本文選題：兒童 + 急性白血病��； 參考：《河北醫(yī)科大學》2012年碩士論文

【摘要】：目的： 在我國，醫(yī)院獲得性肺炎（HAP）是最常見的醫(yī)院感染類型，有較高的發(fā)病率及死亡率。急性白血病患兒由于其自身免疫系統(tǒng)發(fā)育尚不完善，化療使其免疫功能進一步遭到破壞，再加上骨髓抑制，中性粒細胞缺乏，導致HAP發(fā)病率和死亡率進一步增高。直接影響患兒生命安全。 急性白血病患兒化療后罹患HAP時，起病隱匿，臨床表現除發(fā)熱，咳嗽，胸部X射線異常外，呈現的癥狀和體征很少，并且不典型，不易做到早期診斷，可能延誤病情。因此，需要臨床醫(yī)生仔細觀察患兒病情，并且早期注意導致HAP感染的危險因素，努力做到早認識、早診斷、早治療，盡可能降低死亡率。 國內外對急性白血病患者住院期間合并HAP風險因素的研究多針對成年或者老年患者，其研究樣本量偏小，而且對危險因素分析多為單因素分析,只能初步篩選出可能影響HAP危險因素，不能排除混雜因素的影響,結果可能不準確。多因素Logistic回歸分析，可以從整體角度定量描述各因素作用大小，克服單因素分析的片面性。 因此，本文就我院5年來收治的66例化療后發(fā)生醫(yī)院獲得性肺炎的急性白血病患兒進行臨床分析，，并對可能影響HAP發(fā)病的危險因素進行多因素Logistic回歸分析。了解其臨床特點，找到相關危險因素，尋求更好的診療方案。為臨床預防及治療提供依據。 材料與方法： 1病例選擇：采用回顧性查閱病歷的方法，收集自2007年1月至2012年1月在我院兒科血液病專業(yè)住院，均按MICM診斷標準確診，資料完整并且均在我科完成一個療程以上的化療的急性白血病患兒206例。其中急性淋巴細胞白血病142例，急性非淋巴細胞白血病64例。其中男120例,女86例,年齡0.5～14歲，中位年齡6歲，住院時間15～79天，平均37天，初治或復發(fā)患者130例采用誘導緩解期治療，緩解后患者76例采用緩解后維持期治療。共發(fā)生醫(yī)院獲得性肺炎66例，其中急性淋巴細胞白血病47例，急性非淋巴細胞白血病19例。采用誘導緩解期治療者45例，采用維持期治療者21例。 2統(tǒng)計學方法：采用回顧性查閱病歷的方法對所研究資料進行分析總結。同時應用多因素Logistic回歸分析，篩選影響HAP發(fā)病危險因素。數據采用SPSS13.0進行處理.P0.05差異有統(tǒng)計學意義。 結果： 1HAP發(fā)病率：5年內共收治急性白血病患兒206例，其中發(fā)生醫(yī)院獲得性肺炎66例，發(fā)病率為32.04%。 2臨床表現：除重癥感染患兒外，其它患兒僅出現發(fā)熱，咳嗽，少痰或者無痰，10例患兒肺部聽診存在細密濕Up音，余陽性癥狀、體征較少。 3共進行細菌培養(yǎng)71例次，有菌生長27例次，致病菌培養(yǎng)的陽性率為38.03%，以銅綠假單胞菌為主。 4治療策略及效果：抗感染治療采取“降階梯”方案，即最初經驗性抗菌治療聯(lián)合應用美羅培南聯(lián)合去甲萬古霉素治療，然后結合細菌培養(yǎng)結果和臨床表現考慮下調抗生素。本研究中66例患兒經治療，痊愈12例，顯效44例，總有效率84.85%。治療無效死亡10例，死亡率為15.16%。 5多因素Logistic回歸分析顯示：影響醫(yī)院獲得性肺炎危險因素有3個，包括中性粒細胞減少程度(P0.00)、中性粒細胞缺乏持續(xù)時間(P0.04)、住院天數(P0.01)。 6年齡、性別、白血病類型、治療階段和是否應用激素治療對HAP發(fā)病率影響無顯著性差異。 結論： 1中性粒細胞減少程度及中性粒細胞缺乏持續(xù)時間是急性白血病患兒化療后罹患醫(yī)院獲得性肺炎的危險因素。 2年齡、性別、白血病類型、化療階段及是否應用激素治療對急性白血病患兒合并醫(yī)院獲得性肺炎發(fā)病率的影響無顯著差異。 3住院天數是否為急性白血病患兒合并醫(yī)院獲得性肺炎危險因素尚有待進一步論證。 4做到早認識、早診斷、早治療，可提高醫(yī)院獲得性肺炎的治愈率。 5對醫(yī)院獲得性肺炎的最初經驗性治療采取正確“降階梯”治療方案，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 .

【學位授予單位】：河北醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2012
【分類號】：R725.6;R733.7

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