病原菌明确的细菌性脑膜炎146例临床及病原学分析

目的 分析细菌性脑膜炎患儿临床表现和病原特点，为临床诊治提供帮助。方法 收集复旦大学附属儿科医院2001年1月至2012年12月病原菌诊断明确的细菌性脑膜炎住院患儿，采集临床表现、辅助检查、并发症、病原菌种类和耐药情况等资料，分为0~28 d（新生儿组），~1岁、~3岁和>3岁组进行描述分析。结果 146例细菌性脑膜炎患儿进入分析，新生儿组58例，~1岁组36例，~3岁组20例，>3岁组32例。①新生儿组发热、呕吐和脑膜刺激征的发生率较低，>3岁组伴有颅面、脊柱解剖畸形50%（16/32）。②革兰阳性菌占54.8%（80株），以凝固酶阴性葡萄球菌（33株）、肠球菌（19株）和肺炎链球菌（12株）为主；革兰阴性菌占45.2%（66株），以大肠埃希菌（30株）和鲍氏不动杆菌（10株）为主。③革兰阳性菌对万古霉素和利奈唑胺均敏感，革兰阴性菌除3/10株鲍氏不动杆菌和1/3株铜绿假单胞菌对美罗培南耐药外，余均敏感；大肠埃希菌、克雷伯菌和阴沟肠杆菌产超广谱β内酰胺酶阳性率分别达到66.7%、60.0%和100%。④63例（43.2%）出现急性期并发症，以硬膜下积液（26例）、脑积水（20例）和局部神经损害（13例）最常见；出现并发症主要病原菌为大肠埃希菌(15/30)、凝固酶阴性葡萄球菌（14/33）、肺炎链球菌（6/12）和鲍氏不动杆菌(6/10)。⑤出院结局：死亡或放弃治疗31例（21.2%），其中肺炎链球菌性脑膜炎为5/12例（41.7%）。结论 细菌性脑膜炎新生儿临床表现多不典型，>3岁患儿应关注神经系统相关解剖结构缺陷的可能。可根据病原菌分布特点和药敏结果选用敏感抗生素。肺炎链球菌性脑膜炎患儿预后可能不良。

Clinical and pathogenic analysis of bacterial meningitis with pathogen-identified in 146 children

Objective To analyze the clinical characteristics and etiology diagnosis of bacterial meningitis from 2001 to 2012 in Children＇s Hospital of Fudan University. Methods Clinical and pathogenic data were analyzed retrospectively based on the inpatients with pathogens identified bacterial meningitis during 12 years. Results In total, 146 pathogen-identified cases from 570 pediatric patients with bacterial meningitis in the last 12 years were analyzed in this study. These cases were classified into four groups： 58 neonates, 36 patients aged 28 d - 1 years, 20 patients aged 1 - 3 yeats and 32 patients aged 〉 3 years. ①The symptoms of neonates were atypical. Sixteen patients （50%） aged 〉 3 years were associated with traumatic brain injmw, tumor and craniofacial or spinal abnonnal anatomy. ②G ＋ accounted for 54.8% （80/146） and G - accounted for 45.2% （66/146）. The main G ＋ bacteria included Coagulase negative Staphylococcus （ 22.6% ） , Enterococcus （ 13. 0% ）, Streptococcus pneumonia （8.2%）. The main G - bacteria included Eseherichia coli （20.5%） , Acinetobacter baumannii （6.8%）. ③All the G ＋ bacteria were sensitive to vancomycin and linezolid. All G - bacteria were sensitive to meropenem, except 3 of 10 cases with Acinetobacter baumannii and 1 of 3 cases with Psetutomonas nerugirtosa strains. The proportions of ESBLs ＋ in Escherichia coil, Klebsiella and Enterobacter cloacae were 66.7%, 60% and 100%. ④ There were 43.2% （63/146） cases with acute complications. The most common complications included subdural effusion（26 cases） , hydrocephalus（20 cases） and focal neurological lesion （13 cases）. The main pathogens were Escherichia coli（ 15/30 ） , Coagtdase negative Staphylococcus （ 14/33 ） , Streptococcus pneumonia （ 6/12 ） and Acinetobaeter baumannii （6/10）. ⑤31 patients （21. 2%） died or gave up treatment, of them 41. 7% （5/12） were Streptococcus prwumonia. Conclusions The signs and symptoms were atypical in neonates. Anatomy abnormalities should be paid more attention to children older than 3 years. The sensitive antibiotics could be chosen according to the distribution of pathogen and antibiotic susceptibility. The meningitis patients with Streptococcus pneumonia had poor prognosis.