儿童化脓性脑膜炎的临床特点及预后影响因素分析
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摘要
目的:探讨儿童化脓性脑膜炎(Purulent meningitis,PM)的临床特点及影响预后的相关危险因素。方法:选择184例PM患儿作为研究对象,收集所有患儿的临床资料,对其发病情况、临床表现、并发症及后遗症、病原学检查结果等情况进行整理分析。根据Glasgow临床结局评分情况将47例评分5分的患儿纳入预后良好组,评分为1～4分的133例患儿纳入预后不良组,对两组患儿的基本情况、临床特征、治疗经过、辅助检查结果等可能影响患儿预后的因素进行单因素及Logistic回归分析。结果:引起患儿PM的致病原因主要为呼吸道感染(55.4%),其次依次是消化道感染(15.2%)和中耳炎(7.6%);所有患儿的主要临床变现有发热、呕吐、颅内高压、惊厥,发生率均超过50%,其中1岁以内儿童易发生惊厥,发病率高达77.6%,3岁以下儿童前囟隆起发生率高于3岁以上儿童,3岁以上儿童的头痛、呕吐及颅内高压的发生率高于3岁以下儿童;所有患儿在院期间并发症发生率为28.3%,主要为硬膜下积液(23.9%);出院时后遗症发生率为17.4%,主要为继发性癫沬(14.7%);在病原学检测中,血液标本病原菌主要为中葡萄球菌、肺炎链球菌及大肠杆菌;脑脊液标本中病原菌主要为肺炎链球菌、葡萄球菌及大肠埃希菌。经过单因素及多因素Logistic回归分析后得到,年龄低、合并昏迷(意识障碍)、合并瞳孔双侧不等大、脑脊液乳酸水平越高、脑脊液糖/血糖越低是影响PM患儿预后的独立危险因素,差异均具有统计学意义(P<0.05)。结论:儿童PM的发病原因、临床表现、病原微生物均具有多样性,不同年龄阶段的临床表现也存在差异,发病后存在不同程度并发症或后遗症;同时年龄低、合并昏迷(意识障碍)、合并瞳孔双侧不等大、脑脊液乳酸水平越高、脑脊液糖/血糖越低是降低PM患儿预后的独立危险因素。可对不同群体患儿给予针对性的识别和诊治,在早期积极采取防护监控措施,最大程度改善患儿的预后。
Objective To investigate the clinical characteristics of children′s suppurative meningitis(PM) and the related risk factors affecting the prognosis.Method 184 cases of PM were selected as the research subjects.The clinical data of all the children were collected,and the incidence,clinical manifestations,complications and sequelae,and the results of the pathogenic examination were analyzed.According to the scores of clinical outcomes of 47 cases of Glasgow score of 5 were enrolled in the good prognosis group,133 children of scores of 1～4 divided into poor prognosis group,the basic situation,the two groups of children with clinical characteristics,treatment and the results of auxiliary examinations may influence factors analysis of the prognosis of children with single factor and Logistic regression.Results The main causes of PM in children were respiratory tract infection(55.4%),followed by digestive tract infection(15.2%) and otitis media(7.6%).The main clinical realization of all children with fever,vomiting,seizures,intracranial hypertension,the incidence rate of more than 50%,of which less than 1 years old children prone to seizures,the incidence rate of up to 77.6%,children under the age of 3 was higher than that of anterior fontanelle bulge above the age of 3 children,3 children over the age of headache,vomiting and intracranial hypertension.The incidence was higher than that of children under the age of 3;The incidence of complications in all children was 28.3%,mainly in subdural effusion(23.9%).The incidence of sequelae at discharge was 17.4%,mainly secondary epilepsy(14.7%).The main pathogens in blood samples were Staphylococcus Streptococcus pneumoniae and Escherichia coli.The pathogens in CSF were mainly Streptococcus pneumoniae,Staphylococcus and Escherichia coli.After single factor and multi factor Logistic regression analysis,the independent risk factors for the prognosis of PM children were low age,comatose coma(disturbance of consciousness),complicated bilateral pupil size,higher level of lactic acid in CSF and lower CSF glucose/blood glucose.The difference was statistically significant(P<0.05).Conclusion The causes,clinical manifestations and pathogenic microbes of purulent meningitis in children are diverse,there are also differences in clinical manifestations at different ages,and there are different degrees of complications or sequelae after the onset of the disease.At the same time,low age,comatose coma,disturbance of pupil size,high level of lactic acid in CSF,and low glucose in CSF/blood glucose were independent risk factors for the prognosis of PM.It can give specific recognition and treatment to children of different groups,take protective measures actively in early stage,and improve the prognosis of the children to the greatest extent.
Objective To investigate the clinical characteristics of children′s suppurative meningitis(PM) and the related risk factors affecting the prognosis.Method 184 cases of PM were selected as the research subjects.The clinical data of all the children were collected,and the incidence,clinical manifestations,complications and sequelae,and the results of the pathogenic examination were analyzed.According to the scores of clinical outcomes of 47 cases of Glasgow score of 5 were enrolled in the good prognosis group,133 children of scores of 1～4 divided into poor prognosis group,the basic situation,the two groups of children with clinical characteristics,treatment and the results of auxiliary examinations may influence factors analysis of the prognosis of children with single factor and Logistic regression.Results The main causes of PM in children were respiratory tract infection(55.4%),followed by digestive tract infection(15.2%) and otitis media(7.6%).The main clinical realization of all children with fever,vomiting,seizures,intracranial hypertension,the incidence rate of more than 50%,of which less than 1 years old children prone to seizures,the incidence rate of up to 77.6%,children under the age of 3 was higher than that of anterior fontanelle bulge above the age of 3 children,3 children over the age of headache,vomiting and intracranial hypertension.The incidence was higher than that of children under the age of 3;The incidence of complications in all children was 28.3%,mainly in subdural effusion(23.9%).The incidence of sequelae at discharge was 17.4%,mainly secondary epilepsy(14.7%).The main pathogens in blood samples were Staphylococcus Streptococcus pneumoniae and Escherichia coli.The pathogens in CSF were mainly Streptococcus pneumoniae,Staphylococcus and Escherichia coli.After single factor and multi factor Logistic regression analysis,the independent risk factors for the prognosis of PM children were low age,comatose coma(disturbance of consciousness),complicated bilateral pupil size,higher level of lactic acid in CSF and lower CSF glucose/blood glucose.The difference was statistically significant(P<0.05).Conclusion The causes,clinical manifestations and pathogenic microbes of purulent meningitis in children are diverse,there are also differences in clinical manifestations at different ages,and there are different degrees of complications or sequelae after the onset of the disease.At the same time,low age,comatose coma,disturbance of pupil size,high level of lactic acid in CSF,and low glucose in CSF/blood glucose were independent risk factors for the prognosis of PM.It can give specific recognition and treatment to children of different groups,take protective measures actively in early stage,and improve the prognosis of the children to the greatest extent.
引文
[1] 仇世蓉.小儿化脓性脑膜炎的诊断和治疗进展[J].中国实用医药,2016,11(17):283.
[2] 何燕,郭虎,金波,等.小儿难治性化脓性脑膜炎的临床特点及致病因素[J].临床神经病学杂志,2014,27(3):213.
[3] Park B S,Si E K,Si H P,et al.Procalcitonin as a potential predicting factor for prognosis in bacterial meningitis[J].Journal of Clinical Neuroscience,2017,36(5):129.
[4] 胡亚美.诸福棠实用儿科学[M].北京:人民卫生出版社,2002:100.
[5] 张宏亮,李南,黄振光,等.儿童化脓性脑膜炎药物治疗循证指南的系统评价[J].中国药房,2016,27(21):2948.
[6] Qu J,Zhou T,Zhong C,et al.Comparison of clinical features and prognostic factors in HIV-negative adults with cryptococcal meningitis and tuberculous meningitis:a retrospective study[J].Bmc Infectious Diseases,2017,17(1):51.
[7] Kamoun F,Dowlut M B,Ameur S B,et al.Neonatal purulent meningitis in southern Tunisia:Epidemiology,bacteriology,risk factors and prognosis[J].Fetal & Pediatric Pathology,2015,34(4):233.
[8] Neuberger A,Shofty B,Bishop B,et al.Risk factors associated with death or neurological deterioration among patients with Gram-negative postneurosurgical meningitis[J].Clinical Microbiology & Infection,2016,22(6):573.
[9] 秋艳萍,焦艳萍,张孝兴,等.儿童化脓性脑膜炎及结核性脑膜炎临床特点及预后不良危险因素的对比分析[J].神经损伤与功能重建,2017,12(1):37.
[10] Mekitarian F E,Horita S M,Gilio A E,et al.Cerebrospinal fluid lactate level as a diagnostic biomarker for bacterial meningitis in children[J].International Journal of Emergency Medicine,2014,7(1):1.
[11] 徐青青,李梅.317例儿童化脓性脑膜炎临床分析[J].中国当代儿科杂志,2015,17(7):710.
[12] 陈瑞琼,钟晓璇,麦坚凝,等.儿童化脓性脑膜炎后遗症的随访及其预后不良危险因素的探讨[J].广州医药,2015,46(1):36.
[13] 张晓敏,姚春梅,董志恒.儿童化脓性脑膜炎临床观察及预后影响因素分析[J].中国中西医结合儿科学,2016,8(6):586.
[14] 翟颖如,李朝阳.儿童化脓性脑膜炎病原菌分布及耐药性分析[J].中西医结合心脑血管病杂志,2017,15(18):2357.
[15] 胡伟,王秉圆,李继安,等.儿童化脓性脑膜炎病原菌分布及其耐药性分析[J].临床儿科杂志,2017,35(5):366.
[16] Singh A K,Malhotra H S,Garg R K,et al.Paradoxical reaction in tuberculous meningitis:presentation,predictors and impact on prognosis[J].Bmc Infectious Diseases,2016,16(1):1.
[17] 王秀锋,孙瑞雪,付琳,等.化脓性脑膜炎患儿感染后遗症预后危险因素研究[J].中华医院感染学杂志,2016,26(20):4743.
[18] 李海深,黄海波,赖丹娜.大肠杆菌与肺炎链球菌所致儿童化脓性脑膜炎临床特点对比分析[J].吉林医学,2017,38(12):2207.
[19] 辛静,徐曼.儿童化脓性脑膜炎近期不良预后危险因素分析[J].中南医学科学杂志,2016,44(6):657.
[20] 郑飞霞,林忠东,叶秀云,等.婴儿化脓性脑膜炎不良预后的危险因素分析[J].中华全科医学,2017,15(3):460.
[21] Ai J,Xie Z,Gang L,et al.Etiology and prognosis of acute viral encephalitis and meningitis in Chinese children:a multicentre prospective study[J].Bmc Infectious Diseases,2017,17(1):494.
[2] 何燕,郭虎,金波,等.小儿难治性化脓性脑膜炎的临床特点及致病因素[J].临床神经病学杂志,2014,27(3):213.
[3] Park B S,Si E K,Si H P,et al.Procalcitonin as a potential predicting factor for prognosis in bacterial meningitis[J].Journal of Clinical Neuroscience,2017,36(5):129.
[4] 胡亚美.诸福棠实用儿科学[M].北京:人民卫生出版社,2002:100.
[5] 张宏亮,李南,黄振光,等.儿童化脓性脑膜炎药物治疗循证指南的系统评价[J].中国药房,2016,27(21):2948.
[6] Qu J,Zhou T,Zhong C,et al.Comparison of clinical features and prognostic factors in HIV-negative adults with cryptococcal meningitis and tuberculous meningitis:a retrospective study[J].Bmc Infectious Diseases,2017,17(1):51.
[7] Kamoun F,Dowlut M B,Ameur S B,et al.Neonatal purulent meningitis in southern Tunisia:Epidemiology,bacteriology,risk factors and prognosis[J].Fetal & Pediatric Pathology,2015,34(4):233.
[8] Neuberger A,Shofty B,Bishop B,et al.Risk factors associated with death or neurological deterioration among patients with Gram-negative postneurosurgical meningitis[J].Clinical Microbiology & Infection,2016,22(6):573.
[9] 秋艳萍,焦艳萍,张孝兴,等.儿童化脓性脑膜炎及结核性脑膜炎临床特点及预后不良危险因素的对比分析[J].神经损伤与功能重建,2017,12(1):37.
[10] Mekitarian F E,Horita S M,Gilio A E,et al.Cerebrospinal fluid lactate level as a diagnostic biomarker for bacterial meningitis in children[J].International Journal of Emergency Medicine,2014,7(1):1.
[11] 徐青青,李梅.317例儿童化脓性脑膜炎临床分析[J].中国当代儿科杂志,2015,17(7):710.
[12] 陈瑞琼,钟晓璇,麦坚凝,等.儿童化脓性脑膜炎后遗症的随访及其预后不良危险因素的探讨[J].广州医药,2015,46(1):36.
[13] 张晓敏,姚春梅,董志恒.儿童化脓性脑膜炎临床观察及预后影响因素分析[J].中国中西医结合儿科学,2016,8(6):586.
[14] 翟颖如,李朝阳.儿童化脓性脑膜炎病原菌分布及耐药性分析[J].中西医结合心脑血管病杂志,2017,15(18):2357.
[15] 胡伟,王秉圆,李继安,等.儿童化脓性脑膜炎病原菌分布及其耐药性分析[J].临床儿科杂志,2017,35(5):366.
[16] Singh A K,Malhotra H S,Garg R K,et al.Paradoxical reaction in tuberculous meningitis:presentation,predictors and impact on prognosis[J].Bmc Infectious Diseases,2016,16(1):1.
[17] 王秀锋,孙瑞雪,付琳,等.化脓性脑膜炎患儿感染后遗症预后危险因素研究[J].中华医院感染学杂志,2016,26(20):4743.
[18] 李海深,黄海波,赖丹娜.大肠杆菌与肺炎链球菌所致儿童化脓性脑膜炎临床特点对比分析[J].吉林医学,2017,38(12):2207.
[19] 辛静,徐曼.儿童化脓性脑膜炎近期不良预后危险因素分析[J].中南医学科学杂志,2016,44(6):657.
[20] 郑飞霞,林忠东,叶秀云,等.婴儿化脓性脑膜炎不良预后的危险因素分析[J].中华全科医学,2017,15(3):460.
[21] Ai J,Xie Z,Gang L,et al.Etiology and prognosis of acute viral encephalitis and meningitis in Chinese children:a multicentre prospective study[J].Bmc Infectious Diseases,2017,17(1):494.