儿童金黄色葡萄球菌感染性心内膜炎临床分析

Clinical analysis of Staphylococcus aureus infective endocarditis in children

目的探讨儿童金黄色葡萄球菌感染性心内膜炎(SAIE)的临床特点、治疗及预后.方法回顾性分析2007年1月至2017年12月在上海交通大学医学院附属上海儿童医学中心治疗的感染性心内膜炎(IE)患儿151例.其中男88例,女63例;年龄(6.27±4.80)岁(1个月~17岁).23例(15.2%)患儿血培养为金黄色葡萄球菌;128例为非金黄色葡萄球菌(NSAIE).分析比较SAIE、NSAIE 2组患儿的临床特点、治疗及预后.结果23例SAIE患儿中男15例,女8例;年龄(6.2±5.6)岁(3个月~16岁);10例患儿未合并心脏基础疾病.SAIE、NSAIE 2组患儿性别、年龄、先天性心脏病手术史比较,差异均无统计学意义(均P>0.05).SAIE组无心脏基础疾病患儿比例[43.5%(10/23例)]明显高于NSAIE组[20.3%(26/128例)],差异有统计学意义(x2=5.762,P=0.016).SAIE组患儿C反应蛋白、红细胞沉降率[60.0(128.0)mg/L、(59.3±43.2)mm/1 h]均高于NSAIE组患儿[25.0(58.0)mg/L、(39.4±31.5)mm/1 h],血清清蛋白水平明显降低[30.1(12.7)g/L比34.3(8.4)g/L],差异均有统计学意义(Z=-2.033、P=0.042,t=-2.283、P=0.024,Z=-2.282、P=0.022);SAIE组患儿发生严重脓毒症概率[21.7%(5/23例)]亦高于NSAIE组[7.0%(9/128例)],差异有统计学意义(Z=5.014,P=0.045).23例SAIE患儿中12例(52.2%)发生脏器栓塞(其中脑栓塞6例、肺栓塞2例、肢体动脉1例、脾动脉1例、肢体动脉+肠系膜上动脉1例、肢体动脉+脑栓塞1例),明显高于NSAIE组[20.3%(26/128例)],差异有统计学意义(x2=7.978,P=0.016);SAIE组患儿发生神经系统并发症发生率[30.4%(7/23例)]亦高于NSAIE组[10.9%(14/128例)],差异有统计学意义(x2=4.669,P=0.031).SAIE组患儿抗生素联合手术治疗18例,死亡1例;单纯抗生素治疗5例,死亡4例,放弃治疗1例;住院期间总病死率[21.7%(5/23例)]高于NSAIE组[6.3%(8/128例)],差异有统计学意义(x2=4.139,P=0.042).结论与NSAIE相比,SAIE较多见于无心脏基础疾病患儿,发生严重脓毒症、栓塞及神经系统并发症概率、住院病死率明显增高,早期手术治疗可降低患儿住院病死率.

Objective To describe the clinical characteristics,treatment and outcomes of Staphylococcus aureus infective endocarditis(SAIE)in children.Methods One hundred and fifty-one children with infective endocarditis(IE)and treated in Shanghai Children's Medical Center of Shanghai Jiaotong University School of Medicine were retrospectively analyzed,from January 2007 to December 2017.There were 88 boys and 63 girls,the age of IE onset ranged from 1 month to 17 years[(6.27±4.80)years].There were 23 cases(15.2%)with infection of staphylococcus aureus,128 cases with non-Staphylococcus aureus infective endocarditis(NSAIE).The clinical characteristics,treatment and prognosis of patients between the SAIE group and the NSAIE group were analyzed and compared.Results Among the SAIE group,there were 15 boys and 8 girls,the age of IE onset ranged from 3 months to 16 years[(6.2±5.6)years];10 cases of them had no underlying heart disease.There was no significant difference in gender,age and previous cardiac surgery between the SAIE group and the NSAIE group(all P>0.05).The number of patients without underlying heart disease in the SAIE group was more than that in the NSAIE group,and the difference was statistically significant[43.5%(10/23 cases)vs.20.3%(26/128 cases),x2=5.762,P=0.016].Compared with the NSAIE group,the SAIE group was associated with significantly higher levels of C-reactive protein[60.0(128.0)mg/L vs.25.0(58.0)mg/L,Z=-2.033,P=0.042],higher erythrocyte sedimentation rate[(59.3±43.2)mm/h vs.(39.4±31.5)mm/h,t=-2.283,P=0.024],and lower levels of serum albumin[30.1(12.7)g/L vs.34.3(8.4)g/L,Z=-2.282,P=0.022].The proportion of severe sepsis in the SAIE group was also significantly higher than that in the NSAIE group[21.7%(5/23 cases)vs.7.0%(9/128 cases),Z=5.014,P=0.045].Twelve cases(52.2%)of the SAIE group had systemic embolic events,including cerebral events(6 cases),pulmonary(2 cases),limbs(1 case),splenic(1 case),limbs and mesenteric(1 case),limbs and cerebral events(1 case).Eighteen cases in the SAIE group were treated with antibiotics combined with surgery and l case died,while 5 cases were treated with antibiotics alone,4 cases died and 1 case abandoned.The SAIE patients had a significantly higher systemic embolic rate[52.2%(12/23 cases)vs.20.3%(26/128 cases),x2=7.978,P=0.016],neurological events rate[30.4%(7/23 cases)vs.10.9%(14/128 cases),x2=4.669,P=0.031]and in-hospital mortality[21.7%(5/23 cases)vs.6.3%(8/128 cases),x2=4.139,P=0.042]than those in the NSAIE group.Conclusions SAIE was most common in those without heart disease.Compared with NSAIE,SAIE is characterized by a higher prevalence of severe sepsis,major neurological events,and inpatient mortality.Timely surgery is recommended in these cases,when possible,before the occurrence of complications.