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標題: | 在Child-Pugh A肝硬化的病人於急性靜脈瘤出血時使用預防性抗生素以減少再出血之分析 Analysis of antibiotic prophylaxis in the prevention of rebleeding in patients with acute variceal hemorrhage and Child-Pugh classification A liver cirrhosis |
作者: | Min-Chin Chiu 邱敏欽 |
指導教授: | 吳明賢(Ming-Shiang Wu) |
關鍵字: | 靜脈曲張出血,預防性抗生素,肝硬化,再出血,Child-Pugh分級, variceal bleeding,antibiotic prophylaxis,cirrhosis,rebleeding,Child-Pugh classification, |
出版年 : | 2019 |
學位: | 碩士 |
摘要: | 簡介
胃或食道靜脈曲張出血是肝硬化最常見且嚴重的併發症之一。過去的研究顯示,感染的問題對於肝硬化的病人在止血機轉上有負面的影響。肝硬化病人由於本身免疫功能低下以及腸胃道內細菌移行等因素,在消化道出血時有較高的感染風險。對於肝硬化病人,特別是已代償失調的族群,抗生素是一被證實有效預防感染及再出血的醫療處置。然而,過去的探討對象絕大多數都是針對失償性肝硬化,對於尚能代償之Child-Pugh分級A的病人所做的研究仍嚴重缺之。因此,我們希望透過本次回溯性研究,針對Child-Pugh分級A的病人罹患胃或食道靜脈曲張出血時,對預防性抗生素的使用是否能達到防止再出血與感染的效果做進一步的分析。 目的 對於Child-Pugh分級A的病人罹患胃或食道靜脈曲張出血時,使用抗生素以預防再出血與感染的效果分析 方法 本研究資料來源自台大醫院總院與雲林分院的病歷資料,針對Child-Pugh分級A肝病化同時合併胃或食道靜脈曲張出血之病患,查閱其內視鏡檢查報告及電子與紙本病歷資料。本研究收案條件為年齡大於20歲、確認肝硬化Child-Pugh分級A且合併經內視鏡確認胃或食道靜脈曲張出血之病患。本研究排除條件為懷孕、重大器官衰竭、過去曾罹患腦血管病變、合併非源自肝臟相關之癌症病史、目前服用抗血小板或抗凝血藥物、過去兩星期內曾使用抗生素或於內視鏡檢查前已確認感染等情況。對於平時狀況已有腹水或反覆肝性腦病變的病患也排除收案。 結果 本研究總共收錄884位硬化Child-Pugh分級A且合併胃或食道靜脈曲張出血病患。其中511位有使用預防性抗生素,373位沒有使用。整體而言,五天內再出血率為1%,六星期內再出血率為13%,併發感染的機率為13%。使用迴歸分析比較臨床上相關影響因子顯示,預防性抗生素的使用在病人有接受內視鏡治療、同時使用氫離子阻斷劑、合併肝臟惡性腫瘤、較高的心跳速率、較低的血容比以及較低的血中白蛋白濃度有顯著相關。再經過傾向分數配對後,共有466位病患納入比較,其中233位有使用預防性抗生素,233位沒有使用。其分析結果發現抗生素的使用與否和發生五天內再出血、六星期內再出血以及感染等情況無統計學上顯著差異。 討論 數十年來,預防性抗生素的使用已被證實在肝硬化病人身上有預防感染及再出血的功效。然而,近年來研究顯示長期使用抗微生物製劑會導致肝硬化病人發生許多嚴重併發症。在考量抗生素使用的好處與壞處後,以風險為導向分層之使用策略逐漸為大家所接受以作為臨床使用指南。但這些證據主要是針對肝硬化代償失調的病人。對於代償尚可之Child-Pugh分級A的病人,其相關研究則付之闕如。在本研究中,我們針對Child-Pugh分級A的病患族群,探討胃或食道靜脈曲張出血時預防性抗生素的使用與臨床上相關影響預後因子之關係,其結果顯示預防性抗生素的使用和病人有接受內視鏡治療、同時使用氫離子阻斷劑、合併肝臟惡性腫瘤、較高的心跳速率、較低的血容比以及較低的血中白蛋白濃度有顯著相關。此發現和我們臨床使用經驗上相仿,也就是對於明確出血經內視鏡治療、合併癌症、較差的肝臟功能及生命徵象懷疑嚴重出血之病患,第一線醫療人員會有較高的傾向使用抗生素。此外,我們進一步使用傾向分數配對後分析,其結果顯示抗生素的使用與否和發生五天內再出血、六星期內再出血以及感染等情況無統計上顯著差異,此發現暗示預防性抗生素對於再出血以及感染沒有顯著影響。 結論 對於Child-Pugh分級A的病患族群在胃或食道靜脈曲張出血時使用預防性抗生素對於再出血以及併發感染沒有顯著影響。 Introduction Gastroesophageal variceal bleeding is one of the most common and serious complications in cirrhosis. The existing data has shown that infection had negative influence on hemostasis in cirrhotic patients. Due to immunocompromised and bacterial translocation, cirrhotic patients have higher risks of infection when suffering from gastrointestinal bleeding. Antimicrobial agents are of proved efficacy to prevent infection and rebleeding after variceal hemorrhage, especially in decompensated cirrhosis. However, the discussions and reports are still lacking about Child-Pugh (CP) class A. We thus conducted a retrospective study to analyze the relationship between prophylactic antibiotics and rebleeding and infection during acute variceal hemorrhage in CP class A cirrhosis. Aims To analyze whether antibiotic prophylaxis prevents rebleeding and infection in CP class A cirrhotic patients with acute variceal hemorrhage Methods and Materials In this retrospective study, we reviewed the endoscopic reports and medical records from National Taiwan University Main Hospital and Yun-Lin Branch. Individuals with CP class A cirrhosis, age above 20 years and endoscopically confirmed acute variceal bleeding were enrolled into the study. The exclusion criteria were pregnancies, vital organ failures, prior cerebrovascular accidents, non-liver related malignancies, active antiplatelet or anticoagulant agents use, antibiotic exposure within two weeks before bleeding episode and confirmed infection before endoscopic study. CP class A cirrhotic patients with more poor prognostic factors (ascites and frequent hepatic encephalopathy at baseline condition) were also excluded. Results Our study totally recruited 884 CP class A cirrhotic patients with acute variceal hemorrhage. Among these patients, there were 511 cases with antibiotic prophylaxis while 373 without. The overall five-day rebleeding rate was 1%, six-week rebleeding rate was 13% and infection rate was 13%. After logistic regression analysis of relevant variables, antimicrobial prophylaxis had significant association with endoscopic treatments (OR: 3.7264, 95% CI: 2.5079 to 5.5368), PPI use (OR: 1.6893, 95% CI: 1.2378 to 2.3055), hepatocellular carcinoma (OR: 1.3802, 95% CI: 1.0078 to 1.8902), heart rate (OR: 1.0120, 95% CI: 1.0046 to 1.0194), Hematocrit (OR: 0.9638, 95% CI: 0.9418 to 0.9862) and albumin (OR: 0.5291, 95% CI: 0.3720 to 0.7526). After propensity score matching, there were total 466 patients with 233 in each group enrolled comparison. The analysis showed that the rates of five-day rebleeding, six-week rebleeding and infection showed no significant difference between patients with antimicrobial prophylaxis and those without. Discussion For many years, antibiotic prophylaxis is of confirmed efficacy to prevent infection and rebleeding among cirrhotic patients after acute variceal bleeding. However, recent reports have disclosed that prolonged antibiotic exposures lead to serious complications in cirrhosis. Under consideration of benefits and disadvantages of antimicrobial therapy, a stratified-risk guidance of antibiotics use is suggested when treating variceal hemorrhage. Regardless of several evidence demonstrated in decompensated cirrhosis, there is only limited data in discussion about CP class A group. In our study, we focused on CP class A cirrhosis and explored the association between antibiotic agents and clinical factors relevant to variceal bleeding. The results showed that antibiotics use were significantly associated with endoscopic treatment, PPI use, hepatic malignancies, heart rate, hematocrit and serum album. These findings are more illustrated in clinical scenarios that physicians are tend to administer antibiotics when facing endoscopically treated bleeders, malignant comorbidities, lower liver reserve and clinical suspicion of massive hemorrhages. Furthermore, we performed propensity score matching and the analysis showed that there was no difference in five-day, six-week rebleeding or infection showed between two matched groups. The results indicated that antibiotic prophylaxis provided no obvious preventive effects for CP class A cirrhotic patients during variceal bleeding. Conclusion For acute variceal hemorrhage, antibiotic prophylaxis shows no significant effects on prevention of rebleeding or infection in CP class A cirrhosis. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/21378 |
DOI: | 10.6342/NTU201902919 |
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顯示於系所單位: | 臨床醫學研究所 |
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