儿童活体肝移植术后早期肺部感染临床分析

Clinical analysis of early postoperative pulmonary infection in children after living donor livertransplantation

目的分析儿童活体肝移植术后早期（≤30d）肺部感染的发生情况。方法回顾性分析2006年6月至2009年12月在重庆医科大学附属儿童医院接受活体肝移植的36例患儿的临床资料。结果36例中男17例，女19例，年龄2个月-14岁，术前均排除呼吸道感染。术后发生肺部感染24例（67％），死亡4例（17％），其中3例死因与肺部感染相关。婴儿肺部感染17例（17／20，85％），术前肝功能C级者发生肺部感染10例（10／11，91％）。20例（83％）肺部感染发生在术后2周内。肺部感染者中共培养出65株病原菌，分别为革兰阴性菌46株，革兰阳性菌5株，真菌14株。细菌中前三位依次为铜绿假单胞菌（14株）、肺炎克雷伯菌（8株）、鲍曼不动杆菌（8株）。铜绿假单胞菌对复方新诺明、四环素、氯霉素、氨苄青霉素、一、二代头孢，部分三代头孢几乎100％耐药；肺炎克雷伯菌超广谱B内酰胺酶阳性时，对除碳青酶烯类的13内酰胺类药物几乎100％耐药；鲍曼不动杆菌对青霉素类及头孢菌素类耐药性高，对碳青酶烯类未出现耐药株。真菌中主要为白色念珠菌，对两性霉素B高度敏感。在感染病例中合并巨细胞病毒感染2例，EB病毒感染1例。结论儿童活体肝移植术后早期肺部感染发生率高，病死率不容忽视，婴儿为肺部感染易患人群，术后前2周为高发时段。革兰阴性菌为肺部感染的主要病原菌，呈多重耐药、高度耐药特点。

Objective To analyze the condition of early （≤30 d ） postoperative pulmonary infection in children after living donor liver transplantation （LDLT）. Method The clinical data of 36 cases undergoing LDLT in Children＇s Hospital of Chongqing Medical University were analyzed retrospectively from June 2006 to December 2009. Result Of 36 cases without preoperative respiratory disease, 17 were boys, 19 were girls. Their age ranged from 2 months to 14 years. Pulmonary infection developed in 24 patients, of whom 4 cases died （ 17% ） and 3 deaths were related to pulmonary infection. Pulmonary infection occurred in 17 of 20 infants （85%） and 10 of 11 cases （91%） with liver function of Child-Pugh grade C. Twenty cases （83%） developed pulmonary infection within first 2 weeks after LDLT. Totally 65 pathogenic strains of microorganisms were isolated, in which Gram-negative bacteria, Gram-positive bacteria and fungi were 46 strains, 5 strains, 14 strains respectively. The most frequently isolated bacteria were Pseudomonas aeruginosa （ 14 strains ）, Klebsiella pneumoniae （ 8 strains ） and Acinetobacter baumannii （ 8 strains ）. Pseudomonas aeruginosa showed a resistance rate of almost 100% to cotrimoxazole, tetracycline, chloramphenicol, ampicillin, the first, the second and some of the third generation cephalosporins. Klebsiella pneumoniae producing extended spectrum beta-lactamase had a resistance rate of almost 100% to beta-lactams except carbapenems. Acinetobacter baumannii was exquisitely susceptible to carbapenems, but showed a high resistance to penicillins and cephalosporins. Candida albicans, which was the most common fungus, showed a susceptibility rate of 100% to amphotericin B. In the LDLT recipients of pulmonary infection, cytomegalovirus （CMV） infections occured in 2 patients and Epstein Barr virus （EBV） infection in 1 patient. Conclusion The incidence of early postoperative pulmonary infection was high in children undergoing LDLT, especially in infants. And the mortality should not be ignored. The high risk period for infection was within the first 2 weeks after operation. The pathogens were mainly Gram-negative bacteria,which showed high and multidrug resistance.