本文選題：兒童 + 重癥化膿性腦膜炎��； 參考：《重慶醫(yī)科大學(xué)》2015年碩士論文

【摘要】：目的：總結(jié)兒童重癥化膿性腦膜炎臨床特征；探討該病預(yù)后不良的危險(xiǎn)因素；分析該病抗生素療程及出院標(biāo)準(zhǔn)。方法：回顧性分析2011年2月-2014年7月在重慶醫(yī)科大學(xué)兒童醫(yī)院收治的112例重癥化膿性腦膜炎患兒,總結(jié)臨床特征；對(duì)隨訪成功的90例患兒,按照Glasgow臨床結(jié)局評(píng)分標(biāo)準(zhǔn)將患兒分為預(yù)后良好組和預(yù)后不良組,采用單因素及多元Logistic回歸分析,探討兒童重癥化膿性腦膜炎預(yù)后不良的危險(xiǎn)因素,分析出院時(shí)腦脊液恢復(fù)情況與預(yù)后關(guān)系。結(jié)果：(1)兒童重癥化腦高峰年齡1歲(78.6%)。各月份均有分布,秋冬季(9月至次年3月)病例占全年總疫情64.3%。呼吸道、消化道或兩者聯(lián)合感染(54.4%)是最常見的病因(合并癥)。臨床以高熱(47.3%)、嘔吐(58.0%)、驚厥(64.3%),意識(shí)障礙(62.5%)為主要表現(xiàn),體征多見前囟膨隆(26.8%)、頸阻(43.8%)、瞳孔異常(33.9%)。嚴(yán)重感染導(dǎo)致外周血白細(xì)胞升高(75.0%),血小板升高(50.0%),中重度貧血(49.1%),CRP及降鈣素原升高。血培養(yǎng)陽性率(39.22%)高于腦脊液培養(yǎng)(22.94%)。病原學(xué)以肺炎鏈球菌(35.0%)為主。半數(shù)以上的患兒具有頭顱影像學(xué)(81.48%)或腦電圖異常(35.19%)。治療上多為藥物難治性,61.6%患兒住院療程21天。兩聯(lián)及以上抗生素使用達(dá)到92.9%,一半以上選擇萬古霉素、碳青霉烯類、或二者合用。27例(24.11%)患兒需外科處理。多數(shù)重癥化腦患兒出現(xiàn)不同程度并發(fā)癥(74.1%),以硬膜下積液者為主(51.8%),其次為頻繁驚厥需預(yù)防性使用抗癲癇藥物(27.7%),腦積水(20.5%)。(2)對(duì)112例研究病例進(jìn)行電話隨訪,隨訪時(shí)間最短為8個(gè)月,最長為4年,共成功隨訪90例,失訪22例。根據(jù)隨訪結(jié)果按照Glasgow臨床結(jié)局的評(píng)分標(biāo)準(zhǔn)進(jìn)行分類,預(yù)后良好組共33例,其中治愈者共9例,好轉(zhuǎn)者共24例；預(yù)后不良組57例,死亡12例,未愈者45例。11例(24.44%)合并2種/2種以上后遺癥,精神運(yùn)動(dòng)發(fā)育遲滯35例(77.78%),繼發(fā)性癲癇9例(20%),腦積水6例(13.33%),聽力損害4例(8.89%),運(yùn)動(dòng)障礙3例(6.67%)。(3)單因素分析結(jié)果：雙側(cè)瞳孔不等大,巴氏征陽性,CSF-WBC500*106/L, CSF蛋白值1.0 g/L, CSF糖含量1.5 mmol/L,入院時(shí)首次PCT結(jié)果0.1ng/dl,住院期間血紅蛋白90g/L,頭顱影像學(xué)及視頻腦電圖檢查結(jié)果異常與兒童重癥化腦預(yù)后不良有關(guān)聯(lián)；(4)多元Logistic回歸分析發(fā)現(xiàn)雙側(cè)瞳孔不等大、CSF糖含量1.5 mmol/L是重癥化腦預(yù)后不良的獨(dú)立危險(xiǎn)因素。(5)90例成功隨訪的化腦患兒中,腦脊液完全恢復(fù)正常者共28例(31.11%),20例(71.43%)病后1-2月恢復(fù)正常。出院前最后一次CSF-WBC和CSF糖的值在預(yù)后良好組和預(yù)后不良組無統(tǒng)計(jì)學(xué)差異；而CSF蛋白的差別具有統(tǒng)計(jì)學(xué)差異,提示出院時(shí)腦脊液蛋白數(shù)值越高,預(yù)后可能越差。用ROC曲線,確定兩組的切點(diǎn)為0.68 g/L。結(jié)論：1、重癥化腦高發(fā)于1歲嬰幼兒,臨床表現(xiàn)危重,多為藥物難治,致死及致殘率高；2、雙側(cè)瞳孔不等大,入院時(shí)首次CSF糖含量1.5 mmol/L是兒童重癥化腦預(yù)后不良的獨(dú)立危險(xiǎn)因素；3.重癥化腦出院標(biāo)準(zhǔn)建議：完成正規(guī)抗感染治療療程并退熱1周以上,急性期癥狀消失,腦脊液白細(xì)胞≤28*106/L,腦脊液糖1.75mmol/L,蛋白0.68g/L,停藥觀察3-5天,臨床無反復(fù)即可出院隨訪。
[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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