背景:多重耐药(MDR)和广泛耐药(XDR)鲍曼不动杆菌对临床治疗提出了挑战,并导致儿童高死亡率。我们旨在评估MDR/XDR鲍曼不动杆菌感染儿科患者的危险因素和总死亡率。
方法:本回顾性研究纳入2014年12月至2018年5月上海市儿童医院儿科重症监护病房(PICU)102例发生MDR/XDR鲍曼不动杆菌感染的儿科患者。鲍曼不动杆菌临床分离株从不同的标本包括血液,痰,支气管肺泡灌洗液,脑脊液,腹水,胸腔积液,还有尿液.根据临床和实验室标准研究所的解释标准确定抗生素敏感性试验。临床和生物学数据来自患者的医疗记录。
结果:纳入102例鲍曼不动杆菌感染患者。中位年龄为36(9.6,98.8)个月,病例组中有63名男性。总死亡率为29.4%,而鲍曼不动杆菌相关死亡率为16.7%(17/102,12例血流感染,4例脑膜炎和1例腹腔感染)。28例患者发生血流感染(27.5%),和10例患者(9.8%),其中有中央导管相关的血流感染(6个中心静脉导管,2个PICCs,1个静脉输液口和1个动脉导管)。4例(3.9%)患者的脑脊液(CSF)培养呈阳性。14例(13.7%)患者腹水和胸水培养阳性。下呼吸道分离株(56/102)占所有患者的54.9%。非存活患者的NK细胞活性较低(6.2%±3.61%vs.9.15%±6.21%,P=0.029),更高的CD4+T细胞比率(39.67%±12.18%vs.32.66%±11.44%,P=0.039),和更高的血清水平的inlukin-8(IL-8,15.25(1.62,47.22)pg/mL与0.1(0.1,22.99)pg/mL,当鲍曼不动杆菌感染发展时,P=0.01)。多因素Logistic分析表明血清高Cr(RR,0.934,95CI,0.890-0.981;P=0.007)和高BUN/ALB水平(RR,107.893,95CI,1.425-870.574;p=0.005)与MDR/XDR鲍曼不动杆菌感染患者的高死亡风险相关。
结论:MDR/XDR鲍曼不动杆菌感染是儿科患者死亡率高的严重问题。血液和中枢神经系统感染占死亡的高风险。急性肾损伤与高死亡风险相关。
BACKGROUND: Multidrug resistant (MDR) and extensively drug resistant (XDR) Acinetobacter baumannii presents challenges for clinical treatment and causes high mortality in children. We aimed to assess the risk factors and overall mortality for MDR/XDR Acinetobacter baumannii infected pediatric patients.
METHODS: This retrospective study included 102 pediatric patients who developed MDR/XDR Acinetobacter baumannii infection in the pediatric intensive care unit (PICU) of Shanghai Children\'s Hospital in
China from December 2014 to May 2018. Acinetobacter baumannii clinical isolates were recovered from different specimens including blood, sputum, bronchoalveolar lavage fluid, cerebrospinal fluid, ascites, hydrothorax, and urine. Antibiotic susceptibility test was determined according to the Clinical and Laboratory Standards Institute interpretive criteria. Clinical and biological data were obtained from the patients\' medical records.
RESULTS: 102 patients with Acinetobacter baumannii infection were enrolled. The median age was 36 (9.6, 98.8) months, and there were 63 male in the case group. The overall mortality rate was 29.4%, while the Acinetobacter baumannii-associated mortality rate was 16.7% (17/102, 12 bloodstream infections, 4 meningitis and 1 intra-abdominal infection). Bloodstream infections occurred in 28 patients (27.5%), and 10 patients (9.8%) among them had central line-associated bloodstream infections (6 central venous catheters, 2 PICCs, 1 venous infusion port and 1 arterial catheter). Cerebrospinal fluid (CSF) cultures were positive in 4(3.9%) patients. 14(13.7%) patients got positive cultures in ascites and hydrothorax. Lower respiratory isolates (56/102) accounted for 54.9% of all patients. Non-survival patients appeared to have a lower NK cell activity (6.2% ± 3.61% vs. 9.15% ± 6.21%, P = 0.029), higher CD4+ T cell ratio (39.67% ± 12.18% vs. 32.66% ± 11.44%, P = 0.039),and a higher serum level of interlukin-8 (IL-8, 15.25 (1.62, 47.22)pg/mL vs. 0.1 (0.1, 22.99)pg/mL, P = 0.01) when Acinetobacter baumannii infection developed. Multivariate logistic analysis indicated that high serum level of Cr (RR, 0.934, 95%CI, 0.890-0.981; P = 0.007) and high BUN/ALB level (RR, 107.893, 95%CI, 1.425-870.574; p = 0.005) were associated with high risk of mortality in MDR/XDR Acinetobacter baumannii infected patients.
CONCLUSIONS: MDR/XDR Acinetobacter baumannii infection is a serious concern in pediatric patients with high mortality. Bloodstream and central nervous system infection accounted for high risk of death. Acute kidney injury is associated with high risk of mortality.