新生儿呼吸机相关性肺炎的病原菌分布及耐药性变迁

目的 探讨新生儿呼吸机相关性肺炎(ventilator-associated pneumonia,VAP)的病原菌分布和耐药性变迁,以指导临床防治. 方法 收集复旦大学附属儿科医院新生儿重症监护病房(neonatal intensive care unit,NICU)采取综合感染防治措施前后3个不同阶段(2006年2月1日至2007年1月31日为第一阶段,2008年8月1日至2009年7月31日为第二阶段,2010年1月1日至2010年12月31日为第三阶段)使用气管插管机械通气≥48 h,并在NICU住院≥5d的患儿的相关临床及实验室检查资料,对发生VAP患儿的下呼吸道分泌物标本进行病原菌检测,用琼脂扩散敏感试验法测定病原菌耐药性.采用两独立样本t检验、单因素方差分析或x2检验进行统计学分析.结果 3个阶段共纳入491例患儿,其中发生VAP共92例,VAP发生率为27.3/1000个呼吸机使用日.采取综合感染防治措施后新生儿VAP发生率逐渐下降,3个阶段VAP发生例数分别为38、22、32例,VAP发生率分别为48.8/1000个呼吸机使用日、25.7/1000个呼吸机使用日和18.5/1000个呼吸机使用日(x2=26.19,P=0.000).VAP病原菌以革兰阴性杆菌为主,占95.5％ (63/66).其中鲍曼不动杆菌是VAP最主要的致病菌,占65.2％(43/66);其次是肺炎克雷伯菌,占15.2％(10/66);大肠埃希菌及铜绿假单胞菌,各占6.1％(4/66).3个阶段相比,第一阶段致VAP鲍曼不动杆菌对第三代头孢菌素全部耐药,对碳青霉烯类抗生素敏感率为57.9％,有8株多重耐药菌株;第二阶段分离到的病原菌对第三代头孢菌素敏感率上升至75.0％(x2 =16.39,P=0.000),且无耐碳青霉烯类菌株及多重耐药菌株;与第二阶段相比,第三阶段病原菌对头孢菌素及碳青霉烯类药物的敏感率分别下降至5.0％(x2 =11.76,P=0.001)和20.0％(x2=6.72,P=0.01),出现10株多重耐药菌株. 结论 VAP病原菌以革兰阴性菌为主,采取综合感染防治措施可降低新生儿VAP发生率,但VAP病原菌种类逐年变迁.定期监测和分析NICU患儿VAP病原菌分布及其耐药性变迁,对临床合理使用抗菌药物及控制VAP发生具有重要指导意义.     

新生儿坏死性小肠结肠炎血浆谷氨酰胺浓度变化及临床意义

目的探讨血浆谷氨酰胺(Gln)浓度与新生儿坏死性小肠结肠炎(NEC)的关系。 方法选取2002年10月至2003年10月福建省妇幼保健院住院治疗的NEC患儿16例，以同期住院的性别相同，年龄、胎龄、出生体重相当的非NEC患儿16例为对照组，采用反向高效液相色谱法测定血浆Gln值，观察两组间差异；以多因素分析的方法判定血浆Gln浓度与NEC的关系。 结果NEC患儿血浆Gln浓度为(021±008)mmol/L，对照组为(035±014)mmol/L，差异有显著性意义(P<005)。控制了缺氧和感染因素的影响后，NEC组和对照组的血浆Gln浓度的边缘估计均值及95%可信区间分别为：0216mmol/L(0150~0282mmol/L)和0344mmol/L(0278~0410mmol/L)。两组校正均值比较，差异有显著性意义(P=0032)。在单因素分析筛选出关联因素的基础上，建立多因素条件Logistic回归模型，结果显示血浆Gln浓度是NEC的危险因素，OR值为13342(2006~88735)。 结论NEC患儿血浆Gln浓度降低，低浓度的血浆Gln是NEC发生的危险因素。     

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。     

糖尿病和心血管病家族史与胎儿宫内发育及新生儿胰岛素敏感性的关系

目的　探讨胎儿发育受限与成人期冠心病、高血压、2型糖尿病之间的联系是否与遗传基因有关。　方法　选取小于胎龄儿75例,适于胎龄儿224 例。均进行出生测量,记录父母及祖父母是否患有2型糖尿病、冠心病、高血压(母亲糖尿病除外),并于生后第3 天测定餐前血糖和胰岛素水平。　结果　小于胎龄儿组家族中冠心病、高血压、糖尿病的发生率分别为20. 0%、30. 7%和12.0%,显著高于适于胎龄儿组的9.3%、14.7%和3.5%(P<0.01)。与家族史阴性新生儿相比,一种疾病家族史阳性时,发生小于胎龄儿的相对危险度为OR=2.788;95%CI:1.517~5.124。任意两种或三种疾病家族史均阳性时,发生小于胎龄儿的相对危险度为OR= 3. 955; 95%CI: 1. 572 ~9.951。对孕周、出生体重及产时Apgar评分校正后,家族史阳性新生儿与家族史阴性新生儿相比血糖水平差异无统计学意义(P>0.05),但胰岛素/血糖比值则明显增高(P<0.05)。　结论　遗传基因在宫内发育受限及宫内发育受限儿成人后冠心病、高血压和糖尿病的发病过程中很可能起一定作用。     

多胎妊娠新生儿的临床问题及管理

近年来 ,多胎妊娠发生率有所上升 ,多胎妊娠新生儿易发生许多临床问题 ,病死率较高 ,多胎妊娠总的围生儿死亡率达 10 %～ 12 % ,双胎儿的死亡率比单胎儿高 4倍 ,三胎儿、四胎儿的死亡率更高。因此 ,对多胎儿应密切监护 ,及时处理。1　早产儿问题由于多胎 ,容易发生早产 ,出生时体重较低 ,小于胎龄儿的发生率也很高。据统计 ,双胞胎新生儿的平均胎龄为3 7 1周 ,平均出生体重为 2 3 90ｇ ,三胞胎新生儿的平均胎龄为 3 3周 ,平均出生体重为 172 0ｇ ,而四胞胎儿平均胎龄3 1 4周 ,平均出生体重 14 82ｇ。因此 ,多胎新生儿易发生早产儿所常见的问…     

12年早产儿院内感染的临床分析

目的　探讨早产儿发生院内感染的危险因素 ,为院内感染的监控和干预措施提供可靠的理论依据。　方法　对我科 1991年 1月～ 2 0 0 2年 12月共 12年期间住院的 94 8例早产儿及其院内感染病例进行回顾性研究总结。　结果　 94 8例早产儿中 114例发生 135次院内感染 ,发生率为9 0‰。发生院内感染者比未感染者的胎龄及出生体重均小 ,住院时间明显延长。早产儿发生院内感染的危险性相关因素为出生体重 (≤ 15 0 0g)、胎龄 (≤ 32周 )及呼吸机治疗 (P <0 .0 0 1)。以肺炎占首位 ,细菌检出率为 2 3.7% ,其中G 菌占 1/ 3,G-菌占 2 / 3。院内感染病死率为 9.6 5 %。　结论　充分了解和纠正早产儿发生院内感染的高危因素 ,强调洗手的重要性 ,合理应用抗生素 ,尽量减少侵袭性操作次数 ,缩短操作时间 ,加强消毒隔离制度和无菌原则 ,将明显减少院内感染发病率     

脐带因素与胎儿生长发育及新生儿体重的关系

目的探讨应用脐带多项指标评估胎儿宫内生长发育状况及新生儿体重的临床价值。方法2 0 0 0年2月至2 0 0 2年6月间河北医科大学附属第四医院产前经多普勒超声测量脐带、脐动脉、脐静脉直径,脐动脉血流参数,脐静脉流速,并与胎龄比较。产后测量脐带长度、直径、脐带扭转周数,脐血生长激素(GH)、微量元素含量。根据正常新生儿体重分为大、中、小3组,分别与所测指标进行比较。结果脐带、脐动脉、脐静脉直径随胎龄生长而持续增长,并与新生儿体重呈正相关。脐动脉血流参数随胎龄增长而逐渐降低。胎儿脐静脉血流量孕4 0周时为80mL/ (min·kg)。脐带长度与脐带直径、胎儿体重无关。脐带长度与扭转周数有关,与脐带绕颈绕身有关。脐血中GH含量与新生儿体重有关,微量元素与新生儿体重无关。结论产前应用脐带多项指标评估胎儿宫内生长发育状况及体重有临床价值。     

胎盘肥胖基因表达与胎儿宫内生长发育相关性研究

目的　探讨胎盘肥胖基因表达与脐血瘦素水平和胎儿宫内生长发育的关系。　方法　采用逆转录定量聚合酶链反应 (RT- PCR)检测 40例胎盘肥胖基因 m RNA相对表达水平 ,采用放射免疫法检测脐血肥胖基因蛋白 (瘦素 )水平 ,采用 Ponderal指数 [PI=10 0×体重 (g) /身长 (cm) 3 ]估测新生儿营养状态。　结果　胎盘组织肥胖基因呈现高效表达 ,表达水平与孕母脂肪组织肥胖基因表达水平相似 ;13例小于胎龄儿胎盘组织瘦素 - m RNA相对表达水平为 0 .44 9± 0 .0 2 6 ,显著低于 15例适于胎龄儿的表达水平 [0 .487± 0 .0 42 (P<0 .0 5 ) ];12例大于胎龄儿胎盘组织瘦素 - m RNA相对表达水平为 0 .5 2 5± 0 .0 2 9,显著高于适于胎龄儿 (P<0 .0 5 )。胎盘肥胖基因 m RNA相对表达水平与脐血瘦素水平显著相关 (r=0 .6 1,P<0 .0 5 ) ,与新生儿出生体重和 Ponderal指数显著相关 (r=0 .6 0和0 .5 6 ,P<0 .0 5 )。　结论　胎盘是脐血瘦素重要来源 ,胎盘瘦素可能对胎儿宫内生长发育有促进作用     

妊娠期糖尿病合并子前期对母儿的影响

目的研究妊娠期糖尿病(gestationaldiabetesmellitus,GDM)合并子前期对新生儿出生体重及母儿并发症的影响。方法回顾分析中国医科大学附属盛京医院及解放军202医院2002-01-2004-12收治的GDM病例共127例,其中合并子前期者35例(Ⅱ组,余为Ⅰ组),以同期子前期35例(Ⅲ组)及正常妊娠35例(Ⅳ组)为对照,比较四组间新生儿出生体重之间的差异,以及Ⅰ、Ⅱ组母儿并发症。结果(1)GDM孕妇子前期的发生率(27.6%,35/127)明显高于同期子前期的发生率(6.97%,353/5066),差异有统计学意义(P<0.01)。(2)Ⅰ组与Ⅱ组新生儿出生体重差异无统计学意义(P>0.05),Ⅱ组明显高于Ⅲ组及Ⅳ组(P均<0.01)。(3)所有GDM病例中小于胎龄儿2例,均合并重度子前期。(4)Ⅰ组与Ⅱ组孕妇羊水过多、酮症酸中毒等的发生率及新生儿红细胞增多症等的发生率差异无统计学意义(P均>0.05);Ⅱ组孕妇手术产的发生率高于Ⅰ组(P<0.05),新生儿窒息及转科的发生率也明显高于Ⅰ组(P<0.05)。结论GDM易合并子前期,且GDM合并子前期者中,孕妇早产、胎膜早破等围生期并发症增多,新生儿大于胎龄儿及低血糖等并发症亦增多。     

西安市不同胎龄新生儿出生体重标准

出生体重标准曲线作为临床评价胎儿生长发育的依据在国外已广泛应用。为获得西安市城区新生儿出生体重标准 ,我们以西安市城区 1996～ 1999年间出生的新生儿为研究对象 ,在取得西安市城区不同胎龄新生儿出生体重经验百分位数的基础上 ,进行了出生体重标准的研究。一、资料和方法1.资料来源 :随机分层整群抽取西安市城区 1996～ 1999年度出生的活产、单胎、2 5～ 44周分娩的孕产妇系统管理资料 (包括新生儿资料 )共 1185 3例 ,占西安市城区年度活产数的 83.6 3%。排除新生儿出生缺陷者及母亲有妊娠合并症者 ,共分析 110 78例的资料。2 .方法 …     

The effect of minor degrees of glucose intolerance on the incidence of neonatal macrosomia.

The incidence of neonatal macrosomia in infants of mothers who have only one abnormal value in a 3-hour glucose tolerance test (GTT) is greater than normal. Often, corrections for gestational age have not been used in the analysis, and in the few studies in which corrections were made, the results conflicted. In this study, the birth weights of infants from 157 patients who had only one abnormal GTT value were compared with the birth weights of infants from normal mothers, with and without correction for gestational age. Analysis using three different GTT criteria revealed that the incidence of birth weight greater than 4000 g was 20% or greater in the infants of mothers who had only one abnormal GTT value and only 12.4% in controls. However, when adjusted for gestational age, there were no differences in the birth weights and percentage of large for gestational age (LGA) infants in the study groups versus controls. The mean and gestational age-adjusted birth weights of the greater-than-4000-g neonates born to women with one abnormal GTT value were no different than those of controls. However, at delivery, the gestational ages of patients with one abnormal GTT value tended to be slightly greater than those of controls by 0.1-0.6 weeks, suggesting that minor degrees of abnormal glucose metabolism may prolong pregnancy in some patients. When compared with the literature, the findings of this study suggest that the National Diabetes Data Group criteria may be too high as a screen for LGA infants.     

Risk factors predicting vasopressor use after patent ductus arteriosus ligation

Ligation of the patent ductus arteriosus (PDA) is sometimes complicated by postoperative hypotension requiring vasopressor(s). It is unclear which infants are at risk for this complication. We conducted a retrospective and prospective cohort study to identify risk factors predicting vasopressor use after PDA ligation. Our patients were infants < 37 weeks of gestation who underwent PDA ligation. The primary outcome was the use of vasopressor(s) within 72 hours after PDA ligation, defined as beginning vasopressor(s) or increasing the dose of vasopressor(s). Thirty-two of 100 (32%) study infants required vasopressor(s) after PDA ligation. Infants who had lower birth weights, lower gestational ages, higher ventilator support, or whose mothers had received antenatal steroids had a higher risk of vasopressor use. Infants who required vasopressor(s) were at increased risk of dying before 36 weeks postmenstrual age. Lower birth weight, lower gestational age, and higher respiratory support define a high-risk subgroup of patients in whom the prophylactic administration of vasopressor(s) could be studied.     

高龄产妇产褥期感染的病原菌分布及耐药特征分析

目的 探究高龄产妇产褥期感染的病原菌分布及耐药特征分析.方法 选取2017年1月至2019年10月在武汉儿童医院分娩的523例高龄产妇作为研究对象,其中50例发生产褥期感染.采集感染产妇标本,进行病原菌鉴定及药敏试验.分析产褥期感染患者的病原菌及病原菌的耐药率.结果 产褥期感染产妇50例,感染率9.56％,会阴切口感染...     

极低和超低出生体重儿败血症临床分析

目的 了解极低和超低出生体重儿败血症临床特点、病原菌分布及药物敏感情况,以指导临床合理用药.方法 对1999年1月1日至2008年12月31日温州医学院附属育英儿童医院新生儿重症监护病房收治的56例极低和超低出生体重儿败血症(早发型败血症3例,晚发型败血症53例)临床特点、血培养结果及药物敏感情况进行回顾性分析.结果 极低和超低出生体重儿败血症临床表现无特征性.血培养结果阳性43例,以条件致病菌为主,其中新生儿早发型败血症血培养阳性1例.为脑膜炎败血黄杆菌;新生儿晚发型败血症血培养病原菌中,革兰阴性细菌主要是肺炎克雷伯菌(33.3%,14/42);革兰阳性细菌以凝固酶阴性葡萄球菌为首(26.2%,11/42),其次是肠球菌(11.9%,5/42);另有真菌感染2例,为白念珠菌败血症(4.8%,2/42).药物敏感试验方面,所有凝固酶阴性葡萄球菌均为耐苯唑西林凝同酶阴性葡萄球菌,对大部分β-内酰胺类抗生素耐药,对林可霉素、氨基糖苷类、大环内酯类及喹诺酮类抗生素亦不敏感,但对万古霉素未发现耐药,对利福平均敏感;所有肺炎克雷伯菌均产超广谱β-内酰胺酶,仅对碳青霉烯类、氨基糖苷类以及喹诺酮类等少数抗生素敏感.56例败血症患儿治愈43例,死亡13例(包括6例病情恶化放弃治疗),病死率为23.2%.结论极低和超低出生体重儿败血症临床表现缺乏特异性,病原菌主要为条件致病菌,并存在多重耐药,对可疑败血症患儿应及时行病原学检查及药物敏感试验,合理选择抗生素.为减少多重耐药菌感染的发生,应正确合理使用第三代头孢菌素.     

Neonatal outcome in small for gestational age infants: do they really better?

BACKGROUND: There still is a controversy as to the neonatal outcome of small for gestational age (SGA) infants compared to a appropriate for gestational age (AGA) preterm infants. As a part of a randomized multicenter trial on timing of bovine surfactant therapy, we aimed at investigating short-term outcome variables in SGA-infants compared with AGA-infants. METHODS: SGA-infants were classified weighing below the 10th percentile at birth and were compared to AGA-infants in terms of prenatal and neonatal characteristics and neonatal outcome. RESULTS: A total of 317 infants were enrolled, 59 SGA- and 258 AGA-infants. Both groups did not differ in gestational age, however, SGA-infants had a lower birth weight. Preterm premature rupture of fetal membranes was observed more frequently in AGA-, preeclampsia in SGA-infants. The rate of intubation, severity of RDS, rate of surfactant administration, pulmonary airleaks and days on the ventilator did not differ between both groups. However prolonged nasal CPAP, supplemental oxygen therapy and chronic lung disease at 28 days and 36 weeks was diagnosed more often in SGA-infants. Furthermore mortality was significantly higher in SGA-infants as well as total NICU and total hospital days. CONCLUSION: As SGA-infants have an increased mortality rate and an increased risk for developing chronic lung disease, further studies should focus on prevention of intrauterine growth restriction and its complications.     

Obstetric factors associated with intracranial hemorrhage (ICH) in premature infants and antenatal prediction of ICH

Obstetric factors associated with intracranial hemorrhage (ICH) were evaluated in 98 inborn premature infants of less than 1,500 gm birth weight or less than 32 weeks of gestation. ICH was detected in 25 (25.5%) of these infants by ultrasound sonography and/or computed tomography. No association of obstetric factors such as maternal age, parity, gravidity, premature rupture of the membrane, toxemia, placenta previa, fetal position, mode of delivery or fetal sex with ICH was noted. But the ICH group showed a higher incidence of placental abruption, infarction, infection and incompetent cervix than the non-ICH group. In addition, gestational ages and birth weights were less in the ICH group than in the non-ICH group, although differences were not significant except for the group with incompetent cervix (p less than 0.05). However, Apgar scores and FHR scores according to Krebs et al. for the ICH group were significantly lower than those for the non-ICH group. The two groups were distinguished by multivariable discriminant analysis of FHR scores, birth weights and gestational ages (discriminant efficiency, 3.74: F-value, 20.6: true positive ratio, 81.3%). These results suggested that antenatal prediction of ICH in premature infants was possible, but further studies are needed to elucidate the reliability of its prediction.     

A quality improvement approach to optimizing medication use in the neonatal intensive care unit

Despite many years of heavy use in premature and critically ill newborns, surprisingly few medications have been rigorously tested in neonatal multicenter randomized clinical trials. Little is known about the pharmacology of these drugs at various birth weights, gestational ages, and chronologic ages. This article describes a quality improvement approach to evaluating and improving neonatal intensive care unit (NICU) medication use, with an emphasis on adaptation of drug use to the specific clinical NICU context and use of system-based changes to minimize harm and maximize clinical benefit.     

Neonatal-perinatal risk factors for the development of persistent pulmonary hypertension of the newborn in preterm newborns

There is a long-held belief that preterm newborns lack sufficient arteriolar musculature to maintain a prolonged elevated pulmonary vascular resistance (PVR) after birth. Net ductal flow is thought to be minimal, with the developing pulmonary circulation incapable of significant vasoconstriction. We identified retrospectively 15 premature newborns over a 10-year period weighing < or = 1500 g and with a gestational age of < or = 30 weeks with documented persistent pulmonary hypertension of the newborn (PPHN) in the first 24 hours after birth. We matched 36 newborns of similar weight and gestation with no clinical evidence of shunting. The control group weaned to an FiO2 < or = 0.50 by 12 hours after birth. Despite similar gestational ages, the PPHN group (n = 15) had significantly higher birth weights than the control group (n = 36). The duration of ruptured membranes, maternal tobacco use, and use of antenatal steroids were significantly higher in the PPHN group. We speculate that these three factors might act in a synergistic relationship with which to accelerate pulmonary vascular smooth muscle development in premature newborns.     

Risk factors and outcomes for ventilator-associated pneumonia in neonatal intensive care unit patients

In order to determine the risk factors and outcomes of ventilator-associated pneumonia (VAP) in the neonatal intensive care unit (NICU), a retrospective cohort study was conducted on 259 patients who were ventilated >48 h. Clinical characteristics and risk factors were compared and non-conditional logistic regression analysis was performed to determine independent predictors for VAP. There were 52 episodes of VAP (20.1%). The main pathogens were G(-) bacterium (82.1%, 23/28). Hospital stay in the VAP group was 19.9+/-5.9 vs. 16.7+/-7.2 days in controls (P<0.01). The mortality rate of the VAP group was 13.5% (7/52) vs. 12.1% in controls (P>0.05). By logistic regression analysis the following independently predicted VAP: re-intubation (OR 5.3, 95% CI 2.0, 14.0), duration of mechanical ventilation (OR 4.8, 95% CI 2.2, 10.4), treatment with opiates (OR 3.8, 95% CI 1.8, 8.5) and endotracheal suctioning (OR 3.5, 95% CI 1.6, 7.4). VAP occurred at significant rates among mechanically ventilated NICU patients and is associated with care procedures. The risk factors of neonatal VAP were re-intubation, duration of mechanical ventilation, treatment with opiates and endotracheal suctioning. Additional studies are necessary to develop interventions to prevent neonatal VAP.     

A parsimonious explanation for intersecting perinatal mortality curves: understanding the effect of plurality and of parity

BACKGROUND: Birth weight- and gestational age-specific perinatal mortality curves intersect when compared across categories of maternal smoking, plurality, race and other factors. No simple explanation exists for this paradoxical observation. METHODS: We used data on all live births, stillbirths and infant deaths in Canada (1991-1997) to compare perinatal mortality rates among singleton and twin births, and among singleton births to nulliparous and parous women. Birth weight- and gestational age-specific perinatal mortality rates were first calculated by dividing the number of perinatal deaths at any given birth weight or gestational age by the number of total births at that birth weight or gestational age (conventional calculation). Gestational age-specific perinatal mortality rates were also calculated using the number of fetuses at risk of perinatal death at any given gestational age. RESULTS: Conventional perinatal mortality rates among twin births were lower than those among singletons at lower birth weights and earlier gestation ages, while the reverse was true at higher birth weights and later gestational ages. When perinatal mortality rates were based on fetuses at risk, however, twin births had consistently higher mortality rates than singletons at all gestational ages. A similar pattern emerged in contrasts of gestational age-specific perinatal mortality among singleton births to nulliparous and parous women. Increases in gestational age-specific rates of growth-restriction with advancing gestational age presaged rising rates of gestational age-specific perinatal mortality in both contrasts. CONCLUSIONS: The proper conceptualization of perinatal risk eliminates the mortality crossover paradox and provides new insights into perinatal health issues.