本文選題：社區(qū)獲得性肺炎 + 病毒�。� 參考：《中山大學(xué)》2012年碩士論文

【摘要】：研究背景 社區(qū)獲得性肺炎(community acquired pneumonia, CAP)是兒童期最常見的感染性疾病，發(fā)病率高，危害嚴(yán)重，列于我國兒童死亡的五大疾病之首。我國每年約有2110萬5歲以下小兒罹患肺炎（0.22次/人年），發(fā)病率明顯高于發(fā)達國家（0.026次/人年）。兒童CAP的病因通常難以判定，約有40％至60％的肺炎患兒無法找到明確病因。許多研究人員根據(jù)患兒的病史、臨床表現(xiàn)、體征、實驗室及影像學(xué)檢查資料來判斷社區(qū)獲得性肺炎的病因，但尚未發(fā)現(xiàn)足夠可靠的證據(jù)進行鑒別。關(guān)于社區(qū)獲得性肺炎住院患兒管理的大量報道顯示，大約80％的社區(qū)獲得性肺炎患兒采用了經(jīng)驗性治療。當(dāng)患兒被診斷為CAP后，是否使用抗生素進行治療以及如何選擇與病因相關(guān)的適當(dāng)抗生素仍是個很大的問題。一項關(guān)于住院兒童社區(qū)獲得性肺炎的研究表明，絕大多數(shù)兒童肺炎是病毒感染所致，故須對不必要的抗生素治療加以制止。另外，肺炎衣原體和支原體亦日益成為導(dǎo)致兒童獲得性肺炎的重要致病因素。這些非典型細(xì)菌需要特定的抗生素，而針對典型病原體使用的常規(guī)抗生素?zé)o效。肺炎病因研究不足及抗生素治療不當(dāng)最終可導(dǎo)致社區(qū)獲得性肺炎病原體的抗生素耐藥性，這種抗生素耐藥又將成為另一個全球健康問題�；谶@些原因，深入了解CAP在日常臨床中病原流行病學(xué)，不同病原肺炎的臨床特點助于提高診斷，采取適當(dāng)?shù)墓芾砗皖A(yù)防措施，進而減少由于過度治療和不適當(dāng)?shù)目股刂委熕碌慕?jīng)濟負(fù)擔(dān)，同時降低社區(qū)獲得性肺炎相關(guān)疾病的死亡率。 目的 1、闡明兒童社區(qū)獲得性肺炎的常見呼吸道病毒病原譜分布； 2、確定病毒和非典型細(xì)菌病原體的年齡和季節(jié)分布； 3、分析特定病原體的臨床特點。 方法 1.研究對象 本研究在2010年1月至2011年12月期間收集593例住院病區(qū)中確診的社區(qū)獲得性肺炎病例�；純耗挲g范圍為1個月至14歲之間，其中：嬰兒組（1-12個月）286例（48.2％），學(xué)齡前兒童組（12個月至5歲）259例（43.7％），學(xué)齡兒童組（5歲以上至14歲）48例（8.1％）。 2.病例收集、病例評估、數(shù)據(jù)分析 所有患兒在入院24小時內(nèi)均采集2毫升的外周血，用于血常規(guī)，肝、心臟、腎功生化和各項炎癥指標(biāo)的血液化驗，并采集口咽拭子標(biāo)本。將咽拭子標(biāo)本采用實時定量PCR檢測方法對病毒和非典型病原體進行同時檢測。一個患兒樣本中檢測出任何一種病原體，則作為一個陽性病例。如一個患兒樣本中只發(fā)現(xiàn)一種病原體，則該患兒則被認(rèn)為只有一項感染，即單一感染。如發(fā)現(xiàn)了多個病原體，則被認(rèn)為是混合感染。入院時收集的信息包括填寫日期、個人信息、前驅(qū)癥狀、臨床表現(xiàn)。在住院期間，患兒每日的病情變化均詳細(xì)記錄，包括呼吸系統(tǒng)的體格檢查、臨床癥狀的變化、實驗室數(shù)據(jù)、并發(fā)癥、治療措施等。出院日期也被記錄在內(nèi)，以計算患者的住院時間。評估病情嚴(yán)重程度根據(jù)臨床評分（呼吸頻率、三凹征、呼吸音改變、精神狀態(tài)、膚色）。 結(jié)果 1、患兒年齡于1個月至14歲之間，中位年齡為14個月。男性占67％，女性占33％。男女之比為2:1。男女中位年齡之間比較差異無統(tǒng)計學(xué)意義（U=35112，P0.05）。中位發(fā)病時間7天（于1-160天），中位住院時間7天（于2-36天）。 2、593例標(biāo)本中，陽性標(biāo)本共367例，總檢出率為61.9％。單一病原體感染289例（48.7％），混合病原體感染78例（13.2％）。病原體以RSV最常見，共133例（22.4％）；其它依次為Inf A56例（9.4％），EV52例（8.8％），ADV40例（6.7％），Mpp39例（6.6％），hCoV32例（5.4％），hBoV31例（5.2％），PIV29例（4.9％）， hMPV25例（4.2％），Inf B24例（4％），及Cp7例（1.2％）。病原體不明確的標(biāo)本226例（38.1％）。593例患兒中，病毒感染（包括單一或混合病毒感染）共318例（53.6％）。單一的非典型細(xì)菌感染（包括Mpp或Cp）共31例（5.2％），病毒/非典型細(xì)菌混合感染共18例（3％）。 3、289例單一病原體感染標(biāo)本中，RSV為91例（15.3％）占首位，其次為InfA32例（5.4％），ADV30例（5.1％），Mpp28例（4.7％）。78例混合病原體感染標(biāo)本中，以2種病原體混合感染為主（57例，9.6％），3種病原體混合感染為次（20例，3.4％），且有1例是五種病原體混合感染。最常見混合感染為RSV合并其他病毒，其中RSV+EV15例，RSV+Inf A9例，RSV+hCoV5例。 4、CAP患兒年齡及病原體分布情況：在嬰兒組，RSV陽性檢出率最高占33.6％。Inf A、Inf B、hBoV、 hCoV、hMPV常見于學(xué)齡前兒童組，而PIV在嬰兒組多發(fā)。學(xué)齡兒童組當(dāng)中，最常見的病原體是ADV和MPP，各占16.7％。EV感染可見于各年齡組。 5、病原體感染的季節(jié)性分布情況：RSV高峰主要集中在2月份和9月份。hMPV在晚冬逐漸增多。Inf A高峰期在秋及晚冬季，而Inf B高峰期在1-2月份。EV和hCoV感染可出現(xiàn)于任何時節(jié)；EV感染在5月份及9月份呈現(xiàn)高峰，但hCoV發(fā)病率全年均較平穩(wěn)。hBoV感染多發(fā)生于夏季，7月份出現(xiàn)感染高峰。ADV和PIV沒有明顯的季節(jié)變化，但ADV于8-9月份為高峰期。Mpp感染在7月份開始發(fā)病，后秋季9月份為感染高峰期。Cp季節(jié)分布結(jié)果尚未明確�；旌细腥疽远径嘁�。病原體陰性的標(biāo)本四季均有出現(xiàn)。 6、593例CAP患兒病情嚴(yán)重程度分布：輕度病情者358例（60.4％），中度病情者141例（23.8％），重度病情者94例（15.9％）。病情嚴(yán)重程度分布與年齡組有相關(guān)關(guān)系（χ~2=36.682，P 0.001）。病情重度者多見于嬰兒組，而病情輕度者多見于學(xué)齡兒童組。 7、單一病原體感染、混合感染及病原體陰性病例間的臨床特點比較：呼吸窘迫多見于單一病原體感染患兒，與病原體陰性患兒相比有統(tǒng)計學(xué)差異（χ~2=12.876，P 0.001）。粘液痰、細(xì)濕Up音、喘息、三凹癥，支氣管擴張劑及靜脈激素治療多見于單一病原體感染及混合感染患兒，與病原體陰性患兒相比有統(tǒng)計學(xué)差異（P 0.05）。肝腫大多見于混合感染患兒，與單一病原體感染患兒（χ~2=5.817，P 0.05）及病原體陰性患兒（χ~2=7.745，P 0.05）相比有統(tǒng)計學(xué)差異。 8、病情嚴(yán)重程度分布與感染類型有相關(guān)關(guān)系（χ~2=53.805，P 0.001)。病情輕度者多見于病原體陰性感染組，而病情中度者和重度者多見于單一病原體感染組和混合感染組。在不同感染類型各組之間的年齡和住院時間均與病情嚴(yán)重程度有顯著關(guān)聯(lián)。單一病原體感染組、混合感染組及病原體陰性組的臨床評分，與年齡呈負(fù)相關(guān)（P 0.05）；單一病原體感染組及病原體陰性組的臨床評分與住院時間成正相關(guān)（P 0.05）。 9、單一RSV、Inf A、ADV、hBoV、hMPV、Mpp、NOS（非特指病原體）感染的臨床特點比較：RSV感染組患兒的中位年齡小于其他病原體感染組（χ~2=87.120， P 0.05）。RSV感染組的喘息、呼吸氣促和三凹征更常見于InfA、ADV、Mpp、hBoV、NOS、混合感染組和病原體陰性組（P 0.05）。RSV感染患兒更常使用支氣管擴張劑及靜脈激素治療，與其它病原體感染患兒比較均有統(tǒng)計學(xué)差異（P 0.05），而支氣管擴張劑使用與hBoV、Mpp、hMPV感染組和混合感染組比較則無統(tǒng)計學(xué)差異（P0.05）。ADV感染患兒常出現(xiàn)發(fā)熱，與RSV、NOS、混合感染患兒和病原體陰性患兒比較均有統(tǒng)計學(xué)差異（P 0.001）。ADV感染組的hsCRP和ESR水平升高更明顯，除了Inf A和Mpp感染組（P0.05）外，與其余各組比較均有統(tǒng)計學(xué)差異（P 0.05）。各種病原體分布與病情嚴(yán)重程度有相關(guān)關(guān)系（χ~2=128.975，P 0.001）。絕大多數(shù)病原體引起輕度病情，而RSV和ADV感染則多引起重度病情。 10、單一RSV感染組和RSV混合感染組的臨床特點比較：RSV混合感染組患兒的發(fā)熱時間長于單一RSV感染組（U=472，P 0.05）。喘息、氣促、流鼻涕多見于單一RSV感染組，與RSV混合感染組比較，差異有統(tǒng)計學(xué)意義（P 0.05）。肝腫大及ESR異常多見于RSV混合感染組，與單一RSV感染組比較差異有統(tǒng)計學(xué)意義（χ~2=4.855，，P=0.03；χ~2=6.67，P=0.01）。 11、病情嚴(yán)重程度分布與單一RSV感染和RSV混合感染有相關(guān)關(guān)系（χ~2=6.617，P 0.05）。病情重度者多見于單一RSV感染組，而病情輕度者多見于混合感染組。單一RSV感染中，患兒病情嚴(yán)重程度分布與年齡有相關(guān)關(guān)系（χ~2=6.8，P 0.05）；患兒的臨床評份與住院時間成正相關(guān)（ρ=0.213，P 0.05）。RSV混合感染中，患兒病情嚴(yán)重程度分布與年齡無相關(guān)關(guān)系（χ~2=4.178，P0.05）；患兒的臨床評份與住院時間無相關(guān)關(guān)系（ρ=-0.004，P0.05）。 12、RSV病毒滴度與臨床評分呈正相關(guān)關(guān)系（ρ=0.499，P 0.001）；RSV病毒滴度與住院時間無相關(guān)關(guān)系（ρ=-0.013，P0.05）。 結(jié)論 1、廣州地區(qū)2010-2011年社區(qū)獲得性肺炎住院患兒以1歲以下嬰兒多見，且其病毒病原體感染陽性率最高；男性嬰兒比女性更易患感染而需住院治療。 2、RSV感染組患兒的年齡小于其它病原體感染組，RSV是導(dǎo)致嬰兒CAP的最重要病原體；而學(xué)齡兒童組當(dāng)中，最常見的病原體是ADV和Mpp。兒童重癥肺炎中RSV或ADV的檢出率高。 3、RSV病毒滴度水平與CAP病情嚴(yán)重程度呈正相關(guān)；其他病原體混合感染不加重RSV肺炎病情。 4、患兒年齡與疾病嚴(yán)重程度呈負(fù)相關(guān)；住院時間與疾病嚴(yán)重程度呈正相關(guān)。 5、RSV感染以冬末春初高發(fā)，秋季再現(xiàn)一小高峰；hBoV和Mpp感染多發(fā)生于夏季；ADV和PIV感染呈全年散發(fā)；余病原體感染以秋冬季多見。 6、喘息發(fā)作、呼吸氣促、三凹征、支氣管擴張劑及靜脈激素治療多見于RSV和hMPV肺炎患兒；發(fā)熱、hsCRP升高及ESR升高多見于ADV和Mpp肺炎患兒。
[Abstract]:Research background
Community acquired pneumonia (CAP) is the most common infectious disease in childhood, with high incidence and serious harm. It is the first of the five major diseases of children in our country. The incidence of pneumonia in children under 21 million 100 thousand and 5 years of age in China (0.22 times per year) is significantly higher than that in developed countries (0.026 times / year). Children CAP The causes are often difficult to determine, and about 40% to 60% of the pneumonia children are unable to find a clear cause. Many researchers determine the cause of community-acquired pneumonia based on the patient's history, clinical manifestations, signs, laboratory and imaging data, but there is not enough reliable evidence to identify. A large number of reports from hospital children show that about 80% of children with community-acquired pneumonia have been treated with empirical treatment. When the children are diagnosed with CAP, whether they are treated with antibiotics and how to choose appropriate antibiotics associated with the cause are still a big problem. A study on community acquired pneumonia in hospitalized children. It is clear that most children pneumonia is caused by virus infection, so it is necessary to stop the unnecessary antibiotic treatment. In addition, Chlamydia pneumoniae and Mycoplasma pneumoniae are also increasingly becoming an important cause of acquired pneumonia in children. These atypical bacteria need specific antibiotics, and the conventional antibiotics used for typical pathogens are not effective. The inadequacy of the cause of pneumonia and the improper treatment of antibiotics can eventually lead to antibiotic resistance of the pathogens of community-acquired pneumonia, which will also become another global health problem. Based on these reasons, the clinical epidemiology of CAP in the daily clinic is deeply understood, and the clinical characteristics of different pathogenic pneumonia will help to improve the diagnosis, Appropriate management and prevention measures are taken to reduce the economic burden caused by overtreatment and inappropriate antibiotic treatment, while reducing the mortality of community acquired pneumonia related diseases.
objective
1, elucidate the distribution of common respiratory virus pathogens in children with community-acquired pneumonia.
2, determine the age and seasonal distribution of viruses and atypical bacterial pathogens.
3, the clinical characteristics of specific pathogens were analyzed.
Method
1. research objects
From January 2010 to December 2011, 593 cases of community-acquired pneumonia confirmed in the hospital area were collected. The age range of children was from 1 months to 14 years old, including 286 cases (48.2%) in the infant group (1-12 months), 259 (43.7%) in preschool children (12 months to 5 years), and 48 cases (8.1%) in the school age group (over 5 years to 14).
2. case collection, case assessment, data analysis
All children collected 2 milliliters of peripheral blood within 24 hours of admission to the blood routine, liver, heart, kidney function, biochemical and inflammatory indicators, and collected oropharynx swabs. The pharynx swab specimens were detected by real-time quantitative PCR detection method for simultaneous detection of the virus and atypical pathogens. What kind of pathogen is a positive case. If only one pathogen is found in a sample of a child, the child is considered to have only one infection, that is, a single infection. If multiple pathogens are found, it is considered a mixed infection. The information collected at admission includes the date, personal information, precursor symptoms, and clinical manifestations. During the hospital, the patient's daily changes were recorded in detail, including physical examination of the respiratory system, changes in clinical symptoms, laboratory data, complications, treatment and so on. The discharge date was also recorded to calculate the patient's hospitalization time. The severity of the disease was evaluated according to the clinical score (respiratory frequency, three recess, respiratory sound change, sperm). The state of God, the color of the skin.
Result
1, children aged from 1 months to 14 years of age, median age was 14 months, male accounted for 67%, women accounted for 33%. male and female ratio of male and female between men and women in the middle age of no statistically significant difference (U=35112, P0.05). Median onset time was 7 days (at 1-160 days), median hospital stay was 7 days (at 2-36 days).
Of the 2593 specimens, 367 were positive specimens, the total detection rate was 61.9%. single pathogen infection in 289 cases (48.7%) and mixed pathogen infection (13.2%). The most common pathogens were RSV, 133 cases (22.4%); the others were Inf A56 (9.4%), EV52 (8.8%), ADV40 cases (6.7%), Mpp39 cases (6.6%), hCoV32 cases (5.4%), hBoV31 cases (5.2) (%), PIV29 (4.9%), hMPV25 (4.2%), Inf B24 (4%), and Cp7 (1.2%). Among 226 (38.1%) children with unknown pathogens (38.1%).593 cases, the virus infection (including single or mixed virus infection) in 318 cases (53.6%). A single atypical bacterial infection (including Mpp or Cp) in 31 cases (5.2%), virus / atypical bacteria mixed infection A total of 18 cases (3%).
Among the 3289 specimens of single pathogen infection, RSV was 91 (15.3%), followed by InfA32 (5.4%), ADV30 (5.1%), Mpp28 (4.7%).78 cases of mixed pathogen infection, mixed infection with 2 pathogens (57, 9.6%), 3 pathogens mixed infection (20, 3.4%), and 1 cases of pathogen mixing. The most common mixed infection is RSV combined with other viruses, including RSV+EV15 cases, RSV+Inf A9 cases and RSV+hCoV5 cases.
4, age and distribution of pathogens in children with CAP: in the infant group, the highest RSV positive rate is 33.6%.Inf A, Inf B, hBoV, hCoV, hMPV common in the preschool children group, and PIV in the infant group. Among the school age children, the most common pathogens are ADV and MPP, each of which accounts for the age groups of 16.7%.
5, the seasonal distribution of pathogen infection: the peak of RSV peak mainly concentrated in February and September in the late winter and gradually increased at the peak period of.Inf A in autumn and late winter, while the peak period of Inf B in the peak of.EV and hCoV may appear at any time in the month of 1-2; EV infection peak in May and September, but hCoV incidence rate is more stable throughout the year. The infection occurred most in summer. There was no obvious seasonal change in the peak infection peak.ADV and PIV in July, but the peak period of.Mpp infection in ADV began in July, and the seasonal distribution of.Cp in September was not clear in September.
In 6593 cases of CAP, the severity of the disease was distributed in 358 cases (60.4%), 141 (23.8%) and 94 (15.9%) in severe condition (15.9%). The severity of the disease was associated with age group (x ~2=36.682, P 0.001).
7, comparison of clinical characteristics between single pathogen infection, mixed infection and pathogen negative cases: respiratory distress is mostly seen in children with single pathogen infection, and there are statistical differences compared with those with negative pathogens (x ~2=12.876, P 0.001). Mucous phlegm, fine wet Up sound, wheezing, three concave, bronchiectasis and intravenous hormone therapy are often seen in a single case. There were statistical differences in the infection and mixed infection of the children with the pathogen negative children (P 0.05). Most of the hepatomegaly were found in the children with mixed infection, compared with the children with single pathogen infection (x ~2=5.817, P 0.05) and the children with negative pathogens (x ~2=7.745, P 0.05).
8, the distribution of the severity of the disease was related to the type of infection (x ~2=53.805, P 0.001). The mild cases were mostly found in the pathogen negative infection group, and the moderate and severe cases were found in the single pathogen infection group and the mixed infection group. The age and the time of hospitalization between the different types of infection types were all significant with the severity of the disease. The clinical scores of the single pathogen infection group, the mixed infection group and the pathogen negative group were negatively correlated with age (P 0.05), and the clinical score of the single pathogen infection group and the pathogen negative group was positively correlated with the time of hospitalization (P 0.05).
9, comparison of the clinical characteristics of single RSV, Inf A, ADV, hBoV, hMPV, Mpp, NOS (non specific pathogen) infection: the median age of the children of the RSV infection group is less than the other pathogens infection group (chi ~2=87.120, P 0.05) the gasping of the.RSV infection group, the respiratory shortness and the three concave sign, and the mixed infection group and the pathogen negative group (0.05). RSV infected children often use bronchiectasis and intravenous hormone treatment, compared with other pathogens infected children (P 0.05), but bronchiectasis use and hBoV, Mpp, hMPV infection group and mixed infection group have no statistically significant difference (P0.05) children with.ADV infection often have fever, with RSV, NOS, mixed infection children The levels of hsCRP and ESR in the.ADV infection group were significantly higher than those with negative pathogens (P 0.001). Except for Inf A and Mpp infection group (P0.05), there were statistical differences between the other groups (P 0.05). The distribution of various pathogens was related to the severity of the disease (x ~2=128.975, P 0.001). It causes mild illness, while RSV and ADV infection cause severe disease.
10, comparison of the clinical characteristics of the single RSV infection group and the RSV mixed infection group: the fever time of the RSV mixed infection group was longer than that of the single RSV infection group (U=472, P 0.05). The wheezing, the breath, the runny nose were mostly found in the single RSV infection group, and the difference was statistically significant (P 0.05) compared with the mixed RSV infection group (P 0.05). The hepatomegaly and ESR abnormality were more common in RSV mixture. The difference between staining group and single RSV infection group was statistically significant (x ~2=4.855, P=0.03; Chi ~2=6.67, P=0.01).
11, the distribution of the severity of the disease was related to the single RSV infection and the mixed infection of RSV (x ~2=6.617, P 0.05). Most of the severe cases were found in the single RSV infection group, and the mild cases were mostly seen in the mixed infection group. The severity of the disease was associated with the age of the children (x ~2=6.8, P 0.05); the clinical evaluation of the children was evaluated. In a positive correlation with the time of hospitalization (rho =0.213, P 0.05).RSV mixed infection, the distribution of the severity of the disease was not related to age (x ~2=4.178, P0.05), and there was no correlation between the clinical evaluation and the time of hospitalization (P =-0.004, P0.05).
12, RSV virus titer was positively correlated with clinical score (P =0.499, P 0.001); RSV virus titer was not correlated with length of stay (=-0.013, P0.05).
conclusion
1, the 2010-2011 years of community acquired pneumonia in Guangzhou area are more common in infants under 1 years of age, and the positive rate of viral pathogens is the highest; male infants are more susceptible to infection than women and need to be hospitalized.
2, the age of the RSV infection group is less than the other pathogen infection group. RSV is the most important cause of the infant CAP, and the most common pathogen in the school age group is the high detection rate of RSV or ADV in ADV and Mpp. children's severe pneumonia.
3, the level of RSV virus titer was positively correlated with the severity of CAP, and the mixed infection of other pathogens did not aggravate the condition of RSV pneumonia.
4, the age of the children was negatively correlated with the severity of the disease, and the time of hospitalization was positively correlated with the severity of the disease.
5, RSV infection is high onset in early winter and early spring, and a small peak in autumn; hBoV and Mpp infection occur in summer; ADV and PIV infection show all the year round, and the infection of residual pathogens is more common in autumn and winter.
6, asthma attacks, respiratory shortness, three recess, bronchiectasis and intravenous hormone therapy are mostly found in children with RSV and hMPV pneumonia; fever, elevated hsCRP and elevated ESR are common in children with ADV and Mpp pneumonia.

【學(xué)位授予單位】：中山大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2012
【分類號】：R725.6

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相關(guān)期刊論文 前2條

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2 汪天林,陳志敏,湯宏峰,唐蘭芳,鄒朝春,吳利紅;杭州地區(qū)小兒呼吸道合胞病毒感染流行特點與氣象學(xué)因素[J];中華流行病學(xué)雜志;2005年08期

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