社区获得性急性细菌性脑膜炎患儿的管理

细菌性脑膜炎(BM)是小儿常见的神经系统感染性疾病之一,常影响小儿精神运动发育,其正确的诊断和治疗一直是个挑战;美国、欧洲、加拿大、法国、英国先后于2004 - 2010年发布了BM治疗指南,对于指导临床医师处理BM有重要的参考价值.     

细菌性脑膜炎早期并发症的预警因素

目的探讨细菌性脑膜炎早期并发症的预警因素。方法回顾分析2000~2005年本院75例细菌性脑膜炎患儿的临床资料及发生早期并发症的危险因素。结果细菌性脑膜炎患儿早期并发症的发生率为50.7%,以硬膜下积液和脑积水最为常见。早期并发症与发病年龄、是否伴昏迷、是否出现惊厥、脑脊液蛋白定量、脑脊液糖定量密切相关。其中,发病年龄≤12个月（OR=11.867,95%CI：2.592~54.33 P〈0.01）和脑脊液糖≤1.5 mmol/L（OR=14.088,95%CI：3.173~62.54 P〈0.01）是细菌性脑膜炎患儿发生早期并发症的危险因素。结论细菌性脑膜炎早期并发症的危险因素是发病年龄和脑脊液中糖的水平。     

Comparison of Scrub Typhus Meningitis with Acute Bacterial Meningitis and Tuberculous Meningitis

Objective

To compare scrub typhus meningitis with bacterial and tuberculous meningitis.

Methods

Children aged<15 years admitted with meningitis were screened and those who fit criteria for diagnosis of scrub typhus meningitis (n=48), bacterial meningitis (n=44) and tuberculous meningitis (n=31) were included for analysis. Clinical features, investigations and outcomes were compared between the three types of meningitis.

Results

Mean age, duration of fever at presentation, presence of headache and, altered sensorium and presence of hepatomegaly/splenomegaly were statistically significantly different between the groups. Scrub typhus had statistically significant thrombocytopenia, shorter hospital stay and a better neurological and mortality outcome.

Conclusions

Sub-acute presentation of meningitis in older age group children, and good outcome is associated with scrub typhus when compared to bacterial and tuberculous meningitis.

     

Types of Fluid Disorder in Children with Bacterial Meningitis

ABSTRACT. As part of a prospective study of children with bacterial meningitis we analyzed in 36 patients of our hospital the fluid balance on admission and during the first three days of treatment. On admission 10 of them (28%) had inappropriate antidiuretic hormone secretion SIADH, 10 (28%) hypo-osmolal and 10 (28%) iso-osmolal contraction. Six patients (17%) had no clear fluid disorder. The patients with SIADH had significantly lower mean serum NA'(127 vs. 132 mEq/l, p < 0.0l) and higher mean urine Na+ (111 vs. 26 mEq/l, p < 0.01) concentration as well as higher mean urinary Na+/K+ ratio (2.23 vs. 0.365, p < 0.005) than the patients with hypo-osmolal contraction. They also tended to be younger and have a shorter history of fever. The patients with SIADH had a less strict fluid restriction than the patients with hypo-osmolal contraction, and their fluid balance normalized more slowly. Our findings support initial water restriction for all children with bacterial meningitis.     

细菌性脑膜炎266例病原学与耐药性分析

目的 回顾性调查2000-2005年临床诊断符合细菌性脑膜炎（BM）患儿266例的脑脊液致病菌及耐药性情况。方法致病菌采用常规方法分离培养，细菌鉴定采用革兰染色、API生化鉴定系统（法国生物梅里埃），X、V因子试验（嗜血杆菌属）、Optochin试验（肺炎链球菌阳性）及肺炎链球菌、B型流感嗜血杆菌及脑膜炎奈瑟菌抗原检测（乳胶凝集方法）。细菌抗生素耐药检测采用KB及E-test法。结果乳胶凝集法显示BM患儿主要病原菌为肺炎链球菌（20．0％，）、B型流感嗜血杆菌（15．4％）、脑膜炎奈瑟菌（7．7％）。培养法提示凝固酶阴性葡萄球菌引起BM比例为15．4％，大肠埃希菌为4．9％。88．9％凝固酶阴性葡萄球菌对苯唑青霉素耐药（MRS）。结论肺炎链球菌、B型流感嗜血杆菌及脑膜炎奈瑟菌仍是上海地区BM儿童的主要病原菌，葡萄球菌引起BM所占比例超过脑膜炎奈瑟菌且多为苯唑西林耐药株。我国BM儿童病原菌谱存在一定地域差异。     

细菌性脑膜炎的病原体及抗生素敏感性分析

目的　回顾分析我院 1 997～ 2 0 0 3年儿童细菌性脑膜炎 (菌脑 )的病原体及其抗生素敏感性。方法　分析符合菌脑临床诊断患儿脑脊液或血培养分离菌及其药敏试验结果。结果　菌脑 40 1例患儿中 97例细菌培养阳性 ,诊断阳性率 2 4 % ,最常见病原菌为金黄色葡萄球菌 (2 8% ) ,其次是肺炎链球菌 (1 9% )与大肠杆菌 (1 3 % ) ,并出现条件致病菌如微球菌。金黄色葡萄球菌分离株对青霉素不敏感 ,其中 1株对万古霉素与替考拉宁耐药 ;大肠杆菌、肠杆菌和假单胞菌均有对泰能的耐药株。结论　金黄色葡萄球菌是菌脑主要病原菌 ,临床用药须考虑当地的病原菌及其耐药问题。     

细菌性脑膜炎并脑积水的临床特点及危险因素

目的探讨细菌性脑膜炎并脑积水的临床特点,并分析其相关的危险因素,以降低其发生率,改善细菌性脑膜炎的预后。方法对2004年1月-2010年6月本院收治的111例细菌性脑膜炎患儿的临床资料进行回顾性分析。根据影像学结果,将患儿分为细菌性脑膜炎并脑积水组(n=16)及细菌性脑膜炎无脑积水组(n=95),应用SPSS 17.0软件对2组患儿的基本情况、临床表现、实验室结果及抗生素治疗情况等进行比较,对相关因素进行Logistic回归分析,筛选出脑积水发生的高危因素。结果细菌性脑膜炎并脑积水的发生率为14.4%(16/111例),以梗阻性脑积水为主(14/16例,87.5%),75%(12/16例)患儿脑积水出现在起病4周内,确诊时CT/MRI的检查次数为1～3次,2例患儿在起病后2个月行脑室-腹腔分流术,2例脑积水患儿死亡。2组临床资料比较显示年龄、发热>10 d、惊厥、意识障碍、经验性治疗失败、颅内低密度灶、低Hb水平、高脑脊液蛋白水平、低脑脊液葡萄糖水平均与脑积水发生有关(Pa<0.05),Logistic回归分析显示意识障碍、经验性治疗失败、低Hb水平是细菌性脑膜炎并脑积水的独立危险因素。结论脑积水是细菌性脑膜炎的一个严重并发症之一,临床表现及实验室检查结果可作为细菌性脑膜炎并脑积水的预测指标。     

Diagnostic Value of Serum Procalcitonin Level in Differentiating Bacterial from Nonbacterial Meningitis in Children

Objective:

Acute bacterial meningitis in pediatrics remains a serious and potentially lethal disease. Its prognosis is critically dependent on rapid diagnosis and treatment. The use of biological markers, like procalcitonin, has been proposed to facilitate the accuracy of the initial diagnosis of bacterial meningitis. The aim of this study was assessment the diagnostic values of serum procalcitonin (PCT) assay in the diagnosis and differentiation of acute bacterial from non bacterial meningitis.

Methods:

45 patients with suspicion of meningitis were enrolled in the study and were clinically evaluated and investigated by lumbar punctures for cerebrospinal fluid analysis, C-reactive protein and differential leukocyte count. Patients with clinical and laboratory suggestion of bacterial causes were regarded as bacterial meningitis group (29 patients), and those who were suggestive of nonbacterial causes were regarded as nonbacterial group (16 patients).

Findings:

Serum procalcitonin levels were significantly higher in bacterial meningitis group (637±325 pg/ml) compared with non-bacterial meningitis (380±170 pg/ml); P<0.001. Procalcitonin levels were more sensitive and specific (79%, 81%) than C-reactive protein (76%, 75%) and white blood cell count (72%, 75%) in the diagnosis of bacterial meningitis.

Conclusion:

Elevated serum procalcitonin level could be a predictor of bacterial causes of meningitis and is more sensitive and specific than other diagnostic predictors.     

Bacterial Meningitis Caused by Veillonella Parvula

A three-year-old girl injured her right eyelid with a toothbrush. The wound was sutured. Swelling of the eyelid, high fever and vomiting developed in spite of oral antibiotics for seven days. The findings of the cerebrospinal fluid (CSF) were white blood cells (WBC) 26,368/mm³ (90% polymorphs), protein 127 mg/d, and sugar 0 mg/dl. Although Cram negative organisms were seen on the smear, aerobic culture was sterile. Later culture of CSF on admission grew anaerobic bacteria: Veillonella parvula . Intravenous administration of penicillins with cefotaxime (CTX), or of fosfomycin (FOM) were ineffective. Chloramphen-icol (CP) cured the patient without neurological sequelae. There were no abnormal findings on brain CT scan. This is the first report of Veillonella meningitis. V. parvula appeared to have invaded the CSF from the abscess of the eyelid. It is necessary to consider anaerobic meningitis when there is a preceding pyogenic infection in the head.     

新生儿细菌性脑膜炎45例

目的 分析新生儿细菌性脑膜炎的临床表现、病原学特征及治疗方法,为早期诊断及治疗提供临床依据.方法 对本院新生儿科2005年12月-2010年7月收治的45例新生儿细菌性脑膜炎的临床资料进行回顾性分析.根据发病日龄分为≤7 d组(15例)和＞7 d组(30例),分析2组一般情况、临床表现、实验室检查及治疗方法等.结果临床表现以发热(86.7%)、抽搐(66 7%)、激惹(35.6%)为主,＞7 d组肌张力升高、脑膜刺激征阳性多见.脑脊液培养阳性11例(24.4%)、涂片阳性3例(6.7%)、血培养阳性18例(40.0%),其中,凝固酶阴性葡萄球菌12例,G-杆菌11例.脑脊液蛋白水平与白细胞计数在脑脊液培养阳性、涂片阳性或查见脓细胞(18例)患儿与未见明确病原学特征(27例)患儿比较,差异无统计学意义.选用β-内酰胺类联合第三或第四代头孢菌素治疗,培养有阳性细菌生长后,再根据药敏试验及临床疗效选用敏感抗生素.治愈33例(73.3%),无效1例(2.2%),放弃治疗11例(24.5%),包括症状缓解5例和未愈6例.结论 新生儿细菌性脑膜炎临床表现不典型,神经系统体征在发病日龄＞7 d 时表现相对明显;凝固酶阴性葡萄球菌为最常见的致病菌;治疗以β-内酰胺类联合第三代或第四代头孢菌素为主.     

Initial Chemotherapy for Purulent Meningitis in Children

The combination of ampicillin with either gentamicin or chloramphenicol, which is currently the initial chemotherapy for purulent meningitis, has lost its effectiveness in recent years because of an increase in the incidence of ampicillin-resistant strains. This has made it necessary to search for a suitable substitute therapy. Twenty-two new β-lactam agents were compared with penicillin G and ampicillin in terms of their antibacterial activity in relation to the principal causative microbes of meningitis and their ability to transfer into the cerebrospinal fluid (CSF) of rabbits with experimental staphylococcal meningitis. In addition, a survey was conducted of the therapeutic efficacy achieved by these drugs in cases seen by the authors and in other domestic and overseas cases. Finally, an investigation was made as to whether or not the transfer of the drug into the CSF was suppressed when it was administered simultaneously with ampicillin. From the results, it was surmised that in future the most appropriate initial chemotherapy for purulent meningitis will be a combination of cefotaxime, or perhaps ceftriaxone, plus ampicillin.     

Treatment Complications in Children With Lyme Meningitis

BACKGROUND:: The rate and type of treatment complications in children treated for Lyme meningitis have not been described. METHODS:: We performed a retrospective cohort study of children with Lyme meningitis who presented to 1 of 3 emergency departments located in Lyme disease endemic areas between 1997 and 2010. We defined a case of Lyme meningitis as a child with cerebrospinal fluid pleocytosis and either positive Lyme serology or an erythema migrans rash. We identified prescribed treatment and reasons for all return visits. Our primary outcome was the presence of any treatment complication within 30 days of diagnosis. RESULTS:: We identified 157 patients with Lyme meningitis with a median age of 10 years (interquartile range: 7-13 years). Of the 149 children with Lyme meningitis and available follow-up records, 39 (26%) had 1 or more complications, and 21 (14%) required a change in prescribed antibiotic therapy. The median time for developing the first complication was 11 days (interquartile range: 9-14 days). Ten percent of the patients had an adverse drug reaction. Of the 144 children who had a peripherally inserted central catheter placed, 25 (17%) had at least 1 peripherally inserted central catheter-associated complication: 14 (10%) had a mechanical problem, 11 (8%) had an infectious complication and 1 (1%) had a venous thromboembolism. CONCLUSIONS:: As current Lyme meningitis treatment regimens have substantial associated morbidity, future research should investigate the efficacy of alternate regimens.