儿童原发性肾病综合征并尿路感染的临床与病原学分析

Clinical and etiological analysis of primary nephrotic syndrome complicated with urinary tract infection in chil-dren

目的分析儿童原发性肾病综合征（primary nephrotic syndrome，PNS）并尿路感染（urinary tract infection，UTI）的临床特征、病原学分布及药敏特点。方法回顾性分析2008年1月至2017年12月重庆医科大学附属儿童医院肾脏内科收治的221例PNS并UTI患儿的临床及病原学资料。 结果PNS并UTI以学龄前患儿为主（129/221例，58.4%）。复发PNS并UTI发生率（134/822例，16.3%）较初发PNS并UTI（87/1 663例，5.2%）高，差异有统计学意义（χ2＝83.200，P〈0.05）。PNS并UTI的临床表现以无症状尿路感染为主（173例，78.3%）。无症状UTI组中复发PNS和使用激素和/或免疫抑制剂的患儿比例（112/173例、126/173例）均显著高于有症状UTI组（22/48例、27/48例），差异均有统计学意义（χ2＝5.627、4.850，均P〈0.05）。PNS并再发性尿路感染（recurrent urinary tract infection，RUTI）的发生率为13.1%（29/221例），与初发性UTI组[（4.4±3.7）个月]相比，RUTI组中PNS病程[（9.3±3.5）个月]更长，差异有统计学意义（t＝9.427，P〈0.05）。RUTI组PNS复发、使用激素和/或免疫抑制剂、血红蛋白（Hb）下降、补体C3下降的患儿比例及泌尿系统影像学检查异常率（分别为29/29例、26/29例、14/29例、14/29例、7/29例）较初发性UTI组（分别为105/192例、127/192例、51/192例、31/192例、6/192例）更高，差异均有统计学意义（χ2＝5.480、5.721、16.039、20.094，均P〈0.05）。PNS并UTI的致病菌以革兰阴性菌为主（174/263例，66.1%），其中大肠埃希菌（54/263例，20.5%）多见。RUTI组分离出大肠埃希菌、铜绿假单胞菌和产超广谱β-内酰胺酶（ESBLs）菌比例（26/62例、11/62例、21/62例）均显著高于初发性UTI组（28/201例、15/201例、15/201例），差异均有统计学意义（χ2＝22.776、5.620、27.970，均P〈0.05）；药敏试验提示革兰阴性菌对阿米卡星、美罗培南、哌拉西林/他唑巴坦敏感性较高；革兰阳性菌对万古霉素、利奈唑胺和替考拉宁的敏感性较高。结论学龄前PNS和PNS复发患儿易并UTI，其临床表现以无症状菌尿多见。对PNS复发的患儿需警惕合并UTI。PNS病程更长、伴贫血、低补体血症及合并泌尿系统影像学检查异常的PNS患儿可能更易发生RUTI。革兰阴性菌是PNS并UTI的主要致病菌，以大肠埃希菌为主，耐药率高，且RUTI患儿可能更易并产ESBLs菌感染。哌拉西林/他唑巴坦可作为治疗PNS并UTI的首选经验性抗生素。

ObjectiveTo analyze the clinical features, etiological distribution and drug sensitivity of primary nephrotic syndrome （PNS） complicated with urinary tract infection （UTI） in children.MethodsThe clinical data and etiological characteristics of 221 PNS patients complicated with UTI were retrospectively analyzed, who were hospitalized from January 2008 to December 2017 in the Department of Nephrology, Children′s Hospital of Chongqing Medical University.ResultsThe PNS patients complicated with UTI were mainly preschoolers （129/221 cases, 58.4%）. The incidence of relapsed PNS with UTI （134/822 cases, 16.3%） was higher than that of initial PNS with UTI （87/1 663 cases, 5.2%）, and the difference was statistically significant （χ2=83.200, P〈0.05）. The clinical manifestation was mainly present with asymptomatic bacteriuria （173/221 cases, 78.3%）. The proportions of relapsed PNS （112/173 cases） and using prednisone and/or immunosuppressant（126/173 cases） in asymptomatic UTI group were respectively significantly higher than those of the symptomatic UTI group （22/48 cases and 27/48 cases, respectively）, and the difference was statistically significant （χ2=5.627, 4.850, all P〈0.05）. The incidence of recurrent UTI （RUTI）was 13.1% （29/221 cases）. Compared with initial UTI group, RUTI group had longer course [（9.3±3.5） months vs.（4.4±3.7） months, t=9.427, P〈0.05], and significantly higher proportions of relapsed PNS （29/29 cases vs.105/192 cases, P〈0.05）, using prednisone and/or immunosuppressant （26/29 cases vs.127/192 cases）, decreased hemoglobin（Hb）（14/29 cases vs.51/192 cases） and complement C3 （14/29 cases vs.31/192 cases） and higher abnormal rate of urinary system （7/29 cases vs.6/192 cases） （χ2=5.480, 5.721, 16.039, 20.094, all P〈0.05）. Gram-negative bacteria were the dominant pathogens （174/263 cases, 66.1%）, and Escherichia coli was the main bacteria （54/263 cases, 20.5%）. The proportions of Escherichia coli, Pseudomonas aeruginosa and extended-spectrum β-lactamases（ESBLs） producing bacteria were significantly higher in RUTI group than those in initial UTI group（26/62 cases, 11/62 cases, 21/62 cases vs.28/201 cases, 15/201 cases, 15/201 cases）（χ2=22.776, 5.620, 27.970, all P〈0.05）. The drug sensitivity test indicated that gram-negative bacteria were more sensitive to Amikacin, Meropenem, and Piperacillin/Tazobactam, and gram-positive bacteria were more sensitive to Vancomycin, Linezolid and Teicoplanin. ConclusionsPreschoolers with PNS and relapsed PNS are prone to UTI.The clinical manifestation of UTI was mainly presented with asymptomatic bacteriuria.UTI should be considered when children with PNS relapsed.PNS with longer course, anemia, decreased complement, and urinary system abnormity may be more likely to develop RUTI.Gram-negative bacteria were the dominant pathogens.Escherichia coli was the main bacteria with high drug resistance and ESBLs producing bacteria may be more common in RUTI.Piperacillin/Tazobactam could be the first choice of empirical antimicrobial agents for PNS complicated with UTI.