A simple scoring system to differentiate between relapse and re-infection in patients with recurrent melioidosis.
A simple scoring system to differentiate between relapse and re-infection in patients with recurrent melioidosis.
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DOI：
10.1371/journal.pntd.0000327
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发表时间：
2008
影响因子：
3.8
通讯作者：
Peacock SJ
中科院分区：
文献类型：
--
作者：
Limmathurotsakul D;Chaowagul W;Chantratita N;Wuthiekanun V;Biaklang M;Tumapa S;White NJ;Day NP;Peacock SJ
类鼻疽是东亚地区发病和死亡的重要原因。大约 10% 的患者在治疗后会出现复发性类鼻疽，要么是由于相同菌株复发，要么是新的鼻疽伯克霍尔德菌菌株再次感染。区分两者很重要，但需要细菌基因分型。本研究的目的是开发一个简单的评分系统来区分再次感染和复发。在 1986 年至 2005 年间对泰国东北部 Sappasithiprasong 医院就诊的 2,804 名连续成年类鼻疽患者进行的一项前瞻性研究中，有 141 名复发性类鼻疽患者的配对菌株可用于基因分型。其中，92名患者复发，49名患者再次感染。通过多变量逻辑回归确定与复发或再次感染相关的变量，并用于开发预测模型。评分系统的性能在区分（受试者工作特征曲线下面积，AUC）和分类（图形）方面进行了量化。引导重采样用于内部验证预测变量并针对过度乐观进行调整。口服抗菌药物治疗的持续时间、初次发作与复发之间的间隔、季节和复发时的肾功能是复发或再感染的独立预测因素。分数 <5 的患者中，89 名患者中的 76 名患者 (85%) 正确识别出复发，而 52 名患者中的 36 名患者 (69%) 中，分数≥5 的患者正确识别出重新感染。评分指数具有良好的判别力，自举偏差校正 AUC 为 0.80（95%CI：0.73-0.87）。已经开发出一种简单的评分指数来预测复发性类鼻疽的原因，以在无法进行快速细菌基因分型的情况下提供重要的床旁信息。类鼻疽是一种由革兰氏阴性菌类鼻疽伯克霍尔德氏菌引起的严重传染病。这种生物体存在于类鼻疽流行地区（尤其是东亚和澳大利亚北部）的环境中，并且在细菌接种或吸入后获得感染。尽管经过长期口服根除治疗，大约 10% 的急性类鼻疽幸存者仍会复发。复发性类鼻疽可由复发（初始根除治疗失败）或新感染再次感染引起。本研究的目的是开发一个简单的评分系统来区分再次感染和复发，因为这对反复发作的抗菌治疗具有影响，但区分两者通常需要细菌基因分型。 1986 年至 2005 年间对泰国东北部类鼻疽患者进行的一项前瞻性研究确定了 141 名复发性类鼻疽患者。其中，经基因分型技术证实，92 名患者复发，49 名患者再次感染。我们发现复发与之前的治疗不足和复发临床特征的时间较短有关，而再次感染与肾功能不全和雨季表现有关。开发了一个简单的评分指数来帮助区分复发和再感染，以便在无法进行快速细菌基因分型的情况下提供重要的床边信息。提供了如何实施该评分系统的指南。
Melioidosis is an important cause of morbidity and mortality in East Asia. Recurrent melioidosis occurs in around 10% of patients following treatment either because of relapse with the same strain or re-infection with a new strain of Burkholderia pseudomallei. Distinguishing between the two is important but requires bacterial genotyping. The aim of this study was to develop a simple scoring system to distinguish re-infection from relapse. In a prospective study of 2,804 consecutive adult patients with melioidosis presenting to Sappasithiprasong Hospital, NE Thailand, between1986 and 2005, there were 141 patients with recurrent melioidosis with paired strains available for genotyping. Of these, 92 patients had relapse and 49 patients had re-infection. Variables associated with relapse or re-infection were identified by multivariable logistic regression and used to develop a predictive model. Performance of the scoring system was quantified with respect to discrimination (area under receiver operating characteristic curves, AUC) and categorization (graphically). Bootstrap resampling was used to internally validate the predictors and adjust for over-optimism. Duration of oral antimicrobial treatment, interval between the primary episode and recurrence, season, and renal function at recurrence were independent predictors of relapse or re-infection. A score of <5 correctly identified relapse in 76 of 89 patients (85%), whereas a score ≥5 correctly identified re-infection in 36 of 52 patients (69%). The scoring index had good discriminative power, with a bootstrap bias-corrected AUC of 0.80 (95%CI: 0.73–0.87). A simple scoring index to predict the cause of recurrent melioidosis has been developed to provide important bedside information where rapid bacterial genotyping is unavailable. Melioidosis is a serious infectious disease caused by the Gram-negative bacterium, Burkholderia pseudomallei. This organism is present in the environment in areas where melioidosis is endemic (most notably East Asia and Northern Australia), and infection is acquired following bacterial inoculation or inhalation. Despite prolonged oral eradicative treatment, recurrent melioidosis occurs in approximately 10% of survivors of acute melioidosis. Recurrent melioidosis can be caused by relapse (failure of initial eradicative treatment) or re-infection with a new infection. The aim of this study was to develop a simple scoring system to distinguish between re-infection and relapse, since this has implications for antimicrobial treatment of the recurrent episode, but telling the two apart normally requires bacterial genotyping. A prospective study of melioidosis patients in NE Thailand conducted between 1986 and 2005 identified 141 patients with recurrent melioidosis. Of these, 92 patients had relapse and 49 patients had re-infection as confirmed by genotyping techniques. We found that relapse was associated with previous inadequate treatment and shorter time to clinical features of recurrence, while re-infection was associated with renal insufficiency and presentation during the rainy season. A simple scoring index to help distinguish between relapse and re-infection was developed to provide important bedside information where rapid bacterial genotyping is unavailable. Guidelines are provided on how this scoring system could be implemented.
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