【作者】 王颖；

【导师】 杨玉霞；

【作者基本信息】 郑州大学 ， 儿科学（专业学位）， 2021， 硕士

【摘要】 研究背景社区获得性肺炎(Community acquired pneumonia,CAP)是指在医院外(社区)发病的感染性肺炎,包括在医院外(社区)感染了具有明确潜伏期的病原体而在入院后潜伏期内发病的肺炎。CAP是全球5岁以下儿童死亡的主要原因,也是最常见的感染性疾病之一。目前确定CAP的病原体仍然是个难题。感染CAP的病原体既可以是病毒,也可以是细菌,甚至是病毒-细菌共同导致CAP的发生。最新研究证据表明,在许多情况下,病毒-细菌双重感染可能会加重CAP的严重程度。对于儿童重症CAP,早期明确其感染病原体,合理选择药物的应用,是影响患儿治疗效果、预后的关键,也是降低病死率的关键。现临床检测病原体常用的检测方法包括分离培养、抗原检测等方法,过程繁琐,耗时较长,灵敏度低,不能满足临床对病原学快速诊断的要求。本研究采用PCR检测方法—荧光探针熔解曲线技术,对我院PICU科因重症CAP住院患儿的病原学进行分析,以快速准确了解重症CAP患儿感染的病原体,为临床用药提供一定的依据,有助于改善患儿预后。研究目的了解我院重症CAP患儿病原体分布与年龄、性别的关系,并对其并存的基础疾病、临床表现及胸部影像学特点进行统计分析,对疾病的病原学诊断及治疗提供帮助,为临床药物的选择及应用提供一定的依据。研究方法选取我院PICU科2019年8月至2020年10月因重症CAP住院且行机械通气的70例患儿为研究对象,收集其气管导管内痰液标本。采用多重实时荧光PCR技术检测37种病原体(表皮葡萄球菌、肺炎衣原体、金黄色葡萄球菌(Staphylococcus aureus,SA)、肺炎支原体(Mycoplasma pneumoniae,MP)、白色念珠菌、百日咳杆菌、立克次体、肺炎链球菌(Streptococcus pneumoniae,SP)、流感嗜血杆菌、卡他莫拉菌、鲍曼不动杆菌、肺炎克雷伯菌、大肠埃希菌、嗜肺军团菌、隐球菌、铜绿假单孢杆菌、酿脓链球菌、烟曲霉菌以及博卡病毒、人偏肺病毒、副流感病毒Ⅲ、轮状病毒、肠道病毒、副流感病毒Ⅰ、甲型流感病毒、鼻病毒、乙型呼吸道合胞病毒、乙型流感病毒、甲型呼吸道合胞病毒、腺病毒、副流感病毒Ⅱ、冠状病毒NL63、冠状病毒229E、冠状病毒OC43、冠状病毒HKU1、冠状病毒SARS、副流感病毒Ⅳ)。使用Microsoft Excel 2010软件包对数据进行处理。采用SPSS26.0统计软件进行数据分析,采用χ2或Fisher确切概率法。以α=0.05为检验标准,P<0.05为差异有统计学意义。研究结果1.病原体检出情况本研究70例患儿中,有58例患儿检测出病原体,阳性率为82.9%。单一病原体感染检出14例(20.0%),多重病原体感染检出44例(62.9%)。其中副流感病毒(Human parainfluenza virus,HPIVs)检出率最高,共22例,占总例数的31.4%;金黄色葡萄球菌、铜绿假单胞菌、呼吸道合胞病毒(Respiratory syncytial virus,RSV)、肺炎支原体,各检出14例,各占总例数的20.0%。其次为SP,检出10例,占总例数的14.3%;鲍曼不动杆菌检出8例,占总例数的11.4%;检出率较低的为流感嗜血杆菌6例,占总例数的8.6%;白色念珠菌、大肠埃希菌各4例,占总例数的5.7%;肺炎克雷伯菌、卡他莫拉菌2例,占总例数的2.9%。在多重病原体感染中,双重病原体感染36例,三重及以上病原体8例。70例患儿混合感染44例,占62.9%;病毒合并细菌14例,占31.8%;两种病毒感染6例,占13.6%;病毒合并支原体4例,占9.1%;细菌合并真菌2例,占4.5%。2.不同年龄组患儿病原体检出情况研究结果显示,29d~1岁组(44人)患儿中,病原体检出38例(86.4%),其中副流感病毒检出率最高。1~3岁组(12人)患儿中,病原体检出10例(83.3%),其中金黄色葡萄球菌、副流感病毒最高。3岁以上组(14人)患儿中,病原体检出10例(71.4%),其中肺炎支原体检出率最高。本研究显示,不同年龄组患儿的病毒总检出率不同,年龄分布以小年龄儿童为主,其中3岁以下患儿占88.9%,1岁以下患儿占72.2%。本研究显示,重症CAP患儿的主要病毒是副流感病毒,且副流感病毒阳性标本主要来自29d~1岁组患儿。3.不同性别患儿病原体检出情况本研究70例患儿中,其中男40例,女30例,病原体检出差异无统计学意义。4.患儿并存基础疾病的情况患儿并存基础疾病的有60例(85.7%),其中贫血、营养不良的48例(80.0%),先天性心脏病26例(43.3%),遗传代谢性疾病18例(30.0%),神经系统疾病12例(20.0%),甲状腺功能减退8例(13.3%),肺发育不良、先天性气道发育畸形4例(6.7%),其他疾病4例(6.7%)。5.临床表现本研究中,70例临床表现有三凹症阳性及紫绀44例(62.9%),肺部听诊啰音44例(62.9%),呼吸急促36例(51.4%),发热30例(42.9%),咳嗽24例(34.3%),肺部听诊哮鸣音20例(28.6%),抽搐或昏迷14例(20.0%),肝大14例(20%),心音低钝6例(8.6%),呕吐4例(5.7%),呼吸音减低4例(5.7%),尿量减少2例(2.9%)。6.胸部影像学(X线胸片)本研究中,70例患儿胸片结果显示:肺实变30例(42.9%),肺不张并胸腔积液的22例(31.4%),急性呼吸窘迫综合征(Acute respiratory distress syndrome,ARDS)6例(8.6%),肺出血6例(8.6%),弥漫间质渗出性改变6例(8.6%),气胸4例(5.7%),斑片状改变4例(5.7%),肺气肿2例(2.9%)。结论1.我院重症CAP患儿气管导管内痰液检出病毒依次为副流感病毒、呼吸道合胞病毒。2.检出前三位细菌分别为金黄色葡萄球菌、铜绿假单胞菌、肺炎链球菌。3.各种病原体混合检出率为62.9%,其中以细菌-病毒混合检出多见。更多还原

【Abstract】 Background Community acquired pneumonia(CAP)refers to the infectious pneumonia that develops outside the hospital(community),including the pneumonia that develops during the incubation period after admission after being infected with pathogens with a clear incubation period outside the hospital(community).CAP is the leading cause of death among children under 5 years of age worldwide and one of the most common infectious diseases.Identifying the pathogen of CAP remains a challenge.CAP pathogens can be either viruses or bacteria,or even virus-bacteria co-cause CAP.Recent evidence suggests that,in many cases,virus-bacterial dual infections may exacerbate the severity of CAP.For children with severe CAP,early identification of the pathogen of infection and reasonable choice of drug application are the keys to affect the treatment effect and prognosis of children with severe CAP,as well as the key to reduce the mortality.At present,the commonly used detection methods for clinical detection of pathogens include isolation and culture,antigen detection and other methods,which process is very complicated,time and labor consuming,insensitivity,cannot meet the clinical requirements for rapid diagnosis of etiology.In this study,PCR detection method--fluorescent probe fusion curve technique was used to analyze the etiology of hospitalized children with severe CAP in our PICU department,so as to quickly and accurately understand the infection pathogens of children with severe CAP,provide certain basis for clinical medication,and help to improve the prognosis of children.Objective To understand the relationship between the distribution of pathogens and age and gender in children with severe CAP in our hospital,and to conduct statistical analysis on the co-existing basic diseases,clinical manifestations and chest imaging characteristics,is conducive to the etiological diagnosis and treatment of the disease,and to provide a certain basis for clinical medication.Methods Seventy children with severe CAP hospitalized and receiving mechanical ventilation in PICU Department of our hospital from August 2019 to October 2020 were selected as the research subjects,and sputum samples in tracheal tubes were collected.Uses real-time fluorescence PCR technique to detect multiple 37 kinds of pathogens(epidermis staphylococcus,pneumonia chlamydia,staphylococcus aureus(SA),mycoplasma pneumoniae(MP),candida albicans,whooping cough bacili,rickettsia,streptococcus pneumoniae(SP),haemophilus influenzae,catarrh mora bacteria,acinetobacter baumannii,klebsiella pneumoniae,e.coli,eosinophilic lung legionella,cryptococcosis,verdigris false single spore bacillus,streptococcus pyogenes,smoke aspergillus and boca juniors,one partial pulmonary virus,parainfluenza virus Ⅲ,rotavirus,intestinal virus,parainfluenza Ⅰ,influenza a virus,nose,b respiratory syncytial virus,hepatitis b virus,swine respiratory syncytial virus,adenovirus,deputy Ⅱ influenza virus,coronavirus NL63,229 e coronavirus,coronavirus OC43,coronavirus HKU1 deputy flu virus,SARS coronavirus,Ⅳ).Microsoft Excel 2010 software package was used for data processing.SPSS26.0 statistical software was used for data analysis,and χ2 or Fisher exact probability method was used.α=0.05 was used as the test standard,and P < 0.05 was considered statistically significant.Results 1.Pathogen physical examination results Of the 70 children included in the study,pathogens were detected in 58 children,with a positive rate of 82.9%.Single pathogen infection was found in 14 cases(20.0%),and multiple pathogen infection was found in 44 cases(62.9%).The detection rate of Human parainfluenza virus(HPIVs)was the highest,with 22 cases,accounting for 31.4% of the total cases.Staphylococcus aureus,Pseudomonas aeruginosa,Respiratory Syncytial Virus(RSV)and Mycoplasma pneumoniae were detected in 14 cases each,accounting for 20.0% of the total cases.Streptococcus pneumoniae was detected in 10 cases,accounting for 14.3% of the total cases.Acinetobacter baumannii was detected in 8 cases,accounting for 11.4% of the total cases.The detection rate of Haemophilus influenzae was low in 6 cases,accounting for 8.6% of the total cases.Candida albicans and Escherichia coli were 4 cases each,accounting for 5.7% of the total cases.Klebsiella pneumoniae and Moraxella catarae were 2 cases,accounting for 2.9% of the total cases.Among the multiple pathogen infections,there were 36 cases of double pathogen infection and 8 cases of triple or above pathogen infection.In 70 children,44 cases were mixed infection,accounting for 62.9%;14 cases of virus and bacteria,accounting for 31.8%;6 cases were infected by two viruses,accounting for 13.6%.4 cases of virus with mycoplasma,accounting for 9.1%;2 cases of bacteria with fungi,accounting for 4.5%..2.Pathogenic examinations in children of different age groups The results showed that 38 cases(86.4%)of the 44 children aged from 29 days to 1 years were found to be pathogenic,and the detection rate of parainfluenza virus was the highest.Among the 12 children aged 1 to 3 years,10 cases(83.3%)were found to be pathogenic,among which Staphylococcus aureus and parainfluenza virus were the highest.Among the 14 children aged over 3 years,10 cases(71.4%)were found to be pathogenic,and Mycoplasma pneumoniae had the highest detection rate.This study showed that the total detection rate of the virus was different in different age groups,and the age distribution was mainly in younger children,of which 88.9% were children under 3 years old and 72.2% were children under 1 years old.This study showed that the main virus in children with severe CAP was Human parainfluenza virus,and the positive samples of parainfluenza virus were mainly from children aged 29 d to 1 years.3.Pathogenic examinations of children of different genders Among the 70 children included in the study,there were 40 males and 30 females,and the difference in pathogen physical examination was not statistically significant.4.The coexistence of basic diseases in children There were 60 cases(85.7%)of children with basic diseases,including 48 cases of anemia and malnutrition(80.0%),26 cases of congenital heart disease(43.3%),18 cases of genetic metabolic diseases(30.0%),12 cases of nervous system diseases(20.0%),8 cases of hypothyroidism(13.3%),4 cases of pulmonary dysplasia and congenital airway malformation(6.7%),and 4 cases of other diseases(6.7%).5.Clinical manifestations In this study,70 cases of clinical manifestations of three concave positive and purple purple 44 cases(62.9%),lung auscultation then 44 cases(62.9%),shortness of breath 36 cases(51.4%),30 cases(42.9%)of fever,24 cases(34.3%)of cough,20 cases(28.6%)of lung auscultation wheezing,14 cases(20.0%)of convulsions,lethargy,or coma,14 cases(20%)of hepatomegaly,low heart sounds blunt 6 cases(8.6%),4 cases(5.7%)of vomiting,decreased breath sounds in 4 cases(5.7%),reduced the volume of urine in 2 cases(2.9%). In this study,chest radiographs of 70 children showed lung consolidation in 30 cases(42.9%),atelectasis with pleural effusion in 22 cases(31.4%),ARDS in 6 cases(8.6%),pulmonary hemorrhage in 6 cases(8.6%),diffuse interstitial exudative changes in 6 cases(8.6%),pneumothorax in 4 cases(5.7%),patchy changes in 4 cases(5.7%),and emphysema in 2 cases(2.9%).6.Chest Imaging(Chest X-ray)Conclusions 1.Viruses detected in the sputum of tracheal tubes of children with severe CAP in our hospital were parainfluenza virus and respiratory syncytial virus in order.2.The top three bacteria were Staphylococcus aureus,Pseudomonas aeruginosa and Streptococcus pneumoniae.3.The mixed detection rate of various pathogens was 62.9%,among which the mixed detection rate of bacteria and virus was the most common.更多还原