儿童重症化脓性脑膜炎临床特点及预后不良的危险因素分析

发布时间：2018-04-18 04:30

  本文选题：儿童 + 重症化脓性脑膜炎　； 参考：《重庆医科大学》2015年硕士论文

【摘要】：目的：总结儿童重症化脓性脑膜炎临床特征；探讨该病预后不良的危险因素；分析该病抗生素疗程及出院标准。方法：回顾性分析2011年2月-2014年7月在重庆医科大学儿童医院收治的112例重症化脓性脑膜炎患儿,总结临床特征；对随访成功的90例患儿,按照Glasgow临床结局评分标准将患儿分为预后良好组和预后不良组,采用单因素及多元Logistic回归分析,探讨儿童重症化脓性脑膜炎预后不良的危险因素,分析出院时脑脊液恢复情况与预后关系。结果：(1)儿童重症化脑高峰年龄1岁(78.6%)。各月份均有分布,秋冬季(9月至次年3月)病例占全年总疫情64.3%。呼吸道、消化道或两者联合感染(54.4%)是最常见的病因(合并症)。临床以高热(47.3%)、呕吐(58.0%)、惊厥(64.3%),意识障碍(62.5%)为主要表现,体征多见前囟膨隆(26.8%)、颈阻(43.8%)、瞳孔异常(33.9%)。严重感染导致外周血白细胞升高(75.0%),血小板升高(50.0%),中重度贫血(49.1%),CRP及降钙素原升高。血培养阳性率(39.22%)高于脑脊液培养(22.94%)。病原学以肺炎链球菌(35.0%)为主。半数以上的患儿具有头颅影像学(81.48%)或脑电图异常(35.19%)。治疗上多为药物难治性,61.6%患儿住院疗程21天。两联及以上抗生素使用达到92.9%,一半以上选择万古霉素、碳青霉烯类、或二者合用。27例(24.11%)患儿需外科处理。多数重症化脑患儿出现不同程度并发症(74.1%),以硬膜下积液者为主(51.8%),其次为频繁惊厥需预防性使用抗癫痫药物(27.7%),脑积水(20.5%)。(2)对112例研究病例进行电话随访,随访时间最短为8个月,最长为4年,共成功随访90例,失访22例。根据随访结果按照Glasgow临床结局的评分标准进行分类,预后良好组共33例,其中治愈者共9例,好转者共24例；预后不良组57例,死亡12例,未愈者45例。11例(24.44%)合并2种/2种以上后遗症,精神运动发育迟滞35例(77.78%),继发性癫痫9例(20%),脑积水6例(13.33%),听力损害4例(8.89%),运动障碍3例(6.67%)。(3)单因素分析结果：双侧瞳孔不等大,巴氏征阳性,CSF-WBC500*106/L, CSF蛋白值1.0 g/L, CSF糖含量1.5 mmol/L,入院时首次PCT结果0.1ng/dl,住院期间血红蛋白90g/L,头颅影像学及视频脑电图检查结果异常与儿童重症化脑预后不良有关联；(4)多元Logistic回归分析发现双侧瞳孔不等大、CSF糖含量1.5 mmol/L是重症化脑预后不良的独立危险因素。(5)90例成功随访的化脑患儿中,脑脊液完全恢复正常者共28例(31.11%),20例(71.43%)病后1-2月恢复正常。出院前最后一次CSF-WBC和CSF糖的值在预后良好组和预后不良组无统计学差异；而CSF蛋白的差别具有统计学差异,提示出院时脑脊液蛋白数值越高,预后可能越差。用ROC曲线,确定两组的切点为0.68 g/L。结论：1、重症化脑高发于1岁婴幼儿,临床表现危重,多为药物难治,致死及致残率高；2、双侧瞳孔不等大,入院时首次CSF糖含量1.5 mmol/L是儿童重症化脑预后不良的独立危险因素；3.重症化脑出院标准建议：完成正规抗感染治疗疗程并退热1周以上,急性期症状消失,脑脊液白细胞≤28*106/L,脑脊液糖1.75mmol/L,蛋白0.68g/L,停药观察3-5天,临床无反复即可出院随访。
[Abstract]:Objective: To summarize the clinical characteristics of children with severe purulent meningitis; explore the poor prognosis of the disease risk factors; analysis of the disease course of antibiotic treatment and discharge standards. Methods: a retrospective analysis of the February 2011 -2014 year in July 112 cases of severe purulent meningitis admitted to Medical University Of Chongqing children's Hospital, summarize the clinical features of 90 patients were successfully followed up;. In accordance with the Glasgow standard for evaluation of clinical outcomes were divided into good prognosis group and poor prognosis group, by univariate and multivariate Logistic regression analysis, to explore the purulent meningitis of poor prognosis in children with severe risk factors, analysis of discharge between CSF recovery and prognosis. Results: (1) children with severe brain peak age of 1 years (78.6%). Each month are distributed in autumn and winter (September to March) cases accounted for 64.3%. epidemic in respiratory tract, digestive tract infection or a combination of both (54.4% ) is the most common cause (complications). Patients with high fever (47.3%), vomiting (58%), seizures (64.3%), disturbance of consciousness (62.5%) as the main performance, see signs fontanelle bulge (26.8%), neck (43.8%), abnormal pupil resistance (33.9%). Severe infection and peripheral elevated white blood cell (75%), (50%), the platelet count increased in severe anemia (49.1%), CRP and procalcitonin increased. The positive rate of blood culture (39.22%) is higher than that of cerebrospinal fluid culture (22.94%). Pathogenic Streptococcus pneumoniae (35%). More than half of the children with brain imaging (81.48%) or abnormal EEG (35.19%). The treatment for drug refractory, 61.6% inpatient treatment for 21 days. Two or more antibiotics use reached 92.9%, more than half the selection of vancomycin, carbapenems, or the combination of the two.27 cases (24.11%) patients need surgical treatment. Most severe brain occurred in children with different degrees of complications (74.1%), with spinal epidural 涓嬬Н娑茶，

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