苏州地区儿童肺炎链球菌脑膜炎39例临床特征和血清型分析

Analysis of clinical manifestation and serotype of 39 children with meningitis caused by Streptococcus pneumoniae in Suzhou

目的:分析苏州地区儿童肺炎链球菌脑膜炎及死亡病例的血清型和临床特征,寻找降低儿童肺炎链球菌脑膜炎发病率和死亡率的对策。方法:对苏州大学附属儿童医院2011年1月—2016年12月收治97例化脓性脑膜炎患儿中39例肺炎链球菌脑膜炎菌株进行血清学分型,对其临床特征和实验室结果进行统计分析。结果:97例化脓性脑膜炎患儿脑脊液培养出致病菌依次为:肺炎链球菌39例(40.2%),无乳链球菌19例(19.6%)和大肠埃希菌18例(18.6%)等;总病死率为19.6%(19/97),按照病死率高低依次为:肺炎克雷伯菌60.0%(3/5),肺炎链球菌35.9%(14/39)和大肠埃希菌11.1%(2/18);肺炎链球菌脑膜炎死亡组体温>40°、早期纳差、早期嗜睡、休克、弥散性血管内凝血、急性肾损伤、呼吸衰竭、抽搐和昏迷的发生显著高于存活组(P<0.05);肺炎链球菌组分别有17.9%和15.4%出现并发症硬膜下积液和脑积水;肺炎链球菌组首次抗生素使用与药敏结果符合率为20.0%(6/30);39例肺炎链球菌脑膜炎患儿肺炎链球菌疫苗率为0.0%,7价肺炎链球菌疫苗和13价肺炎链球菌疫苗覆盖肺炎链球菌组血清型分别为82.1%和92.3%,对死亡组血清型覆盖率分别是85.7%和92.9%。结论:肺炎链球菌是苏州地区6个月以上儿童化脓性脑膜炎的首要病原体;早期识别高热、纳差和嗜睡等危重症状态及合理选择抗生素对改善肺炎链球菌脑膜炎预后具有重要意义。门诊抗生素选择对肺炎链球菌敏感率低及我国肺炎链球菌疫苗接种率低,是肺炎链球菌脑膜炎高病死率的重要原因。期望通过接种13价肺炎链球菌结合疫苗降低肺炎链球菌脑膜炎的发生率和病死率。

Objective:To analyze the serotypes and clinical manifestation of children with meningitis caused by Streptococcus pneumoniae in Suzhou,so as to find an effective strategy for reducing the incidence and mortality.Methods:Ninty-seven children with purulent meningitis were enrolled into our study from Jan.2011 to Dec.2016.There were 39 children with meningitis caused by Streptococcus pneumoniae among them.The data of erotype,clinical manifestation,laboratory results and prognosis were collected and analyzed.Results:The 97 strains of bacteria isolated from patients with purulent meningitis consisted of 39 strainz(40.2%)of Streptococcus pneumoniae,19 strains(19.6%)of Streptococcus agalactiae,18 strains(18.6%)of Escherichia coli.The mortality of 97 children with purulent meningitis was 19.6%(19/97).The mortality of purulent meningitis form high to low were 60.0%(3/5)Klebsiella pneumonia,35.9%(14/39)Streptococcus pneumoniae and 11.1%(2/18)Escherichia coli.The incidence rates of hyperpyrexia,anorexia,somnolence,shock,disseminated intravascular coagulation,acute kidney injury,respiratory failure,seizure,and coma in dead group with SP-infected meningitis was higher than those in survival group(P<0.05).The children with SP-infected meningitis had complications,including subdural empyema(17.9%),and hydrocephalus(15.4%).The coincidence rate between choice of primary antibiotics and drug sensitivity test was 20.0%(6/30).The pneumococcal conjugate vaccine(PVC)vaccine coverage rate in the 39 children with SP-infected meningitis was 0%.The coverage of cases with SP-infected meningitis serotypes of PCV7 was 82.1%,and PCV13 was 92.3%.The coverage rate in dead cases with SP-infected meningitis serotypes of PCV7 and PCV13 was 85.7%and 92.9%respectively.Conclusion:Streptococcus pneumoniae are main pathogen of purulent meningitis in children aged 6 months or older.Timely recognition of continuous hyperpyrexia,anorexia and somnolence in early stage and appropriate use of antibiotics is the key to improve the outcome of SP-infected meningitis.The low coincidence rate of choices of antibiotics to invasive pneumococcus outpatient and low rate of PCV immunization in China are responsible for the high mortality of SP-infected meningitis.PCV13 immunization provides a robust strategy for reducing the incidence and mortality of SP-infected meningitis.