儿童铜绿假单胞菌脓毒症的临床特征及耐药分析

发布时间：2018-03-20 13:15

本文选题：铜绿假单胞菌　切入点：脓毒症　出处：《重庆医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的通过探讨儿童铜绿假单胞菌脓毒症的临床特征,并分析其耐药情况,以便提高临床诊治能力。方法选取2010年01月到2016年12月在重庆医科大学附属儿童医院住院治疗的46例铜绿假单胞菌脓毒症患儿的临床资料进行回顾性分析。结果1.46例铜绿假单胞菌(Pseudomonas aeruginosa,PA)脓毒症患儿中,男29例(63%,29/46),女17例(37%,17/46),男:女1.7:1。年龄在6小时-14岁5月,其中年龄在1岁以内占73.9%(34/46)。PA院内感染占58.7%(27/46)。有21.7%(10/46)合并基础疾病、ICU治疗史并使用呼吸机辅助呼吸35例、手术病史11例、糖皮质激素使用史3例、烧伤1例。2.PA脓毒症临床特征多种多样,有89.1%(41/46)发热,体温39.0℃占65.9%(27/41)。最常见感染部位为呼吸道56.5%(26/46),其次为消化道32.6%(15/46)、皮肤6.5%(3/46)等。本组导致器官功能障碍中呼吸系统功能障碍占76.1%(35/46)、肝功能障碍占56.5%(26/46)、凝血功能障碍占54.3%(25/46)、神经系统功能障碍占54.3%(25/46)、感染性休克30.4%(14/46)、肾功能障碍占19.6%(9/46)。有6.5%(3/46)患儿皮肤损害表现为坏疽性脓疱疹。3.辅助检查:白细胞升高54.3%(25/46),白细胞降低30.4%(14/46),中性粒细胞百分比升高58.7%(27/46),血小板减少69.6%(32/46),贫血95.7%(44/46)。三系均降低28.3%(13/46)。C反应蛋白升高84.8%,(39/46),其中超过100mg/L 32.6%(15/46);降钙素原明显升高63%(29/40),其中超过10ng/ml 50%(23/40)。低蛋白血症93.5%(43/46);凝血功能异常67.4%(29/43),其中活化部分凝血活酶时间(APTT)100秒占34.9%(15/43)。4.PA培养阳性痰液占45.5%(30/66)、血液22.7%(15/66)、脓液12.1%(8/66)、大便9.1%(6/66)、其他10.6%(7/66)。药敏结果提示PA对亚胺培南、美罗培南、左旋氧氟沙星、环丙沙星、阿米卡星等药物耐药率接近6%左右;对头孢吡肟、头孢他啶、哌拉西林、哌拉西林他唑巴坦以及氨曲南耐药率接近10%左右。对阿莫西林克拉维酸、氨苄西林及氨苄西林舒巴坦、头孢噻肟、头孢唑林、四环素、氯霉素、复方新诺明抗菌药物耐药率接近100%。5.死亡的PA脓毒症患儿占34.8%(16/46)。与预后不良相关的因素有基础疾病、凝血功能障碍、器官功能障碍数目。Logistic回归分析结果显示与预后不良相关的因素为器官功能障碍数目。结论1.铜绿假单胞菌为常见条件致病菌之一,该菌感染引起的脓毒症好发于婴幼儿,1岁以内占73.9%。有基础疾病、类固醇激素治疗、机械通气、烧伤者易感染PA。2.PA脓毒症临床表现缺乏特异性,大部分有发热,多见高热,最常见感染部位为呼吸道,其次为消化道、皮肤等,且合并有呼吸系统功能障碍、凝血功能障碍、神经系统功能障碍、肝肾功能障碍、感染性休克等至少一个以上器官功能障碍。合并皮肤脓疮样病变的脓毒症患者需警惕PA感染。3.PA脓毒症辅助检查中血常规以白细胞升高、血小板及血红蛋白降低为主,严重感染时三系均下降;反应炎性指标的C反应蛋白、降钙素原明显升高;也常见低蛋白血症及凝血功能异常,尤其是APTT明显延长;本研究中PA病原菌培养阳性标本有痰液、血液、大便、脓液,因此对疑诊患者不明感染部位时可行痰液、血液、大便、分泌物培养助诊。本组资料显示PA对儿童常用抗菌药物中的碳氢酶烯类如亚胺培南和美罗培南、青霉素类如哌拉西林他唑巴坦、头孢菌素类如头孢他啶和头孢吡肟有较好的敏感性,因此可为疑诊PA感染患者经验性选择抗菌药物提供参考。4.PA脓毒症病死率高,预后差。与预后不良的因素有基础疾病、凝血功能障碍、器官功能障碍数目。器官功能障碍数目为PA脓毒症预后不良的独立危险因素。
[Abstract]:Objective to investigate the clinical characteristics of children with Pseudomonas aeruginosa sepsis, and analysis of its drug resistance, in order to improve the ability of diagnosis and treatment. Methods from 2010 01 months to December 2016 in children's Hospital Affiliated to Medical University Of Chongqing hospital treatment of 46 cases of Pseudomonas aeruginosa sepsis patients were analyzed retrospectively. Results 1.46 cases Pseudomonas aeruginosa (Pseudomonas aeruginosa, PA) in children with sepsis, 29 cases were male (63%, 29/46), 17 cases were female (37%, 17/46), male: female age 1.7:1. in 6 hours -14 in May, which at the age of 1 years old accounted for 73.9% (34/46) accounted for 58.7% of nosocomial infection in.PA (27/46). 21.7% (10/46) with basic diseases, ICU treatment history and the use of mechanical ventilation in 35 cases, 11 cases of surgical history, glucocorticoid use history in 3 cases, 1 cases of burn sepsis in.2.PA variety of clinical features, 89.1% (41/46) heating, a temperature of 39 DEG C accounted for 65.9% (27/41). The most common infection sites were respiratory tract (56.5% 26/46), followed by the digestive tract 32.6% (15/46), 6.5% (3/46) skin. This leads to organ dysfunction in respiratory dysfunction accounted for 76.1% (35/46), hepatic dysfunction accounted for 56.5% (26/46), blood coagulation dysfunction accounted for 54.3% (25/46), nervous system dysfunction accounted for 54.3% (25/46), septic shock 30.4% (14/46), renal dysfunction accounted for 19.6% (9/46). 6.5% (3/46) in children with skin damage is gangrenous pus herpes.3. auxiliary examination: white blood cells increased 54.3% (25/46), white blood cell decreased 30.4% (14/46), the percentage of neutrophils increased 58.7% (27/46). Thrombocytopenia in 69.6% (32/46), anemia (44/46). 95.7% of three lines were reduced by 28.3% (13/46).C reactive protein (39/46), increased 84.8%, of which more than 32.6% 100mg/L (15/46); procalcitonin (29/40) significantly increased 63%, of which more than 50% 10ng/ml (23/40). 93.5% (hypoproteinemia 43/46); blood coagulation The abnormal function of 67.4% (29/43), the activated partial thromboplastin time (APTT) accounted for 34.9% of 100 seconds (15/43).4.PA positive sputum accounted for 45.5% (30/66) 22.7% (15/66), blood, pus, 12.1% (8/66), (6/66), the other 9.1% stool 10.6% (7/66). The results suggest that PA susceptibility to imipenem imipenem, meropenem, levofloxacin, ciprofloxacin, amikacin drug resistance rate is close to 6%; of cefepime, ceftazidime, piperacillin, piperacillin tazobactam and aztreonam resistance rate close to about 10%. A Moshe Link clavulanate, ampicillin and sulbactam ampicillin, cefotaxime, cefazolin, tetracycline, chloramphenicol, cotrimoxazole resistance rate close to PA in children with sepsis 100%.5. death accounted for 34.8% (16/46). Have basic diseases, and poor prognostic factors related to blood coagulation dysfunction, number of organ dysfunction results of.Logistic regression analysis The factors that are associated with a poor prognosis for the number of organ dysfunction. Conclusion 1. Pseudomonas aeruginosa is one of the common pathogens, occurs in infants and young children sepsis caused by the bacterium infection, less than 1 years old 73.9%. have basic diseases, steroid therapy, mechanical ventilation, burn victims susceptible to clinical manifestations of sepsis in PA.2.PA the lack of specificity, most have a fever, high fever, the most common infection sites were respiratory tract, followed by the digestive tract, skin, and the patients with respiratory dysfunction, coagulation disorders, liver and kidney dysfunction, nervous system dysfunction, septic shock and so on at least one or more organ dysfunction. Patients with skin abscess like lesions in sepsis patients need blood.3.PA sepsis alert PA auxiliary examination to the increase of white blood cell, platelet and hemoglobin decreased, severe infection decreased three; inflammatory reaction C reactive protein index, procalcitonin was significantly increased; also common hypoproteinemia and coagulation abnormalities, especially APTT prolonged; in this study PA pathogenic bacteria culture positive specimens of sputum, blood, stool, pus, the suspected patients with unknown infection when feasible sputum, blood, stool. Culture is useful in diagnosis. The data showed that PA of children antibacterial enzyme alkene hydrocarbon drugs such as imipenem and meropenem, penicillins such as piperacillin tazobactam, cephalosporins such as ceftazidime and cefepime has good sensitivity, so it can be for patients with suspected PA infection empirical selection of antibacterial agents the reference.4.PA sepsis and high fatality rate, poor prognosis. Have basic diseases, and poor prognostic factors of coagulation disorders, organ dysfunction. The number of the number of organ dysfunction were independent risk prognostic PA aeruginosa sepsis Factor.

【学位授予单位】：重庆医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R720.597

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