血源性与非血源性假体周围感染外科治疗疗效差异及危险因素回顾分析

A Retrospective Analysis of Differences in Efficacy of Surgical Treatment of Hematogenous versus Non-Hematogenous Periprosthetic Joint Infections and Risk Factors

摘要: 目的：本文旨在对比血源性假体周围感染(periprosthetic joint infection, PJI)与非血源性PJI外科治疗的疗效，分析造成其疗效差异的原因以及危险因素。方法：回顾分析2001年1月至2022年6月期间在青岛大学附属医院治疗的膝关节或髋关节PJI的患者138例。根据感染途径分为血源性和非血源性PJI，随访3年至18年。结果：138例PJI患者中，血源性PJI (血源组) 54例，非血源性PJI (非血源组) 84例。膝关节感染83例比例明显高于髋关节感染55例(P < 0.05)。138例患者中微生物培养阳性99例，该99例患者中混合感染4例，单一微生物感染95例，在单一微生物感染中，革兰氏阳性菌(G+) 74例，其中金黄色葡萄球菌26例；革兰氏阴性菌13例包括：铜绿假单胞菌、大肠埃希菌、鲍氏不动杆菌、布鲁菌、产酸克雷伯菌、植生物拉尔菌，血源组革兰氏阴性菌感染显著多于非血源组(P < 0.05)，真菌8例。血源组患者治疗失败20例，非血源组患者治疗失败18例，二者有显著性差异(P < 0.05)。危险因素单因素分析表明糖尿病、G+、真菌感染、保留假体的清创术与治疗失败密切相关。多因素分析表明G+、真菌感染，假体保留与治疗失败密切相关，保留假体是血源组PJI中失败的唯一独立危险因素(P < 0.05)；Kaplan-Meier法计算生存率并绘制生存曲线经Log-rank检验显示，血源组患者相较于非血源组患者于外科治疗3、6、12月后的假体生存率显著降低(P < 0.05)。结论：血源性PJI的治疗失败率明显高于非血源性PJI，保留假体的清创术是血源性感染治疗失败的唯一独立危险因素。

Abstract: Objective: This study aims to compare clinical outcomes between hematogenous and non-hematogenous periprosthetic joint infections (PJIs) following surgical treatment, analyze factors contributing to outcome disparities, and identify associated risk factors. Methods: We conducted a retrospective analysis of 138 PJI cases treated at the Affiliated Hospital of Qingdao University from January 2001 to June 2022. Patients were stratified into hematogenous and non-hematogenous groups based on infection etiology, with postoperative surveillance spanning 3~18 years. Results: Among 138 PJI patients, 54 cases were hematogenous PJI (hematogenous group) and 84 cases were non-hematogenous PJI (non-hematogenous group). Knee infections (83 cases) showed significantly higher prevalence than hip infections (55 cases) (P < 0.05). Of the 138 patients, 99 demonstrated positive microbial cultures. Among these 99 patients, 4 cases were mixed infections and 95 were single-microorganism infections. Of the monomicrobial infections, 74 cases involved Gram-positive (G+) bacteria (including 26 Staphylococcus aureus cases), while 13 cases involved Gram-negative bacteria (including Pseudomonas aeruginosa, Escherichia coli, Acinetobacter baumannii, Brucella spp., Klebsiella oxytoca, and Ralstonia pickettii). The hematogenous group showed significantly higher Gram-negative bacterial infections than the non-hematogenous group (P < 0.05). Fungal infections occurred in 8 cases. Treatment failure occurred in 20 hematogenous group patients and 18 non-hematogenous group patients, demonstrating significant intergroup difference (P < 0.05). Univariate analysis identified diabetes mellitus, G+ infections, fungal infections, and debridement with prosthesis retention as significant risk factors for treatment failure. Multivariate analysis revealed G+ infections, fungal infections, and prosthesis retention as independent risk factors for treatment failure, with prosthesis retention being the sole independent risk factor in hematogenous PJI (P < 0.05). Kaplan-Meier survival analysis with Log-rank test demonstrated significantly lower prosthesis survival rates in the hematogenous group compared to the non-hematogenous group at 3, 6, and 12 months post-surgical intervention (P < 0.05). Conclusion: Hematogenous PJIs exhibit significantly higher treatment failure rates compared to non-hematogenous infections. Prosthesis retention during debridement represents the sole independent risk factor for treatment failure in hematogenous PJIs.