中法两家医院早发型新生儿脓毒症临床资料对比分析

Clinical manifestations and treatment of early-onset neonatal sepsis ： a Chinese-French comparison

目的了解中法两国对早发型新生儿脓毒症（early—onsetneonatalsepsis，EONS）在临床表现、诊断、治疗方面的不同，为提高重庆医科大学附属儿童医院（简称重医）对EONS的诊治水平提供依据。方法对法国某医院和重医共146例EONS患儿的细菌谱、临床表现、抗菌药使用、产前危险因素记录和筛查情况进行回顾性分析。结果重医常见致病菌为凝固酶阴性葡萄球菌（69．2％）和大肠杆菌（15．4％）；法国医院为B族链球菌（33．3％）和大肠杆菌（33．3％）。法国医院胃液和周围拭子培养常见大肠杆菌（33．3％），B族链球菌（21．2％），凝固酶阴性葡萄球菌（18．2％）等。重医抗菌药使用总天数11．4±7．2（d）、平均每个患儿抗菌药使用的种类（3．1±0．9）和换抗菌药人数比例（70．2％）均大于法国医院6．2±2．5（d），2．2±0．8（d），（9．9％）。两院首剂抗菌药常联用两种抗菌药（重医二代头孢＋半合成青霉素，法国医院阿莫西林＋阿米卡星）。重医二、三线抗菌药常见碳青霉烯类和万古霉素，法国医院常见三代头孢和万古霉素。重医对多种产前危险因素（绒毛膜羊膜炎、母亲发热、破膜到胎儿娩出时间、孕期是否行阴道拭子或尿路感染情况、羊水污染、产前抗菌药使用、EONS的既往史）的记录率均低于法国医院；产前危险因素筛查阳性率两院差异不大。在生后立即出现异常而入院的患儿中，两院最常见的异常均为呼吸困难（96．5％VS．88．2％）；在生后72h之内出现异常的患儿中，两院常见入院原因构成比不同：重医常见原因为呼吸困难（44．4％），反应差（22．2％）等；法国医院常见原因为C反应蛋白升高（78．2％），发热（5．5％）等。两所医院CRP诊断EONS的假阴性率无统计学差异。结论两所医院对EONS诊断、治疗有很大不同。重视产前危险因素的筛查与记录、加强产科对初生新生儿的监护可提高重医对EONS患儿的早期诊断的准确性。对具有产前／产时危险因素的新生儿积极进行胃液／周围拭子培养并行相应的药敏试验可能帮助临床医生进行抗菌药的选用．减少患儿的换药次数和抗菌药使用时间。

Objective To realize the difference between China and France in the clinical manifestations, diagnosis and treatment of early-onset neonatal sepsis （EONS） and to provide basis to improve the level of our hospital in diagnosing and treating this disease. Method Data of 146 cases of EONS were retrospectively analyzed. All data were collected from our hospital and a French hospital. Bacterial spectrum, clinical manifestations, use of antibacterial drugs, occurrence of recording and screening of perinatal risk factors were compared between the two hospitals. Result The most common pathogenic bacteria in our hospital were coagulase-negative staphylococcus （ 69.2% ） and Escherichia coli （ 15.4% ） while in the French Hospital, group B streptococcus （33.3%） and Escherichia coli （33.3%）. The most common pathogenic bacteria in gastric liquid and peripheral swabs of the French hospital were Escherichia coli （33.3%） and group B streptococcus （21.2%）. Total days of antibacterial use 11.4 ± 7.2 （d） , mean sorts of antibacterial drugs for single patient （ 3. 1 ± 0. 9 ） and proportion of patients who had antibacterialdrug changes （ 70. 2% ） were greater than the French hospital 6. 2 ± 2. 5 （ d）, 2.2 ± 0. 8 （ d）, （ 9. 9% ）. Both hospitals were inclined to combine 2 antibacterial drugs for the first dose （second-generation cephalosporins＋ semi-synthetic penicillin in our hospital vs. amoxicillin ＋ amikacin in the French hospital）. The common second and third line antibacterial drugs in our hospital are carbapenems and vancomycin vs. third-generation cephalosporins and vancomycin in the French hospital. The rates of occurrence of recording and screening perinatal risk factors （ chorioamnionitis, maternal fever, prolonged rupture of membranes, screening results of vaginal swabs or urinary infection, amniotic fluid contamination, prenatal antibacterial prophylaxis, anamnesis of EONS） in our hospital was all lower than those of the French hospital. There was no significant difference in positive rate of perinatal risk factors between the two hospitals. For newborns hospitalized for immediate abnormalities after birth, the most common symptom was respiratory distress （96. 5% vs. 88.2% ）. For those admitted after a period of time after birth, the proportion of abnormalities was different： in our hospital, the most common reasons were respiratory distress （44.4%） and lethargy （22.2%） while in the French hospital there were rise of C reactive proteins （78.2%） and fever （5.5%）. The false negative rate of C reactive proteins in diagnosing EONS was not significantly different between the two hospitals. Conclusion There was significant difference in diagnosing and treating EONS in the two hospitals. Emphasis on screening and recording perinatal risk factors, as well as strengthened surveillance on neonates in obstetric department could improve the accuracy of early diagnosis of EONS of our hospital. Positive attitude to gastric liquid and peripheral swabs culture, with drug susceptibility test may help pediatricians better select antibacterial drugs and reduce unnecessary changes and the total time of antibiotic use.