본 연구는 일 상급종합병원 중환자실 입원한 환자에서 카바페넴 분해효소 생성 장내세균속균종(Carbapenemase producing Enterobacteriaceae, CPE) 획득의 위험요인을 조사하기 위해 의무기록을 이용한 후향적 환자-대조군연구이다. 연구 대상자는 2020년 7월 1일부터 2021년 6월 30일까지 19세 이상의 성인 환자로 총 290명이었다. 대상자의 일반적 특성, CPE 관련 특성, 질병 관련 특성, 치료 관련 특성을 조사하여 최종분석 자료로 활용하였다. 수집된 자료는 SPSS statistics 26.0 version을 이용하여 기술 통계, χ2-test, Independent t-test, 다변량 회귀분석을 통해 분석하였다.

연구 결과는 다음과 같다.

1. 본 연구대상자의 연령은 70세 이상이 170명(58.6%)으로 가장 많았고, 평균 연령은 68.82(SD 15.60)세였고, 남자가 184명(63.4%)이었다. 입원경로는 종합병원 131명(45.2%)으로 가장 많았고, 입원 경험은 184명(62.6%)이 없었으며, 중환자실 입실경로는 응급실이 267명(92.1%)을 차지하였다. 입원기간은 평균 27.43(SD 23.80)일이었고, 중환자실 입원기간은 평균 16.19(SD 14.49)일이었다. 대상자들의 진단명은 147명(50.7%)이 심혈관계 질환이었고, 기저질환은 고혈압이 175명(33.6%), 당뇨가 116명(22.3%)으로 가장 많이 차지하였다.
2. 대상자의 카바페넴 내성 장내세균속균종(Carbapenem Resistant Enterobacteriaceae, CRE) 획득률은 13.4%이었고, CRE중 CPE 획득률은 64.1%이었다. CPE획득기간은 평균 18.96(SD 15.84)일이었고, 획득 후 입원기간은 평균 23.52(SD 27.44)일이었다. CPE 균종은 Serratia marscescens가 21명(87.5%)이었으며, 유전자형은 Klebsiella pneumoniae carbapenemase (KPC)가 25명(100%)이었다.
3. CPE 획득유무에 따라 CPE획득군과 비획득군으로 나누어 대상자의 일반적 특성에 따라 비교한 결과 입원기간(t=2.75, p=.006), 중환자실 입원기간(t=3.19, p=.002), 내과(χ2=5.96, p=.015), 응급의학과(χ2=6.46, p= .011)에서 통계적으로 유의한 차이를 보였다.
4. CPE 획득군과 비획득군의 질병 관련 특성을 비교한 결과 소화기계 질환(χ2 =11.44, p=.001), GCS 점수(t=3.66, p=.001), 혈액에서 분리된 MRAB 유병기간(t =19.47, p=.003), Hgb (t =-1.98, p = .049), PLT (t=-2.57, p=.011), BUN (t=3.02, p=.006), Creatinine (t=2.76, p=.010)에서 통계적으로 유의한 차이를 보였다.
5. CPE 획득군과 비획득군의 치료 관련 특성을 비교한 결과 유치도뇨관(χ2=9.92, p=.002), 동맥관(χ2=26.29, p< .001), 지속적 신대체요법(χ2=5.64, p=.018), 기관지 내시경(χ2=4.95, p=.026), 소화기 내시경(χ2=12.95, p= .006), 혈액투석(χ2=5.08, p=.024), 복수천자(χ2= 8.71, p=.024), Carbapenem(χ2=16.62, p<.001), Vancomycin (χ2=4.23 p= .040), Colistin (χ2=9.85, p=.002)에서 유의한 차이를 보였다.
6. 중환자실 환자의 CPE 획득 위험요인은 중환자실 입원기간이 22일 이상(OR=8.26, 95% CI, 2.73-24.97; p<.001), 소화기계 질환(OR=5.41, 95% CI, 1.48-19.74; p=.011), 소화기내시경(OR=7.63, 95% CI, 1.36-42.77; p=.021), 동맥관(OR=5.73, 95% CI, 1.92-17.06; p=.002), Creatinine (OR=1.29, 95% CI, 1.07-1.57; p=.008), Cabapenem (OR=4.29, 95% CI, 1.40 -13.20; p= .011)으로 나타났으며, 총 설명력은 43.8%이었다.

이상의 본 연구결과를 종합해 볼 때 중환자실 환자가 중환자실 입원기간이 22일 이상인 경우, 소화기계 질환인 경우, 동맥관을 유지한 경우, 소화기 내시경을 한 경우, Creatinine 수치가 높은 경우, 카바페넴 항생제를 사용한 경우 CPE 획득의 위험이 높음을 확인할 수 있었다. 정책입안자들과 관련 부서 및 병원 관계자들은 확인된 위험요인을 기반으로 CPE 감시배양 지침을 마련하고 이를 통해 CPE 조기발견을 통한 감염관리 및 효과적인 예방 관리 프로그램을 마련할 필요가 있다.

This study is a retrospective case-control study to identify the risk factors associated with acquisition Carbapenemase Producing Enterobacteriacae(CPE) in intensive care unit patients at a high level general hospital. The subjects were 290 adult patients (≥ 19 years) from July 1, 2020 to June 30, 2021. General characteristics, CPE-related characteristics, Disease-related characteristics, and Treatment-related characteristics were investigated and used as final analysis data. The collected data were analyzed through descriptive statistics, χ2-test, independent t-test, and multivariate regression analysis using SPSS statistics 26.0 version.

The results of the study are as follows.

1. The age of the subjects was the largest at 170 (58.6%) over the age of 70 years, the average age was 68.82 (SD 15.60) years. By gender, 184 (63.4%) were men. By hospital route, The number of general hospitals were 131(45.2%). History of hospitaliztion were not 184 (62.6%), and Emergency rooms accounted for 267 (92.1%) of the route of admission to the intensive care unit. The average hospitalization period was 27.43 (SD 23.80) days, and the average hospitalization period in the ICU was 16.19(SD 14.49) days. 147 patients (50.7%) were diagnosed with cardiovascular disease, and the number of patients with underlying diseases were 175 (33.6%) with high blood pressure and 116 (22.3%) with diabetes.
2. The Carbapenem Resistant Enterobacteriacae(CRE) acquisition rate of the subject was 13.4%, and the CPE of CRE acquisition rate was 64.1%. The CPE acquisition period was 18.96(SD 15.84) days on average, and the hospitalization period after CPE acquisition was 23.52(SD 27.44) days on average. The CPE strain was 21 people (87.5%) Serratia marcescens, and the CPE genotype was 25 people (100%) KPC.
3. According to the CPE acquisition, the subjects were divided to CPE acquisition groups and non-acquisition groups. As a result of comparing general characteristics of acquisition groups and non-acquisition groups, Hospitalization stay (t=2.75, p=.006), ICU stay (t=3.19, p=.002), Internal medicine (χ2=5.96, p=.015), Emergency Medicine (χ2=6.46, p=.011) showed a statistically significant differences.
4. As a result of comparing disease-related characteristics of CPE-acquired groups and non-acquired groups, digestive system diseases (χ2=11.44, p=.001), GCS score (t=3.66, p=.001), the MRAB prevalence duration separated from the blood (t=19.47, p=.003), Hgb (t=-1.98, p=.049), PLT (t=-2.57, p=.011), BUN (t=3.02, p=.006), Creatinine (t=2.76, p=.010) showed a statistically significant difference.
5. As a result of comparing the treatment-related characteristics of the CPE-acquired groups and non-acquired groups, Foley cath. (χ2=9.92, p=.002), Artety line (χ2=26.29, p<.001), CRRT (χ2=5.64, p=.018), Bronchoscopy (χ2=4.95, p=.026), Digestive Endoscopy (χ2=12.95, p=.006), Hemodialysis (χ2=5.08, p=.024), Paracentesis (χ2=8.71, p=.024), Carbapenem (χ2=16.62, p<.001), Vancomycin (χ2=4.23 p= .040), Colistin (χ2=9.85, p=.002) showed statistically significant differences.
6. The risk factor associated with CPE acquisition in intensive care unit patients were ICU admission period is more than 22 days (OR=8.26, 95% CI, 2.73-24.97; p<.001), Digestive endoscopy (OR=7.63, 95% CI, 1.36-42
.77; p=.021), Artery line (OR=5.73, 95% CI, 1.92-17.06; p=.002), Digestive system disease (OR=5.41, 95% CI, 1.48-19.74; p=.011), Cabapenem (OR=4.29, 95% CI, 1.40–13.20; p=.011), Creatinine (OR=1.29, 95% CI, 1.07-1.57; p=.008). The total explanatory power was 43.8%.

Based on the results of this study, it was confirmed that the risk of CPE acquisition was higher when ICU patients had more than 22 days of admission period, Digestive endoscopy, Artery line, Digestive system disease, Carbapenem antibiotics, Creatinine levels. Policymakers and related departments and hospital officials need to prepare CPE surveillance culture guidelines based on identified risk factors. In addition, it is necessary to prepare an Infection control through CPE early detection and effective prevention management program for CPE through this guidelines.