新生儿肺炎克雷伯菌败血症与大肠埃希菌败血症临床特点及耐药性的比较

目的 对新生儿肺炎克雷伯菌败血症与大肠埃希菌败血症临床特点及耐药性进行对比分析,为临床早期诊断和合理治疗提供理论依据.方法 对2000年1月至2009年10月在我院新生儿重症监护病房住院治疗并确诊为肺炎克雷伯菌败血症(n=42)和大肠埃希菌败血症患儿(n=50)的病历资料进行回顾性分析,比较其临床特征、实验室检查、治疗转归情况.同时将不同发病日龄肺炎克雷伯菌败血症与大肠埃希菌败血症(发病日龄≤3 d为早发型败血症、发病日龄＞3 d为晚发型败血症)对抗生素的耐药情况进行比较分析.结果 (1)临床特点比较:肺炎克雷伯菌败血症比大肠埃希菌败血症新生儿气促、呼吸暂停的发生率高(61.9%和6.0%,x2=17.34,P＜0.05),在更短的时间内发展至多器官功能障碍综合征和弥漫性血管内凝血[(40±28)h和(89±26)h](t=-3.17,P＜0.05);但并发化脓性脑膜炎比例低(4.8%和30.0%,x2=9.65,P＜0.05).(2)非特异性实验室检查结果:肺炎克雷伯菌败血症与大肠埃希菌败血症相比较,白细胞＞25×109/L(42.9%和22.0%,x2=4.60,P＜0.05)、血小板＜100×109/L(52.4%和18.0%,x2=12.07,P＜0.05)、C反应蛋白＞8 mg/L(95.2%和76.0%,x2=6.55,P＜0.05)的比例较高.(3)抗生素耐药情况:对头孢菌素类抗生素肺炎克雷伯菌耐药率高于大肠埃希菌(81.8%～100.0%和17.2%～63.2%,x2=6.97～11.92,P＜0.05);晚发型肺炎克雷伯菌败血症对阿莫西林/棒酸、头孢哌酮/舒巴坦耐药率高于晚发型大肠埃希菌败血症(75.0%和0.0%,x2=26.67;83.3%和0.0%,x2=12.53,P均＜0.05);对亚胺培南均未发现耐药.晚发型大肠埃希菌败血症与肺炎克雷伯菌败血症产超广谱于内酰胺酶菌株检出率均较早发型高(65.0%和17.8%,x2=11.06;100.0%和30.0%,x2=20.22,P均＜0.05),其中晚发型肺炎克雷伯菌败血症产超广谱β-内酰胺酶菌株检出率高于晚发型大肠埃希菌败血症(100.0%和65.0%,x2=9.16,P＜0.05).(4)病死率:肺炎克雷伯菌败血症病死率高于大肠埃希菌败血症(21.4%和4.0%,x2=6.59,P＜0.05).结论 新生儿肺炎克雷伯菌败血症病情比大肠埃希菌败血症重,可迅速发展至多器官功能障碍综合征和弥漫性血管内凝血,病死率高.肺炎克雷伯菌和大肠埃希菌的产超广谱β-内酰胺酶菌株快速增长,临床应合理使用抗生素.

Abstract：

Objective To compare the clinical characteristics and antibiotics resistance of neonatal sepsis caused by Klebsiella pneumoniae and Escherichia coli in order to provide guidance for early diagnosis and appropriate treatment. Methods Forty-two newborns with Klebsiella pneumoniae sepsis and 50 newborns with Escherichia coli sepsis in the neonatal intensive care unit of Yuying Children's Hospital of Wenzhou Medical College from January 2000 to October 2009 were enrolled into this study. The clinical data, laboratory examinations and prognosis of these newborns were retrospectively analyzed and compared. The antibiotic resistance data of different onset age of the two diseases were compared. Early-onset sepsis was defined as the age at the onset ≤3 days, and late-onset sepsis was defined as the age at the onset ＞3 days. Results (1) Comparison of clinical characteristics: Klebsiella pneumoniae sepsis caused higher incidence of apnea or gasp compared with Escherichia coli sepsis (61.9% vs 6.0% ,x2= 17. 34, P＜0. 05); the time of developing to multiple organ dysfunction syndrome or disseminated intravascular coagulation of the newborns with Klebsiella pneumoniae sepsis [(40±28) h] was shorter than that of the newborns with Escherichia coli sepsis [(89±26) h] (t= -3.17, P＜0.05); while the incidence of purulent meningitis of Klebsiella pneumoniae sepsis was lower ( 4. 8% vs 30. 0 %, x2 = 9.65, P ＜ 0. 05 ). ( 2 ) Comparison of non-specific laboratory examinations: compared with Escherichia coli sepsis, Klebsiella pneumoniae sepsis caused higher incidence of the leucocyte count ＞ 25 × 109/L (42. 9% vs 22.0%, x2 = 4. 60,P＜0. 05), platelet count ＜ 100 × 109/L (52.4% vs 18.0%, x2 = 12.07, P＜0. 05) and C-reaction protein ＞8 mg/L (95.2% vs 76.0% ,x2 =6. 55, P＜0. 05). (3) Comparison of results of antibiotic resistance: the resistance rate of Klebsiella pneumoniae (81.8%00-100. 0%) to Cephalosporins was higher than that of Escherichia coli (17. 2%-63. 2%) (x2 =6.97-11.92, P＜0. 05); the resistance rates of late-onset sepsis of Klebsiella pneumoniae to Amoxicillin/clavulanic-acid and Cefoperazone/sulbactam were higher than those of Escherichia coli (75.0% vs 0.0%, x2 =26.67, P＜0. 05;83. 3%vs 0. 0%, x2 = 12.53, P＜0. 05 respectively); no resistance to Imipenem were found. The percentages of extended spectrum β-lactamases (ESBLs) positive Escherichia coli and Klebsiella pneumoniae were obviously higher in neonates with late-onset sepsis than those early-onset ones (65.0% vs 17. 8%,x2 = 11.06, P＜0. 05; 100. 0 % vs 30. 0 %, x2 = 20. 22, P＜0. 05 respectively); and positive ESBLs rate of the late-onset Klebsiella pneumoniae sepsis was higher than that of Escherichia coli sepsis (100. 0% vs 65.0%, x2 =9.16, P＜0. 05). (4) Comparison of mortality rate: the mortality rate of Klebsiella pneumoniae sepsis was higher than that of Escherichia coli sepsis (21.4% vs 4. 0%,x2=6.59, P ＜ 0. 05 ) . Conclusions Compared with Escherichia coli septicemia, Klebsiella pneumoniae septicemia has more severe symptoms, developed to multiple organ dysfunction syndrome or disseminated intravascular coagulation quicker, and has higher mortality rate. The percentage of ESBLs positive Escherichia coli and Klebsiella pneumoniae increased rapidly. The clinical use of antibiotics should be rationale.     

新生儿先天性巨细胞病毒感染的诊断及治疗探讨

目的 探讨新生儿先天性巨细胞病毒(CMV)感染的主要临床表现、诊断及治疗效果.方法采用酶联免疫吸附试验定量检测血清CMV抗体,用荧光实时定量PCR法检测尿CMV-DNA,2007年1月至2008年12月间共确诊新生儿先天性CMV感染145例,其中的101例症状性感染患儿采用更昔洛韦治疗,观察其疗效及副作用.各指标改善情况的比较采用卡方检验. 结果 症状性CMV感染主要临床表现及实验室指标异常为:病理性黄疸、肝脾肿大、间质性肺炎、皮肤瘀点、吸吮力差、血小板下降、血清谷丙转氨酶增高等.尿CMV-DNA阳性87例(60.0%),血清CMV-IgM阳性43例(29.7%),生后2周内血清IgG增高4倍21例(14.5%);13例(9.0%)患儿尿CMV-DNA阳性或血清CMV-IgM阳性,其血清IgG也比母亲高1倍以上.更昔洛韦治疗后,CMV感染的相关症状及体征和实验室指标得到明显改善.治疗期间副作用较少,主要有粒细胞减少、血小板下降,但未见肝肾功能损害. 结论 新生儿先天性CMV感染可造成多器官系统损害,临床表现多样;实验室依据包括尿CMV-DNA阳性,检测阳性率高;其他依次为血清CMV-IgM阳性及CMV-IgG4倍增高;患儿CMV-IgG比母亲增高1倍以上可能是诊断CMV感染实验室依据之一;更昔洛韦治疗症状性CMV感染效果较好.     

Differential growth of human embryos in vitro: role of reactive oxygen species

OBJECTIVE: To examine the relationship of early human embryonic development with the level of reactive oxygen species (ROS) in the culture media on the first day (day 1 ROS) after insemination. DESIGN: A prospective study. SETTING: Patients undergoing assisted reproduction in a teaching hospital. PATIENT(S): Patients undergoing conventional IVF (n = 104; 115 cycles) and intracytoplasmic sperm injection (ICSI) (n = 91; 96 cycles) were included. Both fertilization and early cultures were performed in human tubal fluid with 5% serum substitute supplement. INTERVENTION(S): Day 1 ROS levels in the central well (sample) and the outer well (control) of each embryo culture dish were measured after overnight incubation by chemiluminescence assay using luminol as the probe. MAIN OUTCOME MEASURE(S): Fertilization rate and embryo quality at day 3 and 5 were recorded for each cycle. Age, parity, and demographic features were also compared. RESULT(S): High day 1 ROS levels in culture media were associated with low blastocyst rate, low fertilization rate, low cleavage rate, and high embryonic fragmentation with ICSI but not with conventional IVF. High day 1 ROS levels in culture media were associated with lower pregnancy rates in both IVF and ICSI cycles. CONCLUSION(S): Reactive oxygen species generated in culture media by day 1 may be an important biochemical marker for early embryonic growth. Increased embryonic fragmentation and slow cleavage rate may be partially attributed to early exposure of embryos to high ROS levels in ICSI cycles. Differential growth of ICSI embryos incubated under identical conditions may be in part due to differences in ROS levels of the culture medium surrounding these embryos.     

初乳对新生儿肠道的保护作用

通过对１５例产后１－５天初乳和新生儿粪便的分泌型免疫球蛋白含量测定，以及对新生儿粪便中双歧杆菌和细菌数量的调查，发现初乳ＳＩｇＡ含量以第一天最高，以后几天迅速下降；婴儿摄母乳后，粪便ＳＩｇＡ含量迅速升高，从出生第二天起，母乳喂养新生儿粪便的ＳＩｇＡ水平比人工喂养儿高１０００倍。     

早期综合干预对高危新生儿神经心理发育影响的研究

目的　探讨早期综合干预对围产期高危新生儿神经心理发育的效果。　方法　采用自行编写的 0～ 3岁早期干预和早期教育大纲、早期预防感觉统合失调被动按摩操等干预方法 ,对高危干预组儿童进行综合干预 ,另设高危对照组和正常对照组进行比较 ,用Gesell婴幼儿发育量表进行早期神经心理发育监测。　结果　高危干预组各能区发育商 (DQ)和总DQ( 99.84± 15 .72 )均显著大于高危对照组 ( 80 .99± 15 .0 4 ) (P <0 .0 1) ;但与正常对照组 ( 99.2 2± 13.39)比较 ,差异无显著性 (P >0 .0 5 ) ;高危干预组平均DQ <75的比例 ( 1/ 5 8)显著少于高危对照组 ( 8/ 4 2 ) ,差异有显著性 ( χ2 =8.72 8,P <0 .0 5 )。　结论　早期综合干预能促进高危新生儿的神经心理发育。     

Effect of apoptosis and reactive oxygen species production in human granulosa cells on oocyte fertilization and blastocyst development

Purpose: The aim was to establish the impact of human granulosa cell apoptosis and reactive oxygen species (ROS) production on fertilization competence of the oocyte, embryo developmental stage and implantation rate. Methods: Thirty women undergoing IVF-ET for tubal factor infertility were included; GnRH antagonists and gonadotrophins were used for ovarian stimulation. Granulosa cells were isolated from each aspirated follicle using gradient centrifugation. Apoptosis was studied by flow cytometry using annexin V and propidium iodide. ROS production was studied with hydroethidine staining and analyzed by flow cytometry. Results: There were no differences in characteristics of granulosa cells between the follicles with fertilized and non-fertilized oocytes. The analyzed characteristics of granulosa cells in corresponding follicles had no effect on embryo developmental stage on day 5. The percentage of ROS producing granulosa cells was lower in the follicles giving rise to blastocysts that resulted in implantation compared to those that did not (39.9% versus 69.9%, P = 0.031). Conclusions: Apoptosis and ROS production in granulosa cells have no significant impact on fertilization and do not correlate with the development of blastocysts. An increased percentage of ROS producing granulosa cells results in fewer oocytes retrieved and diminishes implantation rate.     

Reference values of reactive oxygen species in seminal ejaculates using chemiluminescence assay

PurposeA physiological balance exists between seminal reactive oxygen species (ROS) and antioxidant capacity. An overproduction of ROS which exceeds the seminal plasma antioxidant capacity results in oxidative stress (OS). The aim of the present study was to describe a detailed protocol to measure ROS in a diagnostic laboratory and revise our previous cutoff value of ROS in seminal ejaculates in a larger cohort of infertile men and controls with proven and unproven fertility.MethodsA total of 258 infertile men and 92 controls were enrolled in the study. Following initial semen analysis, ROS measurement in whole ejaculates was carried out using luminol-based chemiluminescence assay. Chemiluminescence was measured for 15 min with a Berthold luminometer. Results were expressed as relative light units (RLU/s/10⁶ sperm). The test’s specificity, sensitivity, and cutoff values were calculated using the receiver operating characteristic (ROC) curve.ResultsSignificantly higher ROS levels were seen in infertile men compared to controls (p < 0.001). The optimal cutoff value to differentiate between controls and infertile men was 102.2 RLU/s/10⁶ sperm. At this cutoff value, the test was 76.4% sensitive and 53.3% specific. The positive and negative predictive values of the test were 82.1% and 44.5%, respectively. A total of 76.4% infertile population was above this cutoff value compared to 46.7% of controls.ConclusionsThe luminol-based chemiluminescence assay can be used in routine diagnostic screening to test for male infertility diagnosis in a clinical setting. The current ROS cutoff value substantially distinguishes infertile from normal controls. Patients with elevated ROS must be evaluated for the underlying cause of ROS production.     

新生儿及其母亲骨营养状况的研究

目的 通过对产妇及其新生儿在分娩当天进行血25-(OH)D3、血钙和血磷浓度的测定以及在产后3 d内采用骨定量超声仪对母儿进行骨超声波速度(speed of sound,SOS)的测量来评价母儿的骨营养状况和两者的相关性.方法 32例足月分娩产妇在分娩当天测定血清25-(OH)D3、血钙和血磷浓度,对其分娩的新生儿在出生时留取脐血进行血25-(OH)D3、血钙和血磷浓度的测定.产妇在分娩后3 d内进行桡骨定量超声SOS值的测量,同时对新生儿也进行胫骨SOS值的测量.分析母儿骨SOS值之间的相关性.选取与本实验组孕妇同年龄段健康妇女39例作为对照组,进行桡骨SOS值的测量,比较产妇组与正常妇女组骨SOS值之间有无差异.结果 (1)新生儿脐血中25-(OH)D3的浓度(14.7±7.8)nmol/L平均为孕妇血25-(OH)D3浓度(30.3±10.2)nmol/L的37.3%,两者之间呈正相关(r=0.680,P=0.000);(2)新生儿脐血的血钙浓度(2.36±0.28)mmol/L和血磷浓度(1.57±0.76)mmol/L与孕妇的血钙(2.09±0.17)mmol/L和血磷浓度(1.04±0.28)mmol/L之间无相关性(r=0.146,P=0.467;r=0.148,P=0.445),新生儿脐血中的血钙浓度和血磷浓度显著高于其母血中的血钙和血磷浓度(t=4.35,P=0.000;t=10.58,P=0.000);(3)新生儿骨SOS值(3054±76)m/s与其母亲的骨SOS值(4170±241)m/s之间无相关性(r=-0.223,P=0.220);(4)新生儿脐血25-(OH)D3的浓度与其骨SOS值有显著相关(r=0.412,P=0.026);(5)正常妇女的骨SOS值(4258±100)m/s高于产妇组的骨SOS值(4170±241)m/s,两组比较差异有统计学意义(t=2.062,P=0.043).结论 胎儿维生素D的营养状况与母体维生素D的营养状况密切相关,维生素D的营养状况与胎儿的骨骼发育密切相关.上海地区在秋冬季有较多孕妇可能有维生素D缺乏,应加强对孕产妇骨营养状况的监测.     

血浆肾上腺髓质素前体在新生儿感染中的变化及其意义

目的 观察血浆肾上腺髓质素前体(pro-adrenomedullin,pro-ADM)浓度在新生儿感染中的变化,探讨其评估新生儿感染严重程度的价值. 方法 采用化学发光免疫检测定量法对我院2007年4月至12月间新生儿病房收治的356例新生儿(非感染160例,普通感染114例,重症感染82例)进行pro-ADM血浆水平测定,并同时检测降钙素原(procaleitonin,PCT)和C反应蛋白(C-reactive protein,CRP)水平.以受试者工作特征曲线计算曲线下面积得出pro-ADM诊断新生儿败血症的最佳临界值,以及敏感性和特异性,并与CRP的诊断效率相比较.组间差异比较采用方差分析和Wileoxon检验. 结果重症感染组pro-ADM为(2.079±1.195)nmol/L,较普通感染组和非感染组[1.025土0.421)nmol/L和(0.853±0.488)nmol/L]明显升高(P<0.01).感染是血浆pro-ADM水平变化的独立因素,且呈正相关(r=0.78,P<0.01).pro-ADM在新生儿败血症的诊断效率较CRP高,其敏感性为71.95%,特异性为87.23%.pro-ADM在新生儿重症感染危重组中水平[(2.498±1.140)nmol/L]较非危重组[(1.810±1.162)nmol/L]高,差异有统计学意义(t=2.63,P<0.05),而PCT水平在危重病例与非危重病例间差异无统计学意义. 结论 新生儿感染时pro-ADM水平升高,重症感染时尤为明显;pro-ADM对早期诊断新生儿重症感染及评估疾病严重程度具有潜在的临床应用价值.     

早产和足月新生儿血清瘦素与出生体重及胰岛素关系分析

目的研究早产和足月新生儿血清瘦素与出生体重及胰岛素关系,探讨在早产和足月新生儿中是否存在脂肪-胰岛素内分泌轴。方法共收集264例早产和足月新生儿,按胎龄进行分组,并进行出生测量,于生后第3天采血做餐前血糖、胰岛素及瘦素检查。结果足月儿血清瘦素浓度显著高于早产儿,瘦素浓度与胎龄的关系按非线性模式增加,胎龄34周以后,瘦素浓度增加明显加快。在>32周的新生儿中,血清瘦素浓度与出生体重及胰岛素呈正相关关系(r=0.240,0.227,P<0.05),在胎龄≥37周的新生儿中,瘦素不仅与出生体重及胰岛素呈正相关(r=0.198,0.253,P<0.05),还与胰岛素/血糖呈正相关(r=0.206,P<0.05),在<32周的新生儿中,未发现上述关系。结论胎龄>32周的新生儿体内可能已开始存在脂肪-胰岛素内分泌轴。