【作者】 张瑾；

【导师】 徐青； 时冬彦；

【作者基本信息】 河北医科大学 ， 儿科学（专业学位）， 2014， 硕士

【摘要】 目的：处在生长发育期的儿童代谢旺盛，需氧量高，但是呼吸系统发育不完善，气管、支气管狭小，呼吸肌不发达，纤毛运动较差，肺活量小，且机体免疫功能尚未健全，SIgA、IgA、IgG含量低，乳铁蛋白、溶菌酶、干扰素、补体等数量少、活性不足，故呼吸道感染的发病率较高。下呼吸道感染(Lower respiratory infections，LRTIs)占儿童住院疾病首位。常见病原体包括细菌、病毒、非典型病原体(支原体、衣原体、嗜肺军团菌等)、真菌和原虫等。细菌感染较为常见。随着环境的改变及抗生素的广泛使用，主要致病菌在不断的发生变化。一些生理菌群在特殊条件下变成了致病菌，并逐渐对多种抗生素产生耐药。结合我国各地区差异性大，城乡间经济卫生条件不均，也造成了各地区的致病菌不尽相同，各种细菌感染的治疗原则也各不相同。加之儿科用药范围局限。这些都对临床医师的诊疗造成了很大的困难。因此，定期了解该地区儿童下呼吸道感染病原菌的分布及耐药谱，可以更好的指导临床治疗用药。方法：收集河北医科大学第二医院小儿内科2012年10月—2013年10月入院患儿（生后>28天）中492例明确诊断下呼吸道感染患儿（诊断标准：诸福棠实用儿科学（第7版））的痰(或肺泡灌洗液）行细菌培养及药敏检验。分析检出菌的耐药谱，并对细菌检出率结果进行统计学分析。结果：1在收集的492例合格标本中，培养阳性菌株166例，检出率为33.74%。其中革兰阴性杆菌（G-）123例，占74.10%，主要包括大肠埃希菌，肺炎克雷伯菌，铜绿假单胞菌，鲍曼不动杆菌，嗜麦芽窄食单胞菌等；革兰阳性球菌（G+）43例，占25.90%，主要包括金黄色葡萄球菌，肺炎链球菌，草绿色链球菌等。感染病原菌以G-杆菌为主。2引起儿童下呼吸道感染的主要病原菌在年龄分布上，婴幼儿期及青春期组患儿细菌检出率高于学龄前期及学龄期组；在季节分布上，细菌检出率以秋、冬相对较高；在性别分布上，男女患儿无明显差异。3.1大肠埃希菌对美罗培南、亚胺培南、哌拉西林/他唑巴坦钠、阿米卡星、呋喃妥因敏感率为90%以上，对哌拉西林、氨苄西林及氨苄西林/舒巴坦钠耐药率为90%以上，ESBLs（+）为75%。肺炎克雷伯菌对美罗培南、亚胺培南、哌拉西林/他唑巴坦钠及头孢替坦敏感率为90%以上，对哌拉西林及氨苄西林耐药率为100.00%, ESBLs（+）为47.37%。铜绿假单胞菌对美罗培南、亚胺培南及哌拉西林/他唑巴坦钠敏感率只有60%-70%，对呋喃妥因、氨苄西林、头孢唑林、头孢替坦、氨曲南耐药率为100.00%。鲍曼不动杆菌敏感药物只有阿米卡星（91.67%），左氧氟沙星（69.44%），对头孢呋辛、头孢唑林、头孢吡肟、氨曲南、哌拉西林、哌拉西林/他唑巴坦钠、氨苄西林/舒巴坦及亚胺培南、美罗培南等儿科常用抗生素都有一定耐药性。3.2对金黄色葡萄球菌敏感性高的有呋喃妥因、利奈唑胺、喹努普汀、万古霉素、替加环素、左氧氟沙星、替考拉宁、氯霉素均为100.00%，苄青霉素为100.00%耐药，耐甲氧西林金黄色葡萄球菌（MRSA）的检出率为42.86%。肺炎链球菌对利奈唑胺、万古霉素、左氧氟沙星100.00%敏感，对苄青霉素、克林霉素、苯唑西林全部耐药。结论：1儿童下呼吸道感染致病菌以G-菌为主，不同细菌对抗生素的耐药性不同。2引起儿童下呼吸道感染的主要病原菌在发病年龄、季节分布上有差异性，在性别分布上无明显差异性。3大肠埃希菌和肺炎克雷伯菌仍只对美罗培南、亚胺培南、哌拉西林/他唑巴坦钠有较高的敏感性。非发酵菌多重耐药较严重。G+球菌对万古霉素、利奈唑胺、替考拉宁敏感性高，对苄青霉素、克林霉素、苯唑西林耐药。4了解儿童下呼吸道感染病原菌分布、耐药情况，以及在年龄、季节、性别上的差异,对指导临床用药,合理使用抗生素,降低耐药菌株的产生有重要的指导意义。更多还原

【Abstract】 Objective: In developing children’s metabolism, oxygen demand is high,but the respiratory system is imperfect, the trachea and bronchus is narrow,well developed, the cilia movement is poorer, vital capacity is small, and thebody’s immune function is not yet perfect, low content of SIgA,IgA,IgG, andoferrin, lysozyme, interferon, complement have insufficient number and lessactive, therefore, the incidence of respiratory system infection is higher.Lowerrespiratory infections(LRTIs) of hospitalized children disease first.Commonpathogens include bacteria, viruses and atypical pathogens(mycoplasma,chlamydia, eosinophilic lung legionella bacteria, etc.), fungi and protozoa, etc.Bacterial infections are common. With the change of the environment and thewidespread use of antibiotics, the main pathogenic bacteria is constantlychanging. Some physiological flora in special conditions become pathogenicbacteria, and more resistant to multiple antibiotics. According to our country’sregional difference is big, sanitation inequality between urban and ruraleconomy, also caused the regional different pathogenic bacteria, the principleof the treatment of various bacterial infections are different. Combined withthe scope of pediatric drugs. These are for clinicians and caused greatdifficulties. Understand the region on a regular basis, therefore, children’slower respiratory infection distribution and drug resistance of pathogenicbacteria spectrum, can better guide clinical drug use.Methods: Collection of hebei medical university second hospitalpediatric medical in October2012-October2013hospitalized children (>28days after birth) in492patients with diagnosis of children with respiratorytract infection phlegm (or alveolar lavage) line of bacterial culture and drugsusceptibility test. Results:1In the collection of specimens of492cases of qualified, the positive strains166cases,33.74%detection rate. The gram-negative bacteria (G-) of123cases (74.10%), including e. coli, klebsiella pneumoniae, pseudomonasaeruginosa, acinetobacter baumannii, eosinophilic malt narrow food such asbacterium; Gram-positive bacteria (G+)43cases, accounted for25.90%,including staphylococcus aureus, streptococcus pneumoniae, streptococcusviridans, etc. Infection of pathogenic bacteria is given priority to with G-bacillus.2The main pathogenic bacteria in children’s lower respiratory infection in theage distribution, infants and young children and adolescent group bacteriadetection rate is higher than one preschool and school-age children. On theseason distribution, bacteria detection rate in autumn and winter are relativelyhigh. No significant differences in gender distribution.3.1E. coli sensitive rate was over90%to MeropenemforInjection、Imipenem、 Piperacillin Sodium and Tazobactam Sodium、 amikin、Furadantin.To piperacillin、Ampicillin、Ampicillin Sodium and SulbactamSodium resistant rate of90%above. ESBLs (+) of75%. Klebsiella pneumoniaresistant rate of more than90%to imipenem、meropenemforInjection、piperacillin sodium and tazobactam sodium、cefotetan. To piperacillin andampicillin resistant rate of100.00%. ESBLs (+) of47.37%. Pseudomonasaeruginosa to ampicillin、Furadantin、Cefazolin、Cefotetan、Aztreonamresistant rate of100.00%. To Imipenem、MeropenemforInjection、PiperacillinSodium and Tazobactam Sodium sensitive rate is only60%to70%.Acinetobacter baumannii sensitive drugs only amikacin （91.67%） andlevofloxacin（69.44%）. Have a certain resistance to pediatrics commonly usedantibiotics(Cefuroxime、Cefazolin、cefepime、Aztreonam、Piperacillin Sodiumand Tazobactam Sodium、Piperacillin、Ampicillin Sodium and SulbactamSodium、MeropenemforInjection、Imipenem, etc.).3.2Staphylococcus aureus to Furadantin、 Linezolid、 Quinupristin、Vancomycin、Tigecycline、Teicoplanin、chloroamphenicol、levofloxacinsensitive rate of100.00%.Penicillin resistance is100.00%. MRSA detection rate of42.86%. Streptococcus pneumoniae to Penicillin、Clindamycin、xacillinsensitive rate of100.00%. Of Penicillin、Clindamycin、Oxacillin all resistance.Conclusion:1Children’s lower respiratory infection of pathogenic bacteria is givenpriority to with G-bacteria, different bacterial have different resistance toantibiotics.2E. coli and klebsiella pneumonia bacteria still only to Meropenem-forInjection、Imipenem、Piperacillin Sodium and Tazobactam Sodium havehigher sensitivity.The unfermentation bacteria multi-resistant more serious.G+cocci to Vancomycin、Linezolid、Teicoplanin was high sensitivity, toBenzathine、Clindamycin、Oxacillin was resistance.3The main pathogenic bacteria in children’s lower respiratory infectionare differences in onset age,and seasonal distribution, has no obviousdifference in gender distribution.4Understanding of children’s lower respiratory infection pathogenicbacteria distribution and drug resistance, and the gender, age, seasondifferences, have important guiding significance to guide the clinicalmedication, the rational use of antibiotics, reducing the generation ofdrug-resistant strains.更多还原