大便球杆比指导危重患者腹泻治疗的价值

Value of fecal smear cue ratio in guiding treatment of diarrhea in critically ill patients

摘要

目的：探讨大便球杆比指导重症患者腹泻治疗中的价值。方法：纳入2018年1月—2023年12月入住山东大学齐鲁医院重症医学科、年龄≥18岁、出现不明原因腹泻并进行了两次及以上大便球杆比检测的患者221例，其中155例接受万古霉素治疗，66例非万古霉素治疗。将纳入患者分为万古霉素组和非万古霉素组，为控制基线混杂，采用倾向性得分匹配（propensity score matching，PSM）进行1∶1匹配，PSM后，万古霉素组59例，非万古霉素组59例。主要结局为患者住院期间死亡率，次要结局是腹泻改善率及大便球杆比。采用多因素Logistic回归分析住院期间死亡率的独立危险因素。结果：PSM后两组住院期间死亡率差异无统计学意义。次要结局方面，PSM后，万古霉素组治疗前大便球杆比显著高于非万古霉素组[（4.80±3.75）比（2.11±3.15），P<0.01]；治疗后，两组大便球杆比差异无统计学意义[（3.25±4.33）比（2.44±3.54），P=0.267]。PSM后，两组腹泻改善率差异亦无统计学意义。多因素Logistic回归分析显示，PSM前后大便球杆比、腹泻改善、万古霉素使用均不是影响患者住院期间死亡率的独立危险因素（P>0.05）。结论：基于大便球杆比指导的口服万古霉素治疗，虽可改善大便球杆比，但未能改善腹泻症状或降低重症腹泻患者的住院期间死亡率。大便球杆比不宜独立作为指导此类患者抗感染治疗的依据，未来需进一步研究更精准便捷的检测方法。

Abstract

Objective: To investigate the value of the fecal smear cue ratio in guiding the treatment of diarrhea in critically ill patients. Methods: A total of 221 patients admitted to the Department of Critical Care Medicine, Qilu Hospital of Shandong University from January 2018 to December 2023, aged ≥18 years, who developed unexplained diarrhea and underwent two or more examinations of the fecal smear cue ratio were enrolled. Among them, 155 patients received vancomycin treatment and 66 received non-vancomycin treatment. The enrolled patients were divided into a vancomycin group and a non-vancomycin group. To control for baseline confounding, propensity score matching (PSM) was performed at a 1:1 ratio. After PSM, the vancomycin group comprised 59 patients and the non-vancomycin group comprised 59 patients. The primary outcome was in-hospital mortality, and secondary outcomes were the rate of diarrhea improvement and the fecal smear cue ratio. Multivariate logistic regression analyses were used to identify independent risk factors for in-hospital mortality. Results: After PSM, there was no statistically significant difference in in-hospital mortality between the two groups. Regarding secondary outcomes, after PSM, the pre-treatment fecal smear cue ratio in the vancomycin group was significantly higher than that in the non-vancomycin group [(4.80±3.75) vs. (2.11±3.15), P<0.01]; after treatment, there was no statistically significant difference in the fecal smear cue ratio between the two groups [(3.25±4.33) vs. (2.44±3.54), P=0.267]. After PSM, there was also no statistically significant difference in the diarrhea improvement rate between the two groups. Multivariate logistic regression analysis showed that the fecal smear cue ratio, relief of diarrhea, and vancomycin use were not independent risk factors for in-hospital mortality before or after PSM. Conclusion: Although oral vancomycin therapy guided by the fecal smear cue ratio improved the fecal smear cue ratio, it failed to alleviate diarrhea symptoms or reduce in-hospital mortality in critically ill patients with diarrhea. The fecal smear cue ratio should not be used independently as a basis for guiding anti-infective therapy in these patients, and further research is needed to develop more accurate and convenient detection methods.

关键词

大便球杆比 / 腹泻 / 重症患者 / 万古霉素 / 住院期间死亡率

Key words

Fecal smear cue ratio / Diarrhea / Critical Illness / Vancomycin / Mortality

参考文献

[1] 崔雅婷， 毛智， 刘超， 等 . ICU老年重症患者抗生素相关性腹泻的关联因素分析[J]. 解放军医学院学报， 2024， 45（2）： 163-168. DOI: 10.12435/j.issn.2095—5227.2023.166.

[2] van Ruijven IM , Abma J , Brunsveld—Reinders AH , et al. High protein provision of more than 1.2 g/kg improves muscle mass preservation and mortality in ICU patients: A systematic review and meta—analyses[J]. Clin Nutr, 2023, 42（12）: 2395-2403. DOI: 10.1016/j.clnu.2023.09.026.

[3] Zhang X , Zhang J , You Z B , et al. Effects of enteral nutrition protocols on nutritional indicators and prognosis in neurological ICU patients: a randomized controlled trial[J]. Sci Rep, 2025, 15（1）: 30916. DOI: 10.1038/s41598—025—12650—y.

[4] Yamamoto R , Yamazaki H , Koroki T , et al. Classifying diarrhea in critically ill patients through various criteria: a cohort study[J]. J Intensive Care, 2025, 13（1）: 55. DOI: 10.1186/s40560—025—00824—9.

[5] 祝利红， 庄一渝 . 血糖变异度在预测危重患者早期肠内喂养不耐受中的应用价值[J]. 中华急危重症护理杂志， 2025， 6（6）： 645-652. DOI: 10.3761/j.issn.2096—7446.2025.06.001.

[6] 刘海瑛， 曹莹， 葛现才 . 新式质量控制对ICU重症患者肠内营养不耐受的干预效果[J]. 中国现代普通外科进展， 2025， 28（5）： 401-405. DOI: 10.3969/j.issn.1009—9905.2025.05.012.

[7] Blaser M . Antibiotic overuse: Stop the killing of beneficial bacteria[J]. Nature, 2011, 476（7361）: 393-394. DOI: 10.1038/476393a.

[8] Dubourg G , Lagier J C , Robert C , et al. Culturomics and pyrosequencing evidence of the reduction in gut microbiota diversity in patients with broad—spectrum antibiotics[J]. Int J Antimicrob Agents, 2014, 44（2）: 117-124. DOI: 10.1016/j.ijantimicag.2014.04.020.

[9] Imhann F , Bonder MJ , Vich Vila A , et al. Proton pump inhibitors affect the gut microbiome[J]. Gut, 2016, 65（5）: 740-748. DOI: 10.1136/gutjnl—2015—310376.

[10] Wang F , Meng J , Zhang L , et al. Morphine induces changes in the gut microbiome and metabolome in a morphine dependence model[J]. Sci Rep, 2018, 8（1）: 3596. DOI: 10.1038/s41598—018—21915—8.

[11] Tomizawa Y , Kurokawa S , Ishii D , et al. Effects of psychotropics on the microbiome in patients with depression and anxiety: considerations in a naturalistic clinical setting[J]. Int J Neuropsychopharmacol, 2021, 24（2）: 97-107. DOI: 10.1093/ijnp/pyaa070.

[12] Demehri FR , Barrett M , Teitelbaum DH . Changes to the intestinal microbiome with parenteral nutrition: review of a murine model and potential clinical implications[J]. Nutr Clin Pract, 2015, 30（6）: 798-806. DOI: 10.1177/0884533615609904.

[13] Gianotti L , Alexander J W , Fukushima R , et al. Steroid therapy can modulate gut barrier function, host defense, and survival in thermally injured mice[J]. J Surg Res, 1996, 62（1）: 53-58. DOI: 10.1006/jsre.1996.0172.

[14] 中华预防医学会微生态学分会， 中国医师协会感染科医师分会 . 中国微生态调节剂临床应用专家共识（2025版）[J]. 中国微生态学杂志， 2025， 37（8）： 869-887. DOI: 10.13381/j.cnki.cjm.202508001.

[15] Smith AB , Jenior ML , Keenan O , et al. Enterococci enhance Clostridioides difficile pathogenesis[J]. Nature, 2022, 611（7937）: 780-786. DOI: 10.1038/s41586—022—05438—x.

[16] Kelly CR , Fischer M , Allegretti JR , et al. ACG Clinical Guidelines: Prevention, diagnosis, and treatment of clostridioides difficile infections[J]. Am J Gastroenterol, 2021, 116（6）: 1124-1147. DOI: 10.14309/ajg.00000000000001278.

[17] Qin J , Li R , Raes J , et al. A human gut microbial gene catalogue established by metagenomic sequencing[J]. Nature, 2010, 464（7285）: 59-65. DOI: 10.1038/nature08821.

[18] Turnbaugh P J , Hamady M , Yatsunenko T , et al. A core gut microbiome in obese and lean twins[J]. Nature, 2009, 457（7228）: 480-484. DOI: 10.1038/nature07540.

[19] Hill DA , Siracusa MC , Abt MC , et al. Commensal bacteria—derived signals regulate basophil hematopoiesis and allergic inflammation[J]. Nat Med, 2012, 18（4）: 538-546. DOI: 10.1038/nm.2657.

[20] Forslund K , Hildebrand F , Nielsen T , et al. Disentangling type 2 diabetes and metformin treatment signatures in the human gut microbiota[J]. Nature, 2015, 528（7581）: 262-266. DOI: 10.1038/nature15766.

[21] 许钧尧， 康思源， 余曜宇， 等 . 微生物组与泌尿系统肿瘤研究进展[J]. 同济大学学报（医学版）， 2024， 45（3）： 454-458. DOI: 10.12289/j.Issn.2097—4345.24040.

[22] Naslowski JB , Schieferdecker MEM , Campos ACL . Effects of probiotic supplementation on infectious and gastrointestinal complications of critically ill patients: randomized, blinded, placebo—controlled clinical trial[J]. Clin Nutr ESPEN, 2025, 68: 228-237. DOI: 10.1016/j.clnesp.2025.05.006.

[23] Bagdadi B , Alqazlane A , Alotaibi M , et al. The effectiveness of probiotics or synbiotics in the prevention and treatment of diarrhea among critically ill adults: A systematic review and meta—analysis[J]. Clin Nutr ESPEN, 2025, 65: 218-226. DOI: 10.1016/j.clnesp.2024.11.025.

基金资助

山东省自然科学基金项目(ZR2024MH313)

山东省医学会“青年人才托举”工程项目(2024-GJ-0152)