本文選題：銅綠假單胞菌　切入點(diǎn)：膿毒癥　出處：《重慶醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的通過探討兒童銅綠假單胞菌膿毒癥的臨床特征,并分析其耐藥情況,以便提高臨床診治能力。方法選取2010年01月到2016年12月在重慶醫(yī)科大學(xué)附屬兒童醫(yī)院住院治療的46例銅綠假單胞菌膿毒癥患兒的臨床資料進(jìn)行回顧性分析。結(jié)果1.46例銅綠假單胞菌(Pseudomonas aeruginosa,PA)膿毒癥患兒中,男29例(63%,29/46),女17例(37%,17/46),男:女1.7:1。年齡在6小時(shí)-14歲5月,其中年齡在1歲以內(nèi)占73.9%(34/46)。PA院內(nèi)感染占58.7%(27/46)。有21.7%(10/46)合并基礎(chǔ)疾病、ICU治療史并使用呼吸機(jī)輔助呼吸35例、手術(shù)病史11例、糖皮質(zhì)激素使用史3例、燒傷1例。2.PA膿毒癥臨床特征多種多樣,有89.1%(41/46)發(fā)熱,體溫39.0℃占65.9%(27/41)。最常見感染部位為呼吸道56.5%(26/46),其次為消化道32.6%(15/46)、皮膚6.5%(3/46)等。本組導(dǎo)致器官功能障礙中呼吸系統(tǒng)功能障礙占76.1%(35/46)、肝功能障礙占56.5%(26/46)、凝血功能障礙占54.3%(25/46)、神經(jīng)系統(tǒng)功能障礙占54.3%(25/46)、感染性休克30.4%(14/46)、腎功能障礙占19.6%(9/46)。有6.5%(3/46)患兒皮膚損害表現(xiàn)為壞疽性膿皰疹。3.輔助檢查:白細(xì)胞升高54.3%(25/46),白細(xì)胞降低30.4%(14/46),中性粒細(xì)胞百分比升高58.7%(27/46),血小板減少69.6%(32/46),貧血95.7%(44/46)。三系均降低28.3%(13/46)。C反應(yīng)蛋白升高84.8%,(39/46),其中超過100mg/L 32.6%(15/46);降鈣素原明顯升高63%(29/40),其中超過10ng/ml 50%(23/40)。低蛋白血癥93.5%(43/46);凝血功能異常67.4%(29/43),其中活化部分凝血活酶時(shí)間(APTT)100秒占34.9%(15/43)。4.PA培養(yǎng)陽性痰液占45.5%(30/66)、血液22.7%(15/66)、膿液12.1%(8/66)、大便9.1%(6/66)、其他10.6%(7/66)。藥敏結(jié)果提示PA對亞胺培南、美羅培南、左旋氧氟沙星、環(huán)丙沙星、阿米卡星等藥物耐藥率接近6%左右;對頭孢吡肟、頭孢他啶、哌拉西林、哌拉西林他唑巴坦以及氨曲南耐藥率接近10%左右。對阿莫西林克拉維酸、氨芐西林及氨芐西林舒巴坦、頭孢噻肟、頭孢唑林、四環(huán)素、氯霉素、復(fù)方新諾明抗菌藥物耐藥率接近100%。5.死亡的PA膿毒癥患兒占34.8%(16/46)。與預(yù)后不良相關(guān)的因素有基礎(chǔ)疾病、凝血功能障礙、器官功能障礙數(shù)目。Logistic回歸分析結(jié)果顯示與預(yù)后不良相關(guān)的因素為器官功能障礙數(shù)目。結(jié)論1.銅綠假單胞菌為常見條件致病菌之一,該菌感染引起的膿毒癥好發(fā)于嬰幼兒,1歲以內(nèi)占73.9%。有基礎(chǔ)疾病、類固醇激素治療、機(jī)械通氣、燒傷者易感染PA。2.PA膿毒癥臨床表現(xiàn)缺乏特異性,大部分有發(fā)熱,多見高熱,最常見感染部位為呼吸道,其次為消化道、皮膚等,且合并有呼吸系統(tǒng)功能障礙、凝血功能障礙、神經(jīng)系統(tǒng)功能障礙、肝腎功能障礙、感染性休克等至少一個(gè)以上器官功能障礙。合并皮膚膿瘡樣病變的膿毒癥患者需警惕PA感染。3.PA膿毒癥輔助檢查中血常規(guī)以白細(xì)胞升高、血小板及血紅蛋白降低為主,嚴(yán)重感染時(shí)三系均下降;反應(yīng)炎性指標(biāo)的C反應(yīng)蛋白、降鈣素原明顯升高;也常見低蛋白血癥及凝血功能異常,尤其是APTT明顯延長;本研究中PA病原菌培養(yǎng)陽性標(biāo)本有痰液、血液、大便、膿液,因此對疑診患者不明感染部位時(shí)可行痰液、血液、大便、分泌物培養(yǎng)助診。本組資料顯示PA對兒童常用抗菌藥物中的碳?xì)涿赶╊惾鐏啺放嗄虾兔懒_培南、青霉素類如哌拉西林他唑巴坦、頭孢菌素類如頭孢他啶和頭孢吡肟有較好的敏感性,因此可為疑診PA感染患者經(jīng)驗(yàn)性選擇抗菌藥物提供參考。4.PA膿毒癥病死率高,預(yù)后差。與預(yù)后不良的因素有基礎(chǔ)疾病、凝血功能障礙、器官功能障礙數(shù)目。器官功能障礙數(shù)目為PA膿毒癥預(yù)后不良的獨(dú)立危險(xiǎn)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.

【學(xué)位授予單位】：重慶醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R720.597

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