儿童急性白血病化疗后医院获得性肺炎临床分析

发布时间：2018-04-18 09:05

本文选题：儿童 + 急性白血病　；参考：《河北医科大学》2012年硕士论文

【摘要】：目的：在我国，医院获得性肺炎（HAP）是最常见的医院感染类型，有较高的发病率及死亡率。急性白血病患儿由于其自身免疫系统发育尚不完善，化疗使其免疫功能进一步遭到破坏，再加上骨髓抑制，中性粒细胞缺乏，导致HAP发病率和死亡率进一步增高。直接影响患儿生命安全。急性白血病患儿化疗后罹患HAP时，起病隐匿，临床表现除发热，咳嗽，胸部X射线异常外，呈现的症状和体征很少，并且不典型，不易做到早期诊断，可能延误病情。因此，需要临床医生仔细观察患儿病情，并且早期注意导致HAP感染的危险因素，努力做到早认识、早诊断、早治疗，尽可能降低死亡率。国内外对急性白血病患者住院期间合并HAP风险因素的研究多针对成年或者老年患者，其研究样本量偏小，而且对危险因素分析多为单因素分析,只能初步筛选出可能影响HAP危险因素，不能排除混杂因素的影响,结果可能不准确。多因素Logistic回归分析，可以从整体角度定量描述各因素作用大小，克服单因素分析的片面性。因此，本文就我院5年来收治的66例化疗后发生医院获得性肺炎的急性白血病患儿进行临床分析，，并对可能影响HAP发病的危险因素进行多因素Logistic回归分析。了解其临床特点，找到相关危险因素，寻求更好的诊疗方案。为临床预防及治疗提供依据。材料与方法： 1病例选择：采用回顾性查阅病历的方法，收集自2007年1月至2012年1月在我院儿科血液病专业住院，均按MICM诊断标准确诊，资料完整并且均在我科完成一个疗程以上的化疗的急性白血病患儿206例。其中急性淋巴细胞白血病142例，急性非淋巴细胞白血病64例。其中男120例,女86例,年龄0.5～14岁，中位年龄6岁，住院时间15～79天，平均37天，初治或复发患者130例采用诱导缓解期治疗，缓解后患者76例采用缓解后维持期治疗。共发生医院获得性肺炎66例，其中急性淋巴细胞白血病47例，急性非淋巴细胞白血病19例。采用诱导缓解期治疗者45例，采用维持期治疗者21例。 2统计学方法：采用回顾性查阅病历的方法对所研究资料进行分析总结。同时应用多因素Logistic回归分析，筛选影响HAP发病危险因素。数据采用SPSS13.0进行处理.P0.05差异有统计学意义。结果： 1HAP发病率：5年内共收治急性白血病患儿206例，其中发生医院获得性肺炎66例，发病率为32.04%。 2临床表现：除重症感染患儿外，其它患儿仅出现发热，咳嗽，少痰或者无痰，10例患儿肺部听诊存在细密湿Up音，余阳性症状、体征较少。 3共进行细菌培养71例次，有菌生长27例次，致病菌培养的阳性率为38.03%，以铜绿假单胞菌为主。 4治疗策略及效果：抗感染治疗采取“降阶梯”方案，即最初经验性抗菌治疗联合应用美罗培南联合去甲万古霉素治疗，然后结合细菌培养结果和临床表现考虑下调抗生素。本研究中66例患儿经治疗，痊愈12例，显效44例，总有效率84.85%。治疗无效死亡10例，死亡率为15.16%。 5多因素Logistic回归分析显示：影响医院获得性肺炎危险因素有3个，包括中性粒细胞减少程度(P0.00)、中性粒细胞缺乏持续时间(P0.04)、住院天数(P0.01)。 6年龄、性别、白血病类型、治疗阶段和是否应用激素治疗对HAP发病率影响无显著性差异。结论： 1中性粒细胞减少程度及中性粒细胞缺乏持续时间是急性白血病患儿化疗后罹患医院获得性肺炎的危险因素。 2年龄、性别、白血病类型、化疗阶段及是否应用激素治疗对急性白血病患儿合并医院获得性肺炎发病率的影响无显著差异。 3住院天数是否为急性白血病患儿合并医院获得性肺炎危险因素尚有待进一步论证。 4做到早认识、早诊断、早治疗，可提高医院获得性肺炎的治愈率。 5对医院获得性肺炎的最初经验性治疗采取正确“降阶梯”治疗方案，可降低死亡率。
[Abstract]:Purpose :

In our country , the hospital acquired pneumonia is the most common type of nosocomial infection , and has higher morbidity and mortality . Children with acute leukemia have not been improved due to their own immune system development , and the chemotherapy makes the immune function further damaged , combined with bone marrow suppression and neutropenia , which leads to a higher morbidity and mortality rate , which directly affects the life safety of the children .

In patients with acute leukemia after chemotherapy , after chemotherapy , the symptoms and signs are few , the symptoms and signs are few , and the symptoms and signs are few , which may delay the disease . Therefore , it is necessary for the clinician to observe the condition of the children carefully , and to pay attention to the risk factors that lead to the infection , so as to realize early recognition , early diagnosis and early treatment , and reduce the mortality as much as possible .

There are many researches on the risk factors of patients with acute leukemia during hospitalization for adult or old patients . The study shows that the sample size is small , and the analysis of risk factors is a single factor analysis . It is only possible to screen out the influence of confounding factors . The multivariate logistic regression analysis can quantitatively describe the factors action size from the whole angle , and overcome the single factor analysis .

Therefore , the clinical analysis of 66 patients with acute leukemia acquired from nosocomial acquired pneumonia after 5 years of chemotherapy in our hospital and multivariate logistic regression analysis were carried out on the risk factors which could affect the pathogenesis of the patients . The clinical characteristics of the patients were investigated , the relevant risk factors were found , and the better diagnosis and treatment plan was sought .

Materials and Methods :

1 case selection : A retrospective review of medical records was conducted in 206 children with acute lymphoblastic leukemia in our hospital from January 2007 to January 2012 . Among them , there were 142 cases of acute lymphoblastic leukemia and 64 cases of acute non - lymphocytic leukemia .

2 Statistical methods : A retrospective review of medical records was conducted to summarize the data . At the same time , multivariate logistic regression analysis was used to screen the risk factors influencing the risk factors . The data were treated with SPSS 13.0 . The difference was statistically significant .

Results :

A total of 206 cases of acute leukemia were treated in 5 years , including 66 cases of nosocomial pneumonia and 32.04 % of the incidence of acute leukemia .

Clinical manifestations : Except for children with severe infection , there were only fever , cough , little sputum or no sputum in other children .

The positive rate of bacteria culture was 38.03 % , which was mainly P.aeruginosa .

4 Treatment strategies and effects : Anti - infective therapy adopts " step - down " regimen , that is , the first empirical anti - bacterial treatment is combined with meropenem and norvancomycin for treatment , then the antibiotic is regulated by combining bacterial culture results and clinical manifestations . In the study , 66 children are treated , 12 cases are recovered , 44 cases are obvious , the total effective rate is 84.85 % . 10 cases with ineffective death and 15.16 % mortality rate are treated .

Logistic regression analysis showed that there were 3 risk factors influencing nosocomial pneumonia , including the degree of neutropenia ( P0.05 ) , the duration of neutropenia ( P0.01 ) , the number of days of hospitalization ( P0.01 ) .

No significant difference was found between the age , sex , the type of leukemia , the treatment stage and whether the application of hormone therapy had no significant effect on the incidence of the morbidity .

Conclusion :

1 . The degree of neutropenia and the duration of neutropenia were the risk factors of nosocomial pneumonia after chemotherapy in children with acute leukemia .

Age , sex , leukemia type , chemotherapy stage and application of hormone therapy had no significant difference in the incidence of acquired pneumonia in children with acute leukemia .

Whether the number of days of hospitalization is the risk factor for acute leukemia complicated hospital acquired pneumonia is still to be further demonstrated .

Early diagnosis , early diagnosis and early treatment can improve the cure rate of nosocomial pneumonia .

5 The first empirical treatment of acquired pneumonia in hospitals adopts the correct " step - down " treatment scheme , which can reduce the mortality rate .

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R725.6;R733.7

【参考文献】