摘要
目的:分析近一年大连市儿童医院社区获得性肺炎住院患儿的病原体构成比、不同年龄组病原分布特点以及常见细菌的耐药情况,为临床经验性治疗及病原学检测提供依据,减少抗生素及抗病毒药物的不合理应用。
对象与方法:选择2007年5月~2008年5月于我院呼吸内科病房住院并符合社区获得性肺炎诊断标准[1]的患儿454例,按年龄分4组:~1岁组168例、~3岁组141例、~6岁组80例、~14岁组65例。参考血常规选择性进行如下检测:(1)在治疗前进行咽后壁分泌物一般细菌培养,对阳性细菌行常规药敏定性,部分G-杆菌行超光谱β-内酰胺酶试验。(2)自然病程7-10天进行血清病毒IgM抗体及肺炎支原体IgM抗体测定,≥1:80判定为阳性结果。
结果:1.433例参与病原学检测,44.8%检测出致病原,病原体构成比为细菌感染居首位(31%),其次是肺炎支原体感染(29%),病毒感染(23%),还有17%患儿为混合感染。2.病毒病原特点:280份血清标本送检病毒IgM抗体,阳性率28.2%。主要病毒为呼吸道合胞病毒、腺病毒、副流感病毒。学龄期病毒感染阳性率最高54%(27/50),明显高于其它年龄组〔~1岁15.1%(16/106), ~3岁31.4%(27/86), ~6岁23.7%(9/38)〕,有显著统计学差异(p值均≤0.05),其次是幼儿期。3.肺炎支原体:随年龄增加发病率呈上升趋势,血清肺炎支原体IgM抗体各年龄段阳性率依次为5.5%(7/128) , 13%(14/108) , 40%(22/55) ,58.7%(44/75),各年龄组间差异有显著统计学差异(p值均≤0.05)。4.细菌病原特点:359份呼吸道分泌物送检细菌培养,阳性率22%。阳性菌株82株中,以G-杆菌为主,占73.2%。G-杆菌中阳性率最高的为肺炎克雷伯杆菌肺炎亚种,占30%,它阿莫西林克拉维酸相对敏感,对美平未发现耐药株,产ESBLs(+)株对头孢吡肟耐药性增加、对头孢噻肟高度耐药;G+球菌中阳性率最高的为肺炎链球菌18%,它对青霉素相对敏感,对红霉素、克林霉素、四环素高度耐药。婴儿期细菌检出率34.6%(47/136)高于其它年龄组〔~3岁13.7%(14/102),~6岁22.4%(11/49),~14岁8.3%(6/72)〕。5.17%病例有混合感染,病毒混和其它病原感染最为常见,其次是肺炎支原体。各年龄组间未发现明显规律。
结论:1、病毒感染学龄期检出率较高,其次是婴幼儿,RSV、ADV常见,RSV检出率略高于ADV,对这些儿童应注意抗病毒对症治疗。2、支原体感染主要集中在学龄前及学龄期儿童。3、肺炎链球菌对红霉素、克林霉素、四环素、复方新诺明耐药率高,肺炎克雷伯杆菌产ESBLs株对阿莫西林、哌拉西林、头孢噻肟耐药率高。临床选药应避免选用耐药性高的药物。4、混合感染以病毒合并其它病原感染为最常见,肺炎支原体混合其它病原也占很大比重,各年龄组散发,未发现明显规律。
Objective : To investigate the etiology of children’s community acquired pneumonia (CAP) and the bacterial resistance in patients of dalian city during the last year,and provide evidences to clinical empirical therapy and the pathogenic detection.Thus we could prevent irrational using of antiviral drugs and antibiotics
Methods: The patients in dalian children’s hospital department of respiratory was devided into four groups from May of 2007 to 2008.Before the treatment ,pharyngeal swabs was taken for culture to find bacteries. The cases which bacterial culture were positive would be done drug sensitivity quantitative test and examed the extended spectrumβlactamases. Serum virus antibody and mycoplasma antibodies were detected after 1 week.Positive was defined as IgM≥1:80.
Results:1.In 433 cases ,there are 44.8 % of them were detected positive. The first common is bacteria agent (31%), the second is myoplasma(29%) , the third is virus(23%), and the forth is mix infection(17%).2.In 280 cases which are detected for IgM antibodies, the positive rate is 28.2%.It is mainly consist with respiratory syncytial virus, adenovirus, and parainfluenza virus.The ratio of virus infection in school age group (54%)is higher than other groups,the second is in toddler age . 3.The ratio of myoplasma infection is increase by the age. there was significant difference among the four groups(5.5%,13%,40%,58.7%).4. In 359 cases which are detected for bacteria, the positive rate is 22%. It is mainly consist with gram negative bacteria. Streptococcus pneumoniae(18%) is the most common in gram positive bacteria. It is relative sensitive to amoxicillin-clavulanic acid and there is no drug-resistant strains for panipenam. Drug resistance of ESBLs producing strains to cefepime and cefotaxime is increase. Klebsiella pneumoniae (30%)is most common in gram negative bacteria. And it is highly resistant to erythromycin, clindamycin,and tetracycline. The ratio of bacteria infection in infancy age group (34.6%)is higher than other groups.5.17% of all cases is mixed infection,among which virus mixed with other pathogens are the most important,and the next one is myoplasma.There is no significant difference among the groups.
Conclusion:Bacterial pneumonia are the most common one in infant pneumonia. The most common bacterial agents are gram negative bacteria,such as Klebsiella pneumoniae.The next one are gram positive bacteria ,suah as S. pneumoniae .And myoplasma was the second most common cause of CAP. In the elderly children the myoplasma infectious ratio is increased by the children’s age . The last common one are viral pneumonia.Viral agents are mainly consist with respiratory syncytial virus (RSV)and adenovirus(ADV).
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