤、局部切开减压；1I、1J.分别为入院第21天，用右侧大腿刃厚皮片修复创面+截指手术后掌面、背面观

注：图1A~1E为一例患者患肢情况，图1F~1J为另一例患者患肢情况

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