儿童肺炎克雷白杆菌肺炎临床特点及耐药性分析

目的 探讨儿童肺炎克雷白杆菌肺炎的临床特点及耐药情况,为临床合理应用抗生素提供依据.方法 采集2008年12月至2010年12月我院儿科住院的下呼吸道感染患儿的痰液用Bio Merieum Vitek 2微生物分析仪进行细菌鉴定为肺炎克雷白杆菌感染,共86例患儿纳入试验,分为医院内感染/定植株组(n=68)和医院外感染株组(n=18),记录患儿的临床信息,对分离的菌株进行药敏试验,并检测超广谱β-内酰胺酶(ESBLs).结果 儿童肺炎克雷白杆菌肺炎多发生于婴儿,且多有基础疾病,与普通肺炎临床表现区别不大.肺炎克雷白杆菌β-内酰胺酶的检出率很高(76.7%),医院内感染/定植株组共64例(94.1%,64/68)检出ESBLs阳性株,医院外感染株组共检出2株(11.1%,2/18),两组间ESBLs检出率差异有统计学意义(P＜0.01).医院内感染/定植株组耐药性显著高于医院外感染株组,前者仅对头孢替坦、哌拉西林/三唑巴坦、碳青霉烯类、阿米卡星及环丙沙星敏感,对青霉素类、头孢菌素类及单氨类抗生素高度耐药.医院内感染/定植株组患儿平均住院时间为(15.0±7.1)d,医院外感染株组为(8.2±3.8)d,两组间差异有统计学意义(P＜0.01).结论 肺炎克雷白杆菌肺炎患儿多有基础疾病,且多见于婴儿,临床表现不典型.ESBLs阳性肺炎克雷白杆菌的多重耐药问题相当严重,尤其是对四代头孢菌素耐药性的增加应引起我们的高度重视.对于医院内感染和医院外感染患儿在抗生素的选择上应区别对待.     

肺炎克雷白杆菌感染的表现与治疗

肺炎克雷白杆菌是一种常见的革兰阴性条件致病菌,在机体免疫力低下时,可引起呼吸道、泌尿道、消化道及皮肤软组织等多种部位感染,是导致社区获得性和(或)医院感染性肺炎、菌血症、尿路感染、肝脓肿的重要病原菌。最严重的是脓毒性休克,出现休克的患者病死率高。最常见的疾病是肺炎克雷白杆菌肺炎,儿童及老年人尤为突出。近年来,肺炎克雷白杆菌耐药率已显著升高。如何预防肺炎克雷白杆菌感染,早期诊断及有效治疗耐药菌株感染的病患已成了当务之急。     

产超广谱β-内酰胺酶肺炎克雷白杆菌的体外耐药分析

目的探讨儿童肺炎克雷白杆菌产超广谱肛内酰胺酶（ESBLs）的感染情况及耐药特点。方法2004年10月～2006年10月从住院患儿的痰、粪便、尿、血等标本中分离培养出338株肺炎克雷白杆菌，先用纸片扩散初筛法选出产ESBLs可疑菌株后，再用双纸片法确证为产ESBLs菌株。结果ESBLs肺炎克雷白杆菌占全部测试菌的25．4％，ESBLs菌株的耐药率显著高于非ESBLs菌株（P〈0．01）。结论早期检测ESBLs菌株，临床可参考药敏选用抗生素治疗此类细菌引起的感染。     

新生儿重症监护病房细菌感染及耐药性监测

目的 探讨新生儿重症监护病房细菌感染及其对抗生素的耐药情况.方法 对646株培养阳性菌株以VITEK全自动微生物分析仪进行菌株鉴定及药敏试验.结果 646株培养阳性标本中,革兰阴性菌380株,占58.8％,革兰阳性菌254株,占39.3％.革兰阴性杆菌以肺炎克雷白杆菌最常见,其次为大肠埃希菌;革兰阳性菌以金黄色葡萄球菌最常见.产ESBL阳性菌株73株,包括肺炎克雷白杆菌50株,大肠杆菌23株.常见革兰阴性细菌对氨苄西林、头孢曲松、头孢唑啉耐药率高,对头孢吡肟、头孢他啶、亚胺培南、哌拉西林/他唑巴坦的耐药率低.ESBL阳性肺炎克雷白杆菌及大肠埃希菌对氨苄西林、头孢菌素类耐药显著高于亚胺培南及哌拉西林/他唑巴坦(P＜0.01).常见革兰阳性细菌对青霉素耐药率高达74.6％～ 91.7％,耐甲氧西林金黄色葡萄球菌对氨苄西林/舒巴坦、红霉素、亚胺培南、苯唑西林、青霉素耐药率均高,达80％ ～ 100％,目前未发现耐万古霉素、利奈唑胺革兰阳性细菌.结论 我院新生儿重症监护病房细菌以肺炎克雷白杆菌、金黄色葡萄球菌、大肠埃希菌最常见,对常用抗生素的耐药现象需重视,尤其ESBL阳性细菌及耐甲氧西林金黄色葡萄球菌耐药现象更严重,应尽早根据药敏试验调整抗生素.     

多重耐药肺炎克雷白杆菌重症肺炎的危险因素及细菌耐药性分析

目的 探讨多重耐药肺炎克雷白杆菌重症肺炎的危险因素以及该菌对常用抗菌药物的耐药情况,为防止和减少多重耐药肺炎克雷白杆菌重症肺炎的发生以及合理使用抗生素提供参考依据.方法 采用病例对照研究,选择我院PICU 89例多重耐药肺炎克雷白杆菌重症肺炎患儿作为病例组,选择同期我院PICU 68例非多重耐药肺炎克雷白杆菌重症肺炎患儿作为对照组,对2组患儿的不合理使用抗生素（特别是三代头孢菌素）、住院时间、是否气管插管机械通气、机械通气时间、基础疾病（营养不良、先天性心脏病、遗传代谢病）共5个危险因素进行比较,并对89株多重耐药肺炎克雷白杆菌的药物敏感性进行分析。结果 病例组不合理使用抗生素（特别是三代头孢菌素）病例数（63例,占70.79％）多于对照组（27例,占39.70％）,差异有统计学意义（P＜0.01）;住院时间＞7d病例数（48例,占53.93％）多于对照组（12例,占17.65％）,差异有统计学意义（P＜0.01）;气管插管机械通气病例数（38例,占42.69％）多于对照组（16例,占23.53％）,差异有统计学意义（P＜0.05）;机械通气时间＞5d病例数（18例,占20.22％）多于对照组（5例,占7.35％）,差异有统计学意义（P＜0.05）;伴有基础疾病病例数（13例,占14.61％）多于对照组（2例,占2.94％）,差异有统计学意义（P＜0.05）。多重耐药肺炎克雷白杆菌对青霉素类、头孢菌素类、氨基糖苷类以及喹诺酮类抗生素均有较高的耐药率,而对碳青霉烯类抗生素仍保持较高的敏感率。结论 不合理使用抗生素（特别是三代头孢菌素）、住院时间长、气管插管机械通气以及机械通气时间长、原有基础疾病（营养不良、先天性心脏病、遗传代谢病）是多重耐药肺炎克雷白杆菌重症肺炎的重要危险因素;多重耐药肺炎克雷白杆菌对青霉素类、头孢菌素类、氨基糖苷类以及喹诺酮类抗生素均有较高的耐药性,但对碳青霉烯类抗生素仍有较高的敏感性;碳青霉烯类抗生素可以作为治疗多重耐药肺炎克雷白杆菌重症肺炎的首选抗菌药物。     

小儿急性下呼吸道感染细菌病原构成、变迁及耐药的临床研究

目的 对昆明地区急性下呼吸道感染(acute low respiratory infection,ALRI)患儿进行连续9年监测及临床研究,了解患儿细菌病原菌构成、变迁及对常用抗生素的耐药性.方法 对昆明市儿童医院2002年1月至2010年12月因ALRI住院的患儿痰液培养的致病菌株进行临床分析及研究,对分离菌株进行药敏试验.结果 病原菌构成情况:(1)病原菌总阳性率18.52％ (3006/16 229),其中革兰阴性杆菌占75.35％,革兰阳性球菌占20.23％,真菌占4.42％;病原菌前5位依次为大肠埃希菌、肺炎克雷白杆菌、肺炎链球菌、流感嗜血杆菌、阴沟肠杆菌.(2)监护病房ALRI病原菌以革兰阴性菌为主,主要为大肠埃希菌、肺炎克雷白杆菌;革兰阳性菌以金黄色葡萄球菌为主.普通病房革兰阴性菌中,流感嗜血杆菌取代大肠埃希菌,成为最常见的病原菌,革兰阳性菌以肺炎链球菌为主.病原菌的耐药情况:后4年与前5年比较,病原菌总体耐药情况呈上升趋势,部分达90％左右,并呈多重耐药状态;未发现对亚胺培南及万古霉素耐药的菌株;大肠埃希菌和肺炎克雷白杆菌产超广谱β-内酰胺酶菌株检出率呈上升趋势.结论 昆明地区9年间小儿ALRI细菌病原菌以革兰阴性杆菌为主,其中大肠埃希菌为首位;不同病房病原构成、变迁均不同;病原菌总体耐药情况呈上升趋势.     

新生儿重症监护室中泌尿道感染的流行病学和病原学分析

目的 探讨新生儿重症监护室(NICU)中泌尿道感染(UTI)的流行性和病原学特征,为临床合理选用抗生素提供依据.方法 回顾性分析2005年1月至2006年12月间入住圣路易斯华盛顿大学圣路易斯儿童医院NICU的所有新生儿的住院资料.结果 NICU的住院患儿中UTI的发生率为6.5%,最常见的病原菌是革兰阴性菌(63.7%),其中前3位是大肠埃希菌、肺炎克雷白杆菌和阴沟肠杆菌;革兰阳性球菌占24.8%,主要是肠球菌和凝固酶阴性葡萄球菌(CNS).大肠埃希菌、肺炎克雷白杆菌和阴沟肠杆菌对氨苄青霉素均高度耐药,而对庆大霉素和头孢吡肟则高度敏感.革兰阴性菌中非大肠埃希菌菌属的耐药性高于大肠埃希菌.革兰阳性菌中,肠球菌对氨苄青霉素和万古霉素完全敏感;CNS对青霉素、苯唑青霉素和头孢唑啉完全耐药,对万古霉素和利福平则100%敏感.结论 NICU中泌尿系统感染的病原菌以革兰阴性杆菌最常见.青霉素和氨苄青霉素总体耐药现象严重,已不适合作为一线用药.故有必要在使用抗生素前及时完善病原学检测和药物敏感试验以指导临床合理用药.     

珠海市四家医院儿童产ESBLS肺炎克雷白菌和大肠埃希菌感染的流行状况及耐药特征

目的 了解珠海市四家医院儿童产超广谱β-内酰胺酶(ESBLS)肺炎克雷白菌和大肠埃希菌感染的流行状况及耐药特征.方法 2005年1月至2006年12月随机抽取珠海市人民医院、广东省中医院珠海医院、珠海市第二人民医院、珠海市妇幼保健院儿科临床标本,采用全自动细菌分析仪分离肺炎克雷白菌、大肠埃希菌菌株,并作药敏试验.结果 208份临床标本,获得肺炎克雷白菌112株,大肠埃希菌96株,分别有25.89%、34.37%的菌株产ESBLS.产ESBLS菌株对头孢噻肟、头孢吡肟、头孢他啶、氨苄西林的耐药性为100%,与不产ESBLS菌株比较,差异有显著性.尚未发现对头孢噻肟/克拉维酸、头孢他啶/克拉维酸、亚胺培南耐药菌株.结论 产ESBLS菌株耐药性严重,临床医生应加强病原学研究,合理使用抗生素,减少细菌耐药性的产生.     

230例婴幼儿肺炎克雷白杆菌肺炎临床特点与抗菌治疗研究

目的 探讨小儿肺炎克雷白杆菌肺炎的临床特点及应用抗生素的耐药性和敏感性.方法通过对230例小儿肺炎克雷白杆菌肺炎的临床分析,探讨小儿此类肺炎的临床特点,并对肺炎克雷白杆菌的耐药性和敏感性进行分析.结果(1)230例均为3岁以内的婴幼儿,以1～3月龄发病最多.(2)院内感染占较大比例(44.8％,103/230).(3)患儿的临床特征主要有气促,面色发绀,喉头痰鸣,肺部可闻及广泛的湿哕音、痰鸣音和哮鸣音.(4)辅助检查:白细胞升高占33.9％(78/230),正常占53.9％(124/230),降低12.2％(28/230).201例X线胸片提示大叶性肺炎25例,小叶性肺炎112例,肺间质改变和肺纹理增粗52例.(5)大部分菌株产生超广谱β内酰胺酶(56.6％,129/228).(6)最敏感的抗生素为亚胺培南-西司他丁钠、环丙沙星、哌拉西林/他唑巴坦等.225例患儿临床治疗有效,最常使用的抗生素为哌拉西林/他唑巴坦.结论肺炎克雷白杆菌肺炎好发于小婴儿,起病急,病情重;应对肺炎克雷白杆菌进行耐药性监测,根据药物敏感性试验合理选择抗生素,绝大多数患儿治疗有效,预后较好.     

181例患儿深部痰培养细菌分布与耐药性分析

目的 了解我院儿童肺部感染病原菌分布及耐药性,指导早期经验性抗生素应用.方法 统计分析了2005年1月至2007年12月我院儿科181例住院患儿深部痰细菌培养结果.结果 符合条件的痰标本共分离细菌269株,其中革兰阴性菌占69.14%(186株),主要是大肠埃希菌、鲍曼不动杆菌、铜绿假单胞菌、肺炎克雷白杆菌,其对β内酰胺类抗生素有较高的耐药性,产超广谱β-内酰胺酶(ESBLs)的大肠埃希杆菌和肺炎克雷白杆菌的耐药性尤为突出,但对含β内酰胺酶抑制剂的头孢菌素和亚胺培南仍较敏感.革兰阳性菌占30.86%(83株),粪肠球菌、表皮葡萄球菌与金黄色葡萄球菌占革兰阳性球菌的前三位,除对万古霉素仍敏感外,金黄色葡萄球菌对头孢菌素以及氨基苷类抗生素的耐药率很高.结论 儿童深部痰培养分离菌株以革兰阴性菌为主,其耐药性较强,特别是产ESBLs的菌株对β内酰胺类抗生素的耐药性尤为突出.革兰阳性菌以葡萄球菌、粪肠球菌为主,其耐药率均较高.     

Allergic factors associated with the development of asthma and the influence of cetirizine in a double-blind, randomised, placebo-controlled trial: First results of ETA®

There is a common progression known as the allergic march from atopic dermatitis to allergic asthma. Cetirizine has several antiallergic properties that suggest a potential effect on the development of airway inflammation and asthma in infants with atopic dermatitis. Methods. Over a two year period, 817 infants aged one to two years who suffered from atopic dermatitis and with a history of atopic disease in a parent or sibling were included in the ETAC^® (Early Treatment of the Atopic Child) trial, a multi-country, double-blind, randomised, placebo-controlled trial. The infants were treated for 18 months with either cetirizine (0.25mg/ kg b.i.d.) or placebo. The number of infants who developed asthma was compared between the two groups. Clinical and biological assessments including analysis of total and specific IgE antibodies were performed. Results. In the placebo group, the relative risk (RR) for developing asthma was elevated in patients with a raised level of total IgE (≥ 30 kU/I) or specific IgE (≥ 0.35 kUA/I) for grass pollen, house dust mite or cat dander (RR between 1.4 and 1.7). Compared to placebo, cetirizine significantly reduced the incidence of asthma for patients sensitised to grass pollen (RR = 0.5) or to house dust mite (RR = 0.6). However, in the population that included all infants with normal and elevated total or specific IgE (intention-to-treat - ITT), there was no difference between the numbers of infants developing asthma while receiving cetirizine or placebo. The adverse events profile was similar in the two treatment groups. Discussion. Raised total IgE level and raised specific IgE levels to grass pollen, house dust mite or cat dander were predictive of subsequent asthma. Cetirizine halved the number of patients developing asthma in the subgroups sensitised to grass pollen or house dust mite (i.e. 20% of the study population). In view of the proven safety of the drug, we propose this treatment as a primary pharmacological intervention strategy to prevent the development of asthma in specifically sensitised infants with atopic dermatitis.     

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孤独症谱系障碍(autistic-spectrum disorders,ASDs)近年来患病率逐年攀升至1%左右,其症状往往伴随终生,成为严重威胁儿童健康和发展的神经发育性疾患;注意缺陷多动障碍(attention deficit hyperactivity disorder,ADHD)是儿童期最常见的精神障碍,国内报道患病率为4.13%～5.83%,其症状可延续至青少年期,甚至到成年期[1]。这两类精神障碍在成年期的临床表现、共患病、治疗策略和预后与儿童期有哪些不同呢?本文通过回顾相     

EXCITING NEW TREATMENT APPROACHES FOR PATHYPHYSIOLOGIC MECHANISMS OF SICKLE CELL DISEASE

During the past several decades, our understanding of the complex pathophysiology of vasoocclusion associated with sickle cell disease has improved greatly. Interaction of genes, hemoglobin molecules, red cell membrane and metabolic changes, cell-cell interactions and cell-plasma interactions, red cell adhesion to vascular endothelium, activation of coagulation, and vascular reactivity play a role in vaso occlusion. Penicillin prophylaxis of pneumococcal infections and appropriate use of blood transfusions and other supportive measures improved survival of sickle cell patients. Hydroxyurea made a major impact on sickle cell therapy when it was shown to decrease acute painful episodes, acute chest syndrome, and the need for blood transfusion in adults. Significant experience in the use of hydroxyurea has been accumulated in older children. The benefits and risks of hydroxyurea for younger children and long-term risks in all patients will be evaluated in future investigations. Other promising therapies include butyrate compounds, clotrimazole, magnesium supplementation, poloxamer 188, antiadhesion agents, anticoagulant approaches, and nitric oxide. Hemopoietic transplantation remains the only curative therapy. However, several transgenic mouse models are available for studies of gene therapy or other treatment approaches on biochemical, cellular, and pathologic effects of mutant genes.     

Infiltrations of Epstein-Barr virus-carrying cells in granular lymphocyte-proliferative disorders corresponding to chronic active Epstein-Barr virus infection

A 21-year-old man with granular lymphocyte-proliferative disorders (GLPD) associated with chronic active Epstein-Barr virus (EBV) infection is described. Chromosomal analyses revealed several clonal abnormalities and two of them were mainly repetitious. High copy numbers of monoclonal EBV genome were also detected in the proliferative large granular lymphocytes (LGLs), indicating the monoclonal expansion of EBV-infected LGLs. The patient had an indolent course for several years, and there was no evidence of infiltrations of his bone marrow until the end stage. At autopsy, microscopic studies revealed marked infiltrations of LGL in the liver and spleen, and the infiltrating cells were NK-cell immunophenotype. The infiltrated LGLs showed latency I.     

LUTEINIZING HORMONE RECEPTOR MUTATIONS IN DISORDERS OF SEXUAL DEVELOPMENT AND CANCER

Human male sexual development is regulated by chorionic gonadotropin (CG) and luteinizing hormone (LH). Aberrant sexual development caused by both activating and inactivating mutations of the human luteinizing hormone receptor (LHR) have been described. All known activating mutations of the LHR are missense mutations caused by single base substitution. The most common activating mutation is the replacement of Asp-578 by Gly due to the substitution of A by G at nucleotide position 1733. All activating mutations are present in exon 11 which encodes the transmembrane domain of the receptor. Constitutive activity of the LHR causes LH releasing hormone-independent precocious puberty in boys and the autosomal dominant disorder familial male-limited precocious puberty (FMPP). Both germline and somatic activating mutations of the LHR have been found in patients with testicular tumors. Activating mutations have no effect on females. The molecular genetics of the inactivating mutations of the LHR are more variable and include single base substitution, partial gene deletion, and insertion. These mutations are not localized and are present in both the extracellular and transmembrane domain of the receptor. Inactivation of the LHR gives rise to the autosomal recessive disorder Leydig cell hypoplasia (LCH) and male hypogonadism or male pseudohermaphroditism. Severity of the clinical phenotype in LCH patients correlates with the amount of residual activity of the mutated receptor. Females are less affected by inactivating mutation of the LHR. Symptoms caused by homozygous inactivating mutation of the LHR include polycystic ovaries and primary amenorrhea.     

Resurgence of measles in Singapore: profile of hospital cases

OBJECTIVE: To ascertain the profile of cases of measles seen at a general hospital during a recent outbreak that occurred despite a measles vaccination program. METHODOLOGY: A retrospective study from January 1991 to March 1998. All patients with measles (ICD code 055. 9) seen at the emergency unit or as inpatients were included. RESULTS: There were 87 cases identified. The diagnosis was clinical in all and proven serologically in 71%. Eighty-five per cent of the cases occurred between January 1997 and March 1998. There was a bi-modal age distribution with peaks in the very young (相似文献   

Personality profiles and heart rate variability (vagal tone) in children with recurrent abdominal pain

The aim of the study was to explore psychological factors and autonomic activity in children with recurrent abdominal pain and to compare them with those in a control group of healthy children. The Personality Inventory for Children was used for assessment of developmental, emotional and psychosocial factors in 25 children with recurrent abdominal pain (age, 7-15 y). Parasympathetic and sympathetic functions in these children and in 23 healthy control subjects (age, 7-13 y) were also investigated, non-invasively using a computerized polygraph. Vagal tone (parasympathetic function) was indexed by calculation of respiratory sinus arrhythmia in beats/min. Skin conductance (sympathetic function) was recorded by the constant current method. On the Personality Inventory for Children, 16 patients had high scores on somatic concern. Several patients had scores in the clinical range for depression, withdrawal and anxiety, but the mean scores for these personality profile scales were well within the normal range of healthy children. Interestingly, there was a spike on the L (Lie)-scale for most of the patients and 15 patients had scores above or close to the clinical cut-off value. As compared with the scores in healthy children, vagal tone and sympathetic tone were normal. Conclusion: Many children with recurrent abdominal pain have scores in the clinical range for depression, withdrawal, anxiety and L-scale indicating coping problems, denial and a trend towards somatic concern that may contribute to the evolution of abdominal pain. Autonomic nerve activity was not disturbed in these children.     

Overcoming surfactant inhibition with polymers

Inhibition of the function of pulmonary surfactant in the alveolar space is an important element of the pathophysiology of many lung diseases, including meconium aspiration syndrome, pneumonia and acute respiratory distress syndrome. The known mechanisms by which surfactant dysfunction occurs are (a) competitive inhibition of phospholipid entry into the surface monolayer (e.g. by plasma proteins), and (b) infiltration and destabilization of the surface film by extraneous lipids (e.g. meconium-derived free fatty acids). Recent data suggest that addition of non-ionic polymers such as dextran and polyethylene glycol to surfactant mixtures may significantly improve resistance to inhibition. Polymers have been found to neutralize the effects of several different inhibitors, and can produce near-complete restoration of surfactant function. The anti-inhibitory properties of polymers, and their possible role as an adjunct to surfactant therapy, deserve further exploration.     

Understanding infant formula

The World Health organisation recommends breast feeding infants for the first six months of life. When this breast feeding does not occur either through parental choice or medical need, infant formulas will be required. There is a bewildering array of formulas on the UK market for many different requirements. When faced with an unsettled infant many parents (and healthcare professionals) will experiment with the infant formula available and then attend the paediatric clinic looking for help and advice. It is therefore essential that paediatricians understand what milks are available and what the key differences between different products are. This review attempts to provide a simple guide through many of the formulations currently available in the UK; and offers advice for the dietary management of the child with extra calorie requirements, infants with cow's milk protein allergy, gastro oesophageal reflux disease, apparent unresolved hunger and infantile colic. Whatever the underlying condition, there is likely to be an infant formula that is suitable in this generation of ever expanding formulations.