儿童社区获得性肺炎

社区获得性肺炎 (communityacquiredpneumo nia ,CAP)是指既往健康儿童院外感染所致的肺炎。CAP是全世界范围内威胁儿童健康的一种常见且后果严重的感染。在北美和欧洲 ,5岁以下儿童中的肺炎年发病率为 3 4 %～ 4 % ,5～ 14岁儿童肺炎年发病率为 1 6 %～ 2 2 %。发展中国家儿童肺炎更为常见 ,病情更加严重 ,是儿童的最大杀手。1　病因许多微生物都可引起儿童期肺炎 :病毒有呼吸道合胞病毒 ,流感病毒A、B ,副流感病毒 1、2、3,腺病毒 ,鼻病毒 ,麻疹病毒 ;肺炎支原体 ;沙眼衣原体 ;肺炎衣原体 ;肺炎链球菌 ,金葡菌 ,b型流感嗜血杆菌及未…     

Viridans streptococci causing community acquired pneumonia.

In children under 5 years of age, presenting to the paediatric emergency room with clinical and radiological findings of pneumonia, viridans streptococci were isolated in 10/33 positive haemocultures as the only microorganism. Viridans streptococci should therefore not be ruled out as a cause of pneumonia.     

Community acquired pneumonia--a prospective UK study.

BACKGROUND: There are few data on paediatric community acquired pneumonia (PCAP) in the UK. AIMS: To investigate the aetiology and most useful diagnostic tests for PCAP in the north east of England. METHODS: A prospective study of hospital admissions with a diagnosis of PCAP. RESULTS: A pathogen was isolated from 60% (81/136) of cases, and considered a definite or probable cause of their pneumonia in 51% (70/136). Fifty (37%) had a virus implicated (65% respiratory syncytial virus) and 19 (14%) a bacterium (7% group A streptococcus, 4% Streptococcus pneumoniae), with one mixed infection. Of a subgroup (51 patients) in whom serum antipneumolysin antibody testing was performed, 6% had evidence of pneumococcal infection, and all were under 2 years old. The best diagnostic yield was from paired serology (34%, 31/87), followed by viral immunofluorescence (33%, 32/98). CONCLUSION: Viral infection accounted for 71% of the cases diagnosed. Group A streptococcus was the most common bacterial infective agent, with a low incidence of both Mycoplasma pneumoniae and S pneumoniae. Pneumococcal pneumonia was the most common bacterial cause of pneumonia in children under 2 years but not in older children. Inflammatory markers and chest x ray features did not differentiate viral from bacterial pneumonia; serology and viral immunofluorescence were the most useful diagnostic tests.     

Epidemiology of community acquired pneumonia

Despite efforts in prevention worldwide including recent advances in vaccine therapy, childhood community acquired pneumonia (CAP) remains a major cause of morbidity and mortality both in the developed and the developing world.Traditionally, qualifying the aetiology of CAP proved to be fraught with challenges particularly due to low yields from blood and sputum specimens. In recent years however, new advances in techniques such as enzyme-linked immunosorbent assay and polymerase chain reaction have dramatically improved detection rates of both bacteria and viruses. In addition to qualifying the true burden of disease by known organisms such as Streptococcus pneumoniae it has led to the identification of organisms such as human bocavirus which have not previously been associated with CAP.This article aims to provide a brief update to the clinician on the current epidemiology of CAP in this post-vaccination era. It is based on a combination of recommendations from existing clinical practice guidelines, recent systematic reviews and the current literature.     

Chlamydia sp. in hospitalised children with community acquired pneumonia

Our aim was to document the prevalence of chlamydial infection in children less than five years of age with Community Acquired Pneumonia (CAP). Seventy three children, 1 month to 5 years of age, hospitalized with CAP were enrolled over a period of one year. Microimmunofluorescence (MIF) was done to detect IgM antibodies against Chlamydia sp. in sera of all patients; PCR was performed to detect C. pneumoniae DNA in nasopharyngeal aspirates. The prevalence of Chlamydia species infection in CAP in children < 5 years of age was 5.5% (4/73). Two cases were positive for C. trachomatis antibodies; one case was positive for C. pneumoniae antibodies and one case was positive for C. pneumoniae DNA. Chlamydia sp. have an important role in CAP in children < 5 years and for early diagnosis of infection, use of more than one method i.e. PCR and serology both is advisable.     

A case-control study of SARS versus community acquired pneumonia.

The clinical, laboratory, and radiological features at presentation of 16 children (<12 years) with severe acute respiratory syndrome (SARS) and pneumonia were compared with 32 age matched patients with community acquired pneumonia for determination of predictive factors that could allow early differentiation of the two conditions. A definitive contact history was the most important predictor for SARS. Raised serum lactate dehydrogenase concentration in the presence of low neutrophil count and serum creatine phosphokinase level at presentation also indicated an increased likelihood of SARS-coronavirus infection in young children.     

Viridans streptococci causing community acquired pneumonia

In children under 5 years of age, presenting to the paediatric emergency room with clinical and radiological findings of pneumonia, viridans streptococci were isolated in 10/33 positive haemocultures as the only microorganism. Viridans streptococci should therefore not be ruled out as a cause of pneumonia.     

Procalcitonin in children admitted to hospital with community acquired pneumonia.

AIMS: To assess the sensitivity, specificity, and predictive value of procalcitonin (PCT) in differentiating bacterial and viral causes of pneumonia. METHODS: A total of 72 children with community acquired pneumonia were studied. Ten had positive blood culture for Streptococcus pneumoniae and 15 had bacterial pneumonia according to sputum analysis (S pneumoniae in 15, Haemophilus influenzae b in one). Ten patients had Mycoplasma pneumoniae infection and 37 were infected with viruses, eight of whom had viral infection plus bacterial coinfection. PCT concentration was compared to C reactive protein (CRP) concentration and leucocyte count, and, if samples were available, interleukin 6 (IL-6) concentration. RESULTS: PCT concentration was greater than 2 microg/l in all 10 patients with blood culture positive for S pneumoniae; in eight of these, CRP concentration was above 60 mg/l. PCT concentration was greater than 1 microg/l in 86% of patients with bacterial infection (including Mycoplasma and bacterial superinfection of viral pneumonia). A CRP concentration of 20 mg/l had a similar sensitivity but a much lower specificity than PCT (40% v 86%) for discriminating between bacterial and viral causes of pneumonia. PCT concentration was significantly higher in cases of bacterial pneumonia with positive blood culture whereas CRP concentration was not. Specificity and sensitivity were lower for leucocyte count and IL-6 concentration. CONCLUSIONS: PCT concentration, with a threshold of 1 microg/l is more sensitive and specific and has greater positive and negative predictive values than CRP, IL-6, or white blood cell count for differentiating bacterial and viral causes of community pneumonia in untreated children admitted to hospital as emergency cases.     

Streptococcus pneumoniae and Mycoplasma pneumoniae coinfection in community acquired pneumonia.

The characteristics of nine children with community acquired pneumonia with evidence of Streptococcus pneumoniae and Mycoplasma pneumoniae coinfection are described.     

小儿社区获得性肺炎的管理

肺炎是严重威胁我国儿童健康和生命的四大常见病之一 ,中华医学会儿科学分会呼吸学组和中华儿科杂志编委会在世纪之交制定了“小儿急性呼吸道感染抗生素合理使用指南 (试行 )” ,肺炎在此指南的下部分[1] 中占了相当篇幅。社区获得性肺炎 (ｃｏｍｍｕｎｉｔｙａｃｑｕｉｒｅｄｐｎｅｕｍｏｎｉａ ,ＣＡＰ)是小儿肺炎的主体 ,本文就ＣＡＰ定义、病原学、抗生素合理使用原则、抗生素选择方案、肺炎链球菌耐药时代ＣＡＰ管理作一概述。1　社区获得性肺炎定义我们习惯将小儿肺炎按其病理、病原和病程进行分类 ,但从肺炎病原学和抗生素合理使用角…     

小儿院内获得性肺炎病原学及临床分析

目的：了解小儿院内获得性肺炎(HAP)病原学、药敏、临床特点及易感因素，总结诊断与治疗经验。方法：对170例HAP患儿的临床特点、菌种分布、药敏及转归进行回顾性分析。结果：①170例HAP患儿，小于1岁占73.5%，免疫功能低下占65.3%。原发基础疾病占 74.7%，ICU患儿占68.2%；②体温为38℃者占39.4%，未梢血WBC≥12.0×104/L者占36.4%；③170例HAP检出细菌215株，以革兰阴性杆菌为主共161株，占呼吸道感染菌的74.9%。前4位细菌分别为大肠杆菌、铜绿假单胞菌、肺炎克雷伯杆菌及阴沟肠杆菌。39例HAP患儿的124株的杆菌中检出43株产ESBLs菌(34.7%)。有30例两种菌混合感染，以铜绿假单胞菌、真菌、肺炎克雷伯菌、大肠杆菌为主；④大多数革兰阴性杆菌对一、二代头孢及多数三代头孢均有较高的耐药性，对亚安培南、舒普深敏感性较高。革兰阳性球菌对青霉素、苯唑青霉素及红霉素耐药率高，葡萄球菌、链球菌对万古霉素未产生耐药性菌株，肠球菌对万古霉素100%耐药；⑤治疗初按经验性选药，待痰培养结果选用敏感抗生素，总有效率 85.9%，预后不良(危重退院、死亡)14.1%；⑥影响预后因素主要与原发病、机体免疫力、细菌种类及数量有关。结论：小儿HAP高危因素为：①婴儿；②免疫功能低下；③原发严重基础疾病；④住ICU病人； 菘股厥褂貌坏保虎藁肪骋蛩丶耙轿袢嗽狈婪兑?识不强。小儿HAP临床表现多不典型，需及时做病原学监测及药敏试验。小儿HAP以革兰阴性杆菌感染为主，多数对一、二代头孢耐药，先锋必/舒巴坦及碳青霉烯类敏感性较高，抗感染同时还需提高免疫力、营养支持及调节内环境紊乱。     

Community acquired pneumonia--a prospective UK study

BACKGROUND—There are few data on paediatric community acquired pneumonia (PCAP) in the UK.AIMS—To investigate the aetiology and most useful diagnostic tests for PCAP in the north east of England.METHODS—A prospective study of hospital admissions with a diagnosis of PCAP.RESULTS—A pathogen was isolated from 60% (81/136) of cases, and considered a definite or probable cause of their pneumonia in 51% (70/136). Fifty (37%) had a virus implicated (65% respiratory syncytial virus) and 19 (14%) a bacterium (7% group A streptococcus, 4% Streptococcus pneumoniae), with one mixed infection. Of a subgroup (51 patients) in whom serum antipneumolysin antibody testing was performed, 6% had evidence of pneumococcal infection, and all were under 2 years old. The best diagnostic yield was from paired serology (34%, 31/87), followed by viral immunofluorescence (33%, 32/98).CONCLUSION—Viral infection accounted for 71% of the cases diagnosed. Group A streptococcus was the most common bacterial infective agent, with a low incidence of both Mycoplasma pneumoniae and S pneumoniae. Pneumococcal pneumonia was the most common bacterial cause of pneumonia in children under 2 years but not in older children. Inflammatory markers and chest x ray features did not differentiate viral from bacterial pneumonia; serology and viral immunofluorescence were the most useful diagnostic tests.     

儿童院内及社区获得性肺炎病原菌和药敏试验及分析

目的　了解住院肺炎患儿病原菌分布、药敏情况及临床特点。方法　无菌操作吸取患儿鼻咽深部分泌物或气管插管内合格痰标本 ,接种于 5 %羊血琼脂平皿和巧克力平皿培养 ,用最低抑菌浓度 (MIC)法做药敏试验。结果　院内获得性肺炎 (HAP)组及行气管插管治疗的社区获得性肺炎 (CAP Ⅰ )组病原菌以革兰阴性 (G-)菌为主 ,并以铜绿假单胞菌居首位 (2 5 % ) ;未行气管插管治疗的社区获得性肺炎 (CAP Ⅱ )组革兰阳性 (G+ )球菌相对增多 ,并以肺炎链球菌和表皮葡萄球菌为主 (均占 38 2 % ) ,4 6 2 %的肺炎链球菌分离自 1～ 5岁儿童 ,84 6 %的表皮葡萄球菌分离自 6个月以下婴儿。各种G-菌对环丙沙星较敏感 (总敏感率 77 2 % ) ,而对其他多种抗生素耐药率较高 ;肺炎链球菌对青霉素、氨苄青霉素和万古霉素的敏感率均为 84 6 % ;表皮葡萄球菌对万古霉素 10 0 %敏感 ,对头孢三嗪和阿莫西林 /棒酸的敏感率分别为 76 9%和 6 9 2 % ,对青霉素 10 0 %耐药。HAP组多数预后不佳 ,病死率较高 (8 7% ) ;CAP Ⅰ组 17例重症肺炎中 ,1～ 3个月婴儿 11例 (6 4 7% ) ,其中 2例(18 2 % )死亡。结论　近 5年住院分离的多数病原菌对多种常用抗生素普遍耐药 ;肺炎链球菌感染时仍可考虑首选青霉素治疗 ,但应警惕耐青霉素肺炎链球菌的     

Cytomegalovirus and Pneumocystis carinii pneumonia in children with acquired immunodeficiency syndrome.

To ascertain the effect of cytomegalovirus (CMV) infection on the course of Pneumocystis carinii pneumonia (PCP) in children with acquired immunodeficiency syndrome (AIDS), we reviewed the charts of all children with AIDS who also had a lung biopsy specimen or a bronchoalveolar lavage specimen cultured for CMV at the time PCP was diagnosed. The data indicate that children with AIDS and PCP whose cultures are positive for CMV do not have a poorer prognosis during a first episode of PCP compared with children whose cultures are negative for CMV.     

Rationalised prescribing for community acquired pneumonia: a closed loop audit.

AIMS: To audit the management of community acquired pneumonia before and after the introduction of a protocol. To determine the aetiology of pneumonia using routine investigations and polymerase chain reaction (PCR). METHODS: Retrospective and prospective audit following the introduction of a management protocol. Prospective cases were investigated routinely and with PCR on blood and nasopharyngeal aspirate. RESULTS: There was a significant increase in rational prescribing following introduction of the protocol with 75% of children receiving intravenous penicillin or erythromycin compared with 26% beforehand. Of 89 children in the prospective group, 51 microbiological diagnoses were achieved in 48 children. Seven children had Streptococcus pneumoniae infection, 14 had Mycoplasma infection, six had pertussis, and one had Chlamydia pneumoniae infection. Twenty three children had a viral cause of which respiratory syncytial virus was commonest. CONCLUSIONS: Introduction of the protocol led to improved prescribing. PCR increased the diagnostic yield and the results support the management protocol.     

儿童社区获得性肺炎病原微生物分布研究

了解本院儿童社区获得性肺炎(CAP)病原微生物分布规律。方法：对入选的1 167例年龄在28 d至8岁间的CAP患儿,于入院4 h内分别采集呼吸道分泌物和静脉血进行多病原联合检测。呼吸道分泌物用于细菌培养,并用实时聚合酶链反应法（RT-PCR）检测肺炎支原体和沙眼衣原体;静脉血用酶联免疫吸附法（ELISA）检测呼吸道合胞病毒和腺病毒。结果：在1 167例CAP患儿中,呼吸道分泌物培养出细菌308株,其中革兰阳性菌占53.6%,革兰阴性菌占46.4%。前5位细菌分别为：肺炎链球菌(35.1%),大肠埃希菌(11.7%),金黄色葡萄球菌（8.8%）,肺炎克雷伯菌（6.5%）,卡他莫拉菌（5.8%）。产酶菌株在前5位细菌中占30.1%。非细菌病原体检出率为24.1%（281/1 167）,其中呼吸道合胞病毒的感染率最高,为19.3%（225/1 167）。呼吸道合胞病毒与肺炎链球菌的混合感染率最常见（35.2%）。多数病原微生物在1岁以下患儿中的感染率高于1岁以上患儿。结论：肺炎链球菌与呼吸道合胞病毒为本院儿童CAP的主要病原体;多数病原微生物在1岁以下患儿中的感染率高于1岁以上患儿。［中国当代儿科杂志,2010,12（3）：184-187］