發(fā)布時(shí)間：2018-05-03 18:51

  本文選題：阻塞性睡眠呼吸暫停低通氣綜合癥 + 扁桃體��； 參考：《上海交通大學(xué)》2014年碩士論文

【摘要】：目的分析阻塞性睡眠呼吸暫停低通氣綜合癥（OSAHS）患兒扁桃體、腺樣體表面和實(shí)體組織內(nèi)的細(xì)菌種類、分布以及藥物敏感情況，從而指導(dǎo)臨床治療，同時(shí)探討細(xì)菌培養(yǎng)結(jié)果與滲出性中耳炎、變應(yīng)性鼻炎、扁桃體、腺樣體肥大程度之間的關(guān)系。 方法隨機(jī)選取2012年7月至2013年2月在上海交通大學(xué)附屬兒童醫(yī)院確診的OSAHS并行手術(shù)的患兒213例，其中男140例，女73例，年齡1-13歲，平均年齡4.96±2.29歲。每例患兒分別送檢鼻咽拭子、咽拭子、扁桃體實(shí)體組織、腺樣體實(shí)體組織，①比較四組細(xì)菌培養(yǎng)結(jié)果有無(wú)差異性；②根據(jù)有無(wú)合并變應(yīng)性鼻炎分為變應(yīng)性鼻炎組（AR組）60例和非變應(yīng)性鼻炎組（NAR組）91例，比較AR組與NAR組致病菌檢出有無(wú)差異性；③根據(jù)有無(wú)合并滲出性中耳炎分為滲出性中耳炎組（OME組）22例和非滲出性中耳炎組（NOME組）80例，，比較OME組和NOME組致病菌檢出有無(wú)差異性；④根據(jù)扁桃體肥大程度不同，比較Ⅱ度肥大組168例與Ⅲ度肥大組45致病菌檢出有無(wú)差異性；⑤根據(jù)腺樣體肥大程度不同，比較Ⅲ度肥大組44例和Ⅳ度肥大組78例致病菌檢出有無(wú)差異性。 結(jié)果 1.腺樣體表面與實(shí)質(zhì)細(xì)菌培養(yǎng)結(jié)果無(wú)統(tǒng)計(jì)學(xué)差異（2=0.162～1.554，P0.05）。 2.扁桃體表面與實(shí)質(zhì)細(xì)菌培養(yǎng)結(jié)果無(wú)統(tǒng)計(jì)學(xué)差異（2=0.101～4.512，P0.05）。 3.OSAHS伴有OME組致病菌檢出率低于NOME組（2=4.8014，P=0.02840.05）。進(jìn)一步分析到菌種發(fā)現(xiàn)，金黃色葡萄球菌檢出率OME組低于NOME組（2=0.0025，P=0.00540.05）；其它6種致病菌在兩組之間檢出率無(wú)統(tǒng)計(jì)學(xué)差異（2=0.0924～0.7609，P=0.2034～1.00000.05）。 4.OSAHS伴有AR組與NAR組致病菌檢出率無(wú)統(tǒng)計(jì)學(xué)差異（2=0.1347～1.1828，P=0.2768～0.71360.05）。 5.OSAHS伴有扁桃體Ⅲ度肥大組致病菌檢出率高于Ⅱ度肥大組（2=5.3036，P=0.02130.05）。進(jìn)一步分析到菌種發(fā)現(xiàn)，金黃色葡萄球菌檢出率Ⅲ°組高于Ⅱ°組（2=9.3431，P=0.00220.05）；其它6種致病菌在兩組之間檢出率無(wú)統(tǒng)計(jì)學(xué)差異（2=0.2205～0.3975，P=0.2852～1.00000.05）。 6. OSAHS伴有腺樣體Ⅲ度肥大組與Ⅳ度組致病菌檢出率無(wú)統(tǒng)計(jì)學(xué)差異（2=0.0000～1.5127，P=0.2187～0.1.00000.05）。 7.①金黃色葡萄球菌：對(duì)萬(wàn)古霉素100%敏感，對(duì)頭孢類抗生素（如頭孢唑啉、頭孢呋辛）、β-內(nèi)酰胺酶抑制劑復(fù)合物（氨芐西林/舒巴坦）敏感率較高（80%以上），對(duì)克林霉素，氨芐西林、紅霉素敏感率依次降低，對(duì)青霉素耐藥率達(dá)90%以上。MRSA對(duì)青霉素、頭孢類抗生素、β-內(nèi)酰胺抑制劑復(fù)合物100%耐藥，但是磺胺類抗菌藥復(fù)方新諾明100%敏感。②肺炎鏈球菌：對(duì)苯唑青霉素、紅霉素、克林霉素耐藥率達(dá)95%以上，對(duì)喹諾酮類（如莫西沙星）、萬(wàn)古霉素敏感率達(dá)100%。③化膿性鏈球菌：對(duì)單純青霉素、萬(wàn)古霉素、頭孢曲松100%敏感，對(duì)克林霉素、紅霉素耐藥率達(dá)94%。④流感嗜血桿菌、副流感嗜血桿菌：對(duì)阿莫西林/棒酸，阿奇霉素敏感率達(dá)90%以上，對(duì)頭孢呋辛敏感率達(dá)80%以上，對(duì)喹諾酮類、氨芐西林/舒巴坦、氨芐西林敏感率依次降低，對(duì)克林霉素耐藥率達(dá)80%以上。β-內(nèi)酰酶陽(yáng)性的HIN,HHE對(duì)頭孢呋辛耐藥率為100%，對(duì)氨芐西林/舒巴坦耐藥率達(dá)90%以上。⑤肺炎克雷伯氏菌、銅綠假單胞菌：對(duì)所選抗生素如頭孢類、β-內(nèi)酰胺抑制劑復(fù)合物、亞胺培南敏感率幾乎全達(dá)100%。 結(jié)論 1.咽拭子細(xì)菌培養(yǎng)及藥敏試驗(yàn)結(jié)果可以代表扁桃體實(shí)體組織細(xì)菌種類、分布及藥物敏感程度。 2.鼻咽拭子細(xì)菌培養(yǎng)及藥敏試驗(yàn)結(jié)果可以代表腺樣體實(shí)體組織細(xì)菌種類、分布及藥物敏感程度。 3.伴有滲出性中耳炎的OSAHS患兒，致病菌檢出率低于非滲出性中耳炎的OSAHS患兒，我們認(rèn)為可能是OME患兒在術(shù)前使用抗生素類藥物干預(yù)的結(jié)果，也可能與中耳炎患者由于炎癥反應(yīng)而產(chǎn)生局部免疫而使細(xì)菌檢出率降低有關(guān)。 4.伴有變應(yīng)性鼻炎的OSAHS患兒與伴有NAR的OSAHS患兒致病菌檢出率比較無(wú)統(tǒng)計(jì)學(xué)差異，需要更大樣本的進(jìn)一步深入研究。 5.伴有扁桃體Ⅲ度肥大組的OSAHS患兒，致病菌檢出率高于Ⅱ度組，且主要是金黃色葡萄球菌檢出率具有差異性，金葡菌感染與扁桃體肥大關(guān)系密切。 6.伴有腺樣體Ⅲ度肥大的OSAHS患兒致病菌檢出率與Ⅳ肥大的OSAHS患兒比較無(wú)統(tǒng)計(jì)學(xué)差異，目前還無(wú)法解釋這一結(jié)果，需要更大樣本的進(jìn)一步深入研究。 7.合理規(guī)范的使用抗生素是以細(xì)菌培養(yǎng)及藥物敏感性試驗(yàn)為基礎(chǔ)的，因此，根據(jù)致病菌的特點(diǎn)和藥物敏感試驗(yàn)結(jié)果有針對(duì)性地選擇抗生素，且應(yīng)用足夠的劑量和療程，可以提高治療效果且減慢耐藥菌株的產(chǎn)生。
[Abstract]:Objective to analyze the species, distribution and drug sensitivity of the tonsil, adenoid and solid tissue in children with obstructive sleep apnea hypopnea syndrome (OSAHS), to guide the clinical treatment, and to explore the relationship between the results of bacterial culture and oozing otitis media, allergic rhinitis, tonsillar and adenoid hypertrophy.
Methods from July 2012 to February 2013, 213 cases of OSAHS parallel surgery in the Affiliated Children's Hospital of Shanghai Jiao Tong University were randomly selected, of which 140 were male, 73 women, 1-13 years old, and the average age was 4.96 + 2.29 years old. Each case was examined for nasopharyngeal swabs, swabs, almond body tissues and adenoid body tissues, and the four groups were compared. There were no differences in the results of bacterial culture; (2) there were 60 cases of allergic rhinitis (group AR) and 91 cases of non allergic rhinitis (group NAR) based on or without allergic rhinitis, and there were no differences in the detection of pathogenic bacteria in group AR and group NAR; (3) 22 cases of otitis media group (group OME) and non exudative otitis media were divided into 22 cases and non exudative otitis media according to the otitis media with or without exudative otitis media. Group NOME (group NOME) had no difference in detection of pathogenic bacteria in group OME and NOME. (4) according to the degree of tonsillar hypertrophy, there was no difference between 168 cases of the hypertrophy group and 45 pathogenic bacteria in the group of III degree hypertrophy. 5. According to the degree of adenoid hypertrophy, 44 cases in the group of third degree hypertrophy and 78 cases of IV degree hypertrophy group were detected to be detected by pathogenic bacteria. Difference.
Result
1. there was no significant difference between the surface of adenoids and the results of parenchymal bacterial culture (2=0.162 ~ 1.554, P0.05).
2. there was no significant difference in tonsil surface and parenchymal bacterial culture (2=0.101 to 4.512, P0.05).
The detection rate of pathogenic bacteria in group 3.OSAHS with OME was lower than that of group NOME (2=4.8014, P=0.02840.05). Further analysis showed that the detection rate of Staphylococcus aureus in OME group was lower than that of group NOME (2=0.0025, P=0.00540.05), and there was no statistical difference between the other 6 pathogenic bacteria in the two groups (2=0.0924 ~ 0.7609, P=0.2034 to 1.00000.05).
4.OSAHS and AR group and NAR group had no significant difference in the detection rate of pathogens (2=0.1347 ~ 1.1828, P=0.2768 ~ 0.71360.05).
The detection rate of pathogenic bacteria in 5.OSAHS with tonsillar III degree hypertrophy group was higher than that of the hypertrophic group (2=5.3036, P=0.02130.05). Further analysis showed that the detection rate of Staphylococcus aureus was higher than that of group II (2=9.3431, P=0.00220.05), and there was no statistical difference between the other 6 pathogenic bacteria in the two groups (2=0.2205 ~ 0.3975, P=0.2852). ~ 1.00000.05).
There was no significant difference in the detection rate of pathogenic bacteria between 6. OSAHS and adenoid 3 degree hypertrophy group and grade IV group (2=0.0000 to 1.5127, P=0.2187 to 0.1.00000.05).
7. Staphylococcus aureus: sensitive to vancomycin 100%, the sensitivity of cephalosporins (cefazolin, cefuroxime), beta lactamase inhibitor complex (ampicillin / sulbactam) was higher (more than 80%), and the sensitivity rate of clindamycin, ampicillin and erythromycin decreased in turn, and penicillin resistance rate was over 90%.MRSA against Penicillium. Antibiotics, cephalosporins and beta lactam inhibitor complexes were 100% resistant, but sulfamethoxy compound Sulfamethoxine 100% was sensitive. (2) Streptococcus pneumoniae: the resistance to benzoxamillin, erythromycin and clindamycin was over 95%. Quinolones (such as moxifloxacin) and vancomycin were sensitive to 100%. suppurative Streptococcus: pure Penicillium. It was sensitive to 100% of vancomycin and ceftriaxone. To clindamycin, the resistance rate of erythromycin to erythromycin was 94%. (Haemophilus influenzae) and Haemophilus parainfluenza, the sensitivity of amoxicillin / stick acid to azithromycin was above 90%, and the sensitivity rate of cefuroxime was over 80%, and the sensitivity rate of quinolones, ampicillin / sulbactam and ampicillin decreased in turn. The resistance rate of clindamycin was above 80%. The resistance rate of HIN to beta lactamase positive, HHE to cefuroxime was 100%, and the resistance rate to ampicillin / sulbactam was over 90%. 5. Klebsiella pneumoniae, Pseudomonas aeruginosa: the sensitivity of imipenem to the selected antibiotics, such as cephalosporin, beta lactam inhibitor complex, and imipenem almost all up to 100%.
conclusion
1. the results of bacterial culture and drug sensitivity test of throat swab can represent the species, distribution and drug sensitivity of bacteria in tonsil tissue.
2. the results of bacterial culture and drug sensitivity test of nasopharyngeal swabs can represent the species, distribution and drug sensitivity of bacteria in the tissues of adenoids.
3. of OSAHS children with exudative otitis media, the detection rate of pathogenic bacteria is lower than that of OSAHS in non exudative otitis media. We think it may be the result of the use of antibiotics in children with OME before operation, and it may also be related to the reduction of bacterial detection rate with the inflammatory response of the otitis media.
4. there was no significant difference in the detection rate of OSAHS among children with allergic rhinitis and those with NAR in OSAHS. Further studies were needed for larger samples.
5. the incidence of pathogenic bacteria in OSAHS children with the tonsillar III degree hypertrophy group was higher than that of the second degree group, and the detection rate of Staphylococcus aureus was different. The infection of Staphylococcus aureus was closely related to the tonsil hypertrophy.
6. the detection rate of pathogenic bacteria in OSAHS children with adenoid hypertrophy is not statistically different from that of OSAHS children with hypertrophy. It is not possible to explain this result and need further in-depth study of a larger sample.
7. the rational use of antibiotics is based on bacterial culture and drug sensitivity tests. Therefore, the selection of antibiotics according to the characteristics of pathogenic bacteria and the results of drug sensitivity tests, and the application of sufficient doses and courses of treatment, can improve the effect of treatment and slow down the production of resistant strains.

【學(xué)位授予單位】：上海交通大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R766

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