新生儿脓毒症临床诊断标准评估

目的 通过分析新生儿脓毒症的临床特点,寻找其更实用的诊断标准.方法 选择2008年6月- 2009年6月因疑诊脓毒症入住本院的285例新生儿,对其中87例确诊脓毒症和160例非脓毒症新生儿的临床资料进行回顾性研究.采用x2检验和Logistic回归分析筛选与脓毒症相关的临床指标,所有阳性指标的总和计算非权重临床评分(UWCS),而每个指标评分的总和为权重临床评分(WCS).结果 与新生儿脓毒症显著相关的5个临床指标分别为脓毒症临床表现(OR=2.308,95％ CI=1.054 ～5.098)、未成熟与总中性粒细胞比(I/T)(OR=3.414,95％ CI =0.527 ～22.110)、CRP(OR =4.312,95％ CI=1.497 ～ 12.420)、病理性黄疸( OR=10.301,95％CI=4.684 ～ 22.654)、心率(OR=18.837,95％ CI=1.968 ～ 180.292) (Pa＜0.05).WCS和UWCS诊断标准ROC曲线下的面积分别是0.845(95％ CI=0.791～0.900)和0.794(95％ CI=0.731 ～0.856),二者差异无统计学意义(P=0.085).现行新生儿脓毒症临床诊断标准、WCS标准最佳诊断界点(总WCS值=12或15)和UWCS标准最佳诊断界点(总UWCS值=2)的Youden指数分别为0.235、0.604和0.401.结论 新生儿脓毒症显著相关的5个临床指标组成的WCS标准最佳诊断界点(总WCS值=12或15)和UWCS标准最佳诊断界点(总UWCS值=2)的诊断准确度,均高于现行临床诊断标准.但其是否能应用于临床诊断,尚需大样本实验研究证明其可行性.     

宫内感染与新生儿肺疾病

宫内感染和新生儿肺疾病如脓毒症/肺炎、呼吸窘迫综合征、支气管肺发育不良存在一定关系.宫内感染增加新生儿感染风险,可能发生脓毒症/肺炎;也增加了支气管肺发育不良发生率,但可能降低呼吸窘迫综合征发生率和严重性.近年来,各种动物实验研究有助于解释产前炎症对胎儿肺成熟、肺发育的影响.宫内感染可导致新生儿肺不良结局,但远期影响有待进一步观察.     

超声心输出量监护仪监测脓毒症新生儿心功能的研究

目的 使用便携式超声心输出量监护仪(ultrasonic cardiac output monitor,USCOM)监测脓毒症新生儿的心功能变化.方法 使用USCOM测量32例轻度脓毒症新生儿、19例重度脓毒症新生儿及33例健康新生儿(对照组)心功能相关指标,比较3组心功能差异及所有脓毒症新生儿给予改善心功能治疗前后心功能变化的差异.结果 轻度脓毒症组、重度脓毒症组与对照组相比,心率、外周血管阻力高于对照组,心脏指数、心输出量、每搏输出量、主动脉峰流速低于对照组,差异有统计学意义(P<0.05).重度脓毒症组患儿心脏指数、心输出量、每搏输出量低于轻度脓毒症组患儿,差异有统计学意义(P<0.05).所有脓毒症患儿改善心功能治疗后心功能相关指标较治疗前改善,差异有统计学意义(P<0.05).结论 脓毒症新生儿存在早期心功能变化,使用USCOM可快速、简便、动态了解脓毒症新生儿的心功能及整体循环状态,为治疗及评估病情提供依据.     

Ⅲ级新生儿病房643例早产儿临床流行病学现状分析

目的 探讨近年来Ⅲ级新生儿病房早产儿临床流行病学特点.方法 对我科2005年2月至2006年2月住院的643例早产儿的临床资料进行回顾性分析.结果 住院新生儿中早产儿占33.6%.早产多数有明确的原因,以胎膜早破、妊高症、多胎妊娠为主要原因.402例(62.5%)早产儿存在一种或多种并发症,主要为早产儿脑损伤、脓毒症、湿肺、肺炎、呼吸窘迫综合征、呼吸暂停、高胆红素血症.死亡的主要原因是呼吸窘迫综合征、脓毒症、肺出血、新生儿持续肺动脉高压.胎龄愈小、出生体重愈低,病死率愈高(P<0.05).结论 Ⅲ级新生儿病房早产儿发生的常见原因以及影响早产儿转归的因素明确,应加强围生期保健和监护,降低早产儿出生率,防止院内感染,降低早产儿病死率,改善预后.     

新生儿脓毒症与肠道微生态研究进展

近年来,脓毒症越来越受到人们的关注,是新生儿死亡的常见原因。肠道是人体最大的细菌储备库,在多种疾病发生发展中起始动作用。抗生素的使用、喂养方式、分娩方式及胎龄均可影响新生儿肠道菌群的定植。近期的研究表明,肠道菌群失调可以激活不受控的促炎反应从而导致脓毒症的发生。脓毒症新生儿肠道微生态可发生菌群紊乱、多样性降低及菌群移位...     

降钙素原对新生儿脓毒症诊断价值的Meta分析

目的 探讨降钙素原（PCT）对新生儿脓毒症的诊断价值。方法 检索Cochrane 图书馆、PubMed、Ovid、Springer数据库、中国期刊全文数据库、万方数据库和中国生物医学文献数据库（1990年1月至2009年10月）中的文献,按照诊断试验的纳入标准筛选文献,提取纳入研究的特征信息（研究背景、设计信息和诊断参数信息）。数据分析采用Meta-DiSc 1.4和SPSS 12.0软件,检验异质性,并根据异质性结果选择相应的效应模型。对所有研究予以加权定量合并,计算敏感度、特异度及其95%CI。绘制汇总受试者工作特征（SROC）曲线,并计算曲线下面积（AUC）,最后进行敏感度分析和不同组间敏感度比较。结果 共检索出相关英文文献446篇,中文文献98篇,其他语种文献21篇。阅读标题和摘要,按照纳入标准,最终获取文献33篇（英文文献18篇,中文文献11篇,其他语种文献4篇）,入选新生儿3 599例。3篇文献新生儿出生时检测脐血PCT水平临床诊断早发型脓毒症,汇总敏感度、特异度和SROC AUC分别为77.7%、82.8%和0.833 7;8篇文献新生儿出生后至12 h检测血清PCT水平临床诊断早发型脓毒症,汇总敏感度、特异度和SROC AUC分别为76.7%、87.1%和0.896 5;4篇文献新生儿出生后12~24 h检测血清PCT水平临床诊断早发型脓毒症,汇总敏感度、特异度和 SROC AUC分别为76.6%、88.5%和0.884 4;6篇文献新生儿出生后24~48 h检测血清PCT水平临床诊断早发型脓毒症,汇总敏感度、特异度和SROC AUC分别为69.8%、88.2%和0.894 7;15篇文献新生儿出生后≥72 h检测血清PCT水平临床诊断晚发型脓毒症,汇总敏感度、特异度和SROC AUC分别为79.0%、92.3%和0.963 2;15篇文献新生儿出生后≥72 h检测血清PCT水平确诊晚发型脓毒症,汇总敏感度、特异度和SROC AUC分别为84.5%、80.9%和0.934 5。PCT检测敏感度分析表明,国家、研究人群、疾病严重程度和PCT检测阈值的不同是产生异质性的原因。结论 PCT对新生儿脓毒症诊断效能较高,临床可多应用该诊断指标,有助于脓毒症的早期诊断,同时临床上需要注意联合PCT和其他诊断指标,进一步提高新生儿脓毒症诊断的敏感度和特异度。     

脓毒症新生儿肾上腺皮质功能的研究

目的 明确脓毒症新生儿肾上腺皮质的功能状态、肾上腺皮质功能不全的发生率、肾上腺皮质功能与脓毒症病情及预后的关系.方法 将60例≥36周的脓毒症新生儿分为脓毒症组(49例)和严莺脓毒症组(11例),经化学发光免疫技术检测血清基础皮质醇水平及小剂量ACTH激发试验后的皮质醇峰值水平.结果 ①脓毒症组血清基础皮质醇平均水平为23.24 μg/dl,峰值平均水平为42.04 μg/dl;严重脓毒症组血清基础皮质醇平均水平为51.89μg/dl,峰值平均水平为60.36μg/dl;严重脓毒症组血清基础皮质醇和血清皮质醇峰值的平均水平都高于脓毒症组.②60例中肾上腺皮质功能不全18例,其血清基础皮质醇平均水平为7.69μg/dl,峰值平均水平为31.43 μg/dl;肾上腺皮质功能正常的脓毒症新生儿血清基础皮质醇平均水平为35.27μg/dl,峰值平均水平为50.16μg/dl;肾上腺皮质功能正常组血清基础皮质醇和血清皮质醇峰值的平均水平都高于肾上腺皮质功能不全组.③脓毒症组无死亡病例,严重脓毒症组死亡6例,两组差异有统计学意义;肾上腺皮质功能小全组死亡1例,肾上腺皮质功能正常组死亡5例,两组差异无统计学意义.结论 脓毒症新生儿血清皮质醇的合成分泌增加,且病情越重,血清基础皮质醇的水平越高;脓毒症新生儿的病死率与病情的严重程度呈正相关;部分脓毒症新生儿可继发肾上腺皮质功能不全,未发现脓毒症新生儿病死率与肾上腺皮质功能不全之间存在相关性.     

新生儿和婴儿呼吸道合胞病毒致急性下呼吸道感染临床特征和疾病负担

目的了解上海地区新生儿和婴儿呼吸道合胞病毒（RSV）感染的严重程度及疾病负担,为RSV感染的监测及临床防治提供科学依据。方法回顾性收集2012年3月至2013年2月复旦大学附属儿科医院内科和新生儿科住院并确诊为急性下呼吸道感染（ALRI）≤1岁患儿的病历,截取人口学资料、临床特征、病死率、并发症、住院时间和费用等指标,并采用严重度指数(SI)进行RSV感染严重程度综合评价。分为新生儿组和婴儿组,并进一步分为单一感染和混合感染亚组进行分析。 结果1 726例ALRI≤1岁患儿中RSV阳性913例（52.9%）进入分析。新生儿组295例,婴儿组618例。①SI评分新生儿组高于婴儿组,(2.5±0.2) vs (1.9±0.1)分,P<0.05;较重度和重度比例新生儿组显著高于婴儿组,但单一感染和混合感染亚组间差异无统计学意义。②RSV感染的≤1岁患儿病死率为5.0％,新生儿组病死率与婴儿组差异无统计学意义,婴儿组合并基础疾病患儿病死率高。③机械通气比例两组间差异无统计学意义,婴儿组混合感染亚组高于单一感染亚组。④并发症情况：新生儿组呼吸暂停和脓毒症发生率较高,新生儿组混合感染亚组脓毒症发生率显著高于单一感染亚组。⑤住院天数新生儿组与婴儿组差异无统计学意义,合并基础疾病者显著高于未合并疾病疾病患儿;住院费用婴儿组显著高于新生儿组,新生儿混合感染亚组显著高于单一感染亚组,合并基础疾病患儿显著高于未合并基础疾病患儿。 结论RSV感染新生儿的重症比例和并发症的发生率较高,婴儿组住院费用较高。混合感染和合并基础疾病是影响RSV感染严重程度和疾病负担的重要因素。     

PICU婴儿脓毒症及严重脓毒症临床特征及预后危险因素分析

目的 分析PICU婴儿脓毒症、严重脓毒症的临床特征,探讨影响其预后的危险因素.方法 对2006年1月至2011年12月我院PICU收治的141例脓毒症患儿运用回顾性病例对照（存活组与死亡组）的研究策略,以患儿入院日为研究起点,死亡或出院为终点,进行临床特点分析.并选择性别、年龄、是否有基础疾病、脓毒症严重程度、脏器受累数、入PICU当天的危重病评分、血生化指标（乳酸、白蛋白、血糖）、血气指标（碱剩余、碳酸氢根、pH值）、是否休克、培养阳性等14个变量,建立Logistic回归模型,分析预后的危险因素.结果 141例患儿的年龄1～12个月,其中脓毒症72例,严重脓毒症69例,死亡29例,病死率为20.6％.29例死亡患儿中,13例有基础疾病.脓毒症和严重脓毒症患儿的感染部位均以肺部为主,分别占47.2％（34/72）、47.8％（33/69）;血培养均有34例阳性,分别占47.2％ （34/72）、49.3％ （34/69）.单因素分析显示,性别、基础疾病、年龄、脓毒症严重程度、休克、脏器受累数、危重病例评分、血乳酸、血气pH值、碱剩余、碳酸氢根与脓毒症死亡有关.经逐步引入剔除法,建立Logistic回归模型,仍然与死亡相关的因素包括脓毒症严重程度（OR=22.5,95％CI=5.089,99.475）和脏器受累数（OR=3.305,95％CI=2.152,5.075）.结论 婴儿脓毒症严重程度越重和器官受累数越多,死亡风险越大.     

新生儿脓毒症及脓毒性休克诊疗策略

脓毒症是指各种病原微生物(包括细菌、真菌、病毒及原虫)入侵机体血液循环,产生毒素所造成的全身性感染.新生儿脓毒症早期症状多不典型,特别是早产儿,起病急,进展迅速,极易发生脓毒性休克,甚至危及生命.因此,早期识别、准确诊断和积极干预新生儿脓毒症及脓毒性休克,对降低病死率及改善预后至关重要.     

新生儿细菌和真菌败血症的临床特征和住院费用比较

目的 分析比较革兰阳性菌(G+)、革兰阴性菌(G-)和真菌所致新生儿败血症的临床特征和住院费用.方法 对236 例新生儿败血症患儿的临床资料进行回顾性分析,包括G+ 菌败血症110 例,G-菌败血症68 例,真菌败血症58 例.结果 G+ 菌组足月儿占62%,G-菌组足月儿占38%,真菌组早产儿占86%,真菌组新生儿的胎龄、出生体重小于G+ 菌组和G-菌组(P-菌组、真菌组中多胎所占比例高于G+ 菌组(P-菌组胎膜早破>18 h、羊水Ⅲ度污染、早发型败血症的比例均高于G+ 菌组和真菌组(P+ 菌组起病症状为体温异常、脐炎或疱疹的患儿比例高于G-菌组和真菌组(P+ 菌组和G-菌组(P+ 菌组和G-菌组(P+ 菌组和G-菌组(P+ 菌组和G-菌组(P结论 G+菌败血症以足月儿为主;G-菌败血症多见于早发型;真菌败血症多见于早产儿和低出生体重儿,易发生呼吸暂停、血小板减少,且住院时间和住院费用高于细菌败血症.     

New diagnostic possibilities in systemic neonatal infections: metabolomics

Systemic neonatal infection is a serious complication in preterm and term infants and is defined as a complex clinical syndrome caused by bacteria, fungi and virus. Sepsis remains among the leading causes of death in both developed and underdeveloped countries above all in the neonatal period. Earlier diagnosis may offer the ability to initiate treatment to prevent adverse outcomes. There have been many studies on various diagnostic haematological markers like acute phase reactants, C-reactive protein, procalcitonin, interleukins and presepsin. However, there is still no single test that satisfies the criteria as being the ideal marker for the early diagnosis of neonatal sepsis. In this regard, metabolomic analysis seems to be a promising method for determining metabolic variations correlated with systemic neonatal infections.     

早产儿医院感染败血症的临床特点与病原学分析

目的调查分析早产儿医院感染败血症的临床特点、病原菌分布及药敏情况。方法回顾性分析我院新生儿科2007年1月至2011年12月发生医院感染败血症的早产儿病例。结果研究期间共出院早产儿5660例,排除染色体异常和住院时间小于5天的病例,纳入分析5392例,发生医院感染败血症81例,发生率1.5%,共治愈60例,治愈率74.1%。发病时表现多种多样,最常见的实验室指标异常是C反应蛋白（CRP）升高。病原菌以革兰阴性菌最多见（57.6%）,真菌占第二位（30.3%）。其中,革兰阴性杆菌以肺炎克雷伯菌为主,对大部分β内酰胺类抗生素耐药;革兰阳性菌以表皮葡萄球菌为主,大多对青霉素耐药,对万古霉素敏感;真菌感染均为念珠菌,对氟康唑、两性霉素B均敏感。结论早产儿医院感染败血症临床表现各异,CRP升高是较敏感的指标。致病菌主要为革兰阴性菌和真菌,革兰阴性菌对大部分β-内酰胺类抗生素耐药。     

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??Objective To analyse the pathogen distribution and drug resistance status in 268 cases of neonatal sepsis. Methods Totally 268 cases of neonatal sepsis were chosen who had been hospitalized between 2010 and 2015 with blood culture being positive. They were divided into early-onset and late-onset sepsis groups and their clinical characteristics??pathogen distribution and drug resistance were explored. Results The gram-negative bacteria were the major pathogens early-onset sepsis group??58.3%????in which escherichia coli was 31.2% and klebsiella pneumoniae was 23.9%. Gram-positive bacteria were the major pathogen in late-onset sepsis group??65.1%????in which coagulase negative staphylococcus was 46.5% and excrement enterococcus was 11.6%. Gram-positive bacteria were sensitive to vancomycin with durg resistance rate ??90% to penicillin????80% to erythromycin????60% to clindamycin??ampicillin and cefazolin . Gram-negative bacteria were sensitive to meropenem. Gram-negative bacteria showed high resistance to ampicillin??piperacillin and cefotaxime??but low resistance to ceftazidime and cefoperazone. Conclusion The common pathogens and clinical characteristics are different in the early-onset and late-onset sepsis groups. It is important to choose reasonable antibiotic drugs and strengthen drug resistance surveillance.     

Clinical features of neonatal sepsis caused by resistant Gram-negative bacteria

Background:  Clinical features and outcomes of neonatal sepsis caused by resistant Gram-negative bacteria are not well described in Jordan. The aim of the present study was therefore to describe microbiology and clinical features, laboratory findings and outcomes of early- and late-onset Gram-negative neonatal sepsis.
Methods:  All patients with Gram-negative bacteremia between July 2003 and June 2005 were retrospectively included. Resistance profiles, clinical features and outcomes of early and late-onset neonatal sepsis were compared.
Results:  A total of 79 patients (after excluding all nine cases of Gram-positive bloodstream infection (BSI) were identified as having Gram-negative BSI (25 had early-onset and 54 had late-onset neonatal sepsis). Respiratory distress, metabolic acidosis and requirement of ventilation were found in 74.7%, 40.5%, and 58.2%, respectively. Hypotension was found in 22.9% of patients. Klebsiella pneumoniae was responsible for 43 cases (54.4.2%). Klebsiella pneumoniae resistance rates to ampicillin and ceftazidime were 100% and 50%, respectively. Mortality rate was 30.9%. Forty-eight percent of deaths occurred within 3 days of sepsis. Meningitis was diagnosed in five cases. Elevated C-reactive protein (CRP) and thrombocytopenia were seen in 28% and 24% of infants with early-onset sepsis, respectively, and in 79.6%, 59.3% of infants with late-onset sepsis respectively.
Conclusion:  Both early- and late-onset neonatal sepsis are caused by highly resistant Gram-negative bacteria. Mortality of sepsis is high. Elevated CRP and thrombocytopenia is seen more commonly in late-onset neonatal sepsis.     

Systemic inflammatory response syndrome

Despite advances in perinatal care in the past decade, sepsis and its complications continue to present problems for the neonate, remaining a major cause of neonatal morbidity and mortality. Sepsis research is focusing on how the neonate (host) responds to bacteria. The newborn may develop a systemic reaction to bacteria that induces the release of substances known as inflammatory mediators. Termed the systemic inflammatory response syndrome (SIRS), this reaction is believed to be responsible for the signs and symptoms of sepsis. This article introduces the neonatal nurse to SIRS, providing an overview of various inflammatory mediators and cytokines, their clinical consequences, and potential new therapies in the management of SIRS.     

Antimicrobial therapy of bacterial sepsis in the newborn infant

Septicemia continues to be an important cause of neonatal morbidity and mortality. The bacteria most commonly responsible are group B beta-hemolytic streptococci and Escherichia coli, but regional differences exist. Recently sepsis caused by Staphylococcus epidermidis has occurred with increasing frequency in several neonatal intensive care units. Other organisms are less commonly responsible. The choice of antibiotics for suspected sepsis is based on the possible organisms involved and their antibiotic susceptibility patterns, which vary from hospital to hospital and at different times in the same hospital. Currently recommended initial therapy consists of a penicillin and an aminoglycoside, usually ampicillin and gentamicin. The addition of vancomycin is indicated when staphylococcal septicemia is suspected. During outbreaks of neonatal sepsis caused by aminoglycoside-resistant gram-negative bacteria, the use of third-generation cephalosporins or acylaminopenicillins may be appropriate, depending on the results of susceptibility tests. Continuing efforts to develop antibiotics for the treatment of neonatal sepsis are warranted.     

Strategies for prevention of nosocomial sepsis in the neonatal intensive care unit

PURPOSE OF REVIEW: Infants hospitalized in the neonatal intensive care unit, particularly preterm infants, have very high rates of nosocomial sepsis (also referred to as late onset sepsis or healthcare-associated sepsis). Today's preventive strategies for nosocomial sepsis focus on augmenting the immunologic and functional immaturities of premature infants and ameliorating the risks of extrinsic factors by the use of prophylactic antibiotics and best clinical practices. RECENT FINDINGS: Topical emollients improved neonatal skin condition, but were associated with an increased risk of nosocomial bacterial sepsis and coagulase negative staphylococcal infections, and thus should not be used in extremely-low-birth-weight infants. Single-center studies have shown that probiotics containing anaerobic bacteria may reduce the rate of necrotizing enterocolitis, the severity of necrotizing enterocolitis, and/or bacterial sepsis. Single-center studies have shown that prophylactic fluconazole reduces the rates of invasive candidiasis and/or colonization of extremely-low-birth-weight infants. Quality improvement projects to improve adherence to appropriate hand hygiene and best practices for central venous catheter insertion and maintenance can reduce rates of nosocomial sepsis. SUMMARY: The safety and efficacy of probiotics and prophylactic fluconazole require large multicenter trials. Quality improvement initiatives, however, can be performed now and can reduce the rates of nosocomial sepsis in the neonatal intensive care unit.