小婴儿无乳链球菌细菌性脑膜炎临床分析

Clinical analysis of purulent meningitis caused by Streptococcus agalactiae in young infants

目的探讨小婴儿无乳链球菌细菌性脑膜炎的临床特点及治疗措施与预后。方法回顾性分析2013年1月至2016年5月青岛市妇女儿童医院收治的15例小婴儿无乳链球菌细菌性脑膜炎患儿的临床资料，分析其临床特点、治疗方法和预后。结果15例患儿的脑脊液均符合细菌性脑膜炎诊断标准且培养出无乳链球菌，发病年龄5 d～3个月。15例均有发热，10例伴烦躁或易激惹，7例伴抽搐，5例伴嗜睡，3例伴吐奶或拒奶；7例并硬膜下积液，3例并颅内出血，2例并脑积水，1例并中枢性呼吸衰竭；15例患儿中8例并支气管肺炎，6例并脓毒症，1例并腹泻，5例并感染性休克。外周血白细胞计数降低13例，C反应蛋白和降钙素原等炎性指标明显升高14例。脑脊液检查：白细胞计数〉5 000×106/L 4例，（1 000～5 000）×106/L 5例，〈1 000×106/L 6例；脑脊液葡萄糖均〈2.54 mmol/L；蛋白质均升高（781～3 000 mg/L）。14例患儿于入院1周内完善头颅磁共振成像（MRI）及脑电图检查，头颅MRI示正常2例，硬膜下积液7例，颅内出血3例，脑积水2例；脑电图示正常12例，背景活动慢化2例。15例患儿脑脊液中均培养出无乳链球菌。无乳链球菌体外药敏试验示患儿对利奈唑胺、万古霉素、氨苄西林、替加环素100%敏感。抗生素以头孢曲松＋青霉素或青霉素/万古霉素＋美罗培南为主，7例硬膜下积液患儿中3例行硬膜下穿刺引流。12例好转出院，2例治疗2周自动出院后失访，1例放弃治疗后死亡。随访1个月～3.5年，6例精神运动发育基本同健康同龄儿，6例精神运动发育落后。结论小婴儿无乳链球菌细菌性脑膜炎临床治疗困难，重症病例比例高，部分患儿可遗留后遗症，尽早选择敏感抗生素治疗及做好预防是关键。

ObjectiveTo investigate the clinical manifestations, treatment, prognosis of purulent meningitis caused by Streptococcus agalactiae in young infants.MethodsThe clinical data, treatment and prognosis of 15 young infants with purulent meningitis caused by Streptococcus agalactiae admitted to Qingdao Women and Children′s Hospital from January 2013 to May 2016 were analyzed retrospectively.ResultsThe cerebrospinal fluids of 15 cases aged 5 days to 3 months were all accorded with the diagnostic criteria of purulent meningitis and cultivated Streptococcus agalactiae.All of them had fever, 10 cases with restlessness or irritability, 7 cases with convulsions, 5 cases with drowsiness, and 3 cases with sucking rejection or vomiting milk.Seven cases had subdural effusion, intracranial hemorrhage in 3 cases, hydrocephalus in 2 cases, and central respiratory failure in 1 case.All cases had complications, including pneumonia in 8 cases, sepsis in 6 cases, diarrhea in 1 case, and septic shock in 5 cases.The white blood cells were reduced in 13 cases.The serum of procalcitonin and C-reactive protein were elevated in 14 infants.The level of white blood cells in 4 cases′ cerebrospinal fluid was 〉5 000×106/L, （1 000-5 000）×106/L in 5 cases, 〈1 000×106/L in 6 cases.The glucoses of cerebrospinal fluid were all 〈2.54 mmol/L, the protein of cerebrospinal fluid was all elevated （781-3 000 mg/L）. In 14 cases, the head MRI and electroencephalogram（EEG） examination were completed within 1 week after admission.The head MRI showed normal in 2 cases, subdural effusion in 7 cases, intracranial hemorrhage in 3 cases, and hydrocephalus in 2 cases.EEG showed normal in 12 cases, and background activity slowed down in 2 cases.All cases had Streptococcus agalactiae growth in cerebrospinal fluid cultures.The sensitive rates to Linezolid, Vancomycin Ampicillin and Tigecycline were 100%.Ceftriaxone combined with Penicillin, Penicillin combined with Vancomycin or Vancomycin combined with Meropenem were the main combined therapy.Three out of 7 subdural effusion cases were treated with subdural drainage.Twelve cases were improved and discharged.Two cases lost to follow-ups after 2 weeks treatment.One case died after his giving up of treatment.Follow-up period was from 1 month to 3.5 years, 6 cases had a normal development and 6 cases had motor retardation.ConclusionsPurulent meningitis caused by Streptococcus agalactiae in the neonates and infants is more difficult in clinical treatment.High proportions of severe cases exist, some cases will have sequelae.It is imperative to apply sensitive antibiotics in time and timely prevention.