儿童急性淋巴细胞白血病中性粒细胞缺乏伴发热单中心血流感染病原菌分析

Single center clinical analysis of bloodstream infection pathogens in febrile neutropenic children with acute lymphoma leukemia

目的:分析儿童急性淋巴细胞白血病(ALL)化疗后中性粒细胞缺乏伴发热(FN)血流感染的临床特点、危险因素和病原菌分布。方法:回顾性分析2007年1月1日至2016年12月31日上海交通大学附属儿童医院血液肿瘤科收治的ALL化疗后发生FN住院患儿的临床资料和血培养结果,分析菌株的分布及药敏特点。结果:纳入ALL患儿312例,FN1 548例次,共送检1 700例次血培养,血培养阳性率7.5%(127/1 700),血流感染发生率8.2%(127/1 548),病死率9.4%(12/127)。血流感染革兰阳性菌51.1%(65/127),革兰阴性菌47.2%(60/127),真菌1.5%(2/127)。革兰阴性菌血流感染与革兰阳性菌血流感染比较,ANC<0.1×10^9·L^-1的患儿占比(P=0.041)和感染性休克发生率更高(P=0.002)。2012~2016年铜绿假单胞菌构成比较2007~2011年增加(χ^2=4.712,P=0.030)。ALL的危险程度分层IR/HR(OR=2.560,P=0.045)和ANC<0.1×10^9·L^-1(OR=0.754,P=0.025)是血流感染发生的独立危险因素。结论:ALL患儿发生FN时血流感染病原菌阳性率较高(8.2%),以革兰阳性菌感染为主。在严重粒细胞缺乏时以革兰阴性菌血流感染为主,铜绿假单胞菌感染有增加趋势,合并感染性休克是FN死亡的独立危险因素。

Objective :To analyze the clinical characteristics, risk factors and distribution of bloodstream infection pathogens in febrile neutropenic children with acute lymphoma leukemia in Children's Hospital of Shanghai Jiaotong University from Jan.2007 to Dec.2016. Methods :Clinical and pathogen data of febrile neutropenic children with acute lymphoma leukemia were retrospectively reviewed and analyzed. Results :In total, 312 children with ALL were enrolled into the study, including 1,548 FN cases and 1,700 blood cultures. The occurrence rate of bloodstream infection was 8.2% (127/1,548). Bloodstream infection mortality rate was 9.4% (12/127). Among 127 strains of isolated bloodstream pathogens,Gram-positive bacteria accounted for 51.1 % (65/127), Gram-negative bacteria 47.2% (60/127) and fungi 1.5% (2/127). Compared with Gram-positive bacterial bloodstream infection, Gram-negative bacterial bloodstream infection had higher incidence of ANC <0.1×10 ^9 ·L ^-1 ( P =0.041) and septic shock ( P =0.002). Gram-negative bacilli Pseudomonas aeruginosa had an increasing trend of infection. There was no significant increase in drug-resistant gram-negative bacilli. Conclusion :Gram-positive bacteria were still the main pathogens of FN bloodstream infection. Coagulasenegative Staphylococcus was the most common pathogen of Gram-positive bacteria, and Escherichia coli was the main pathogen of Gram-negative bacteria. Gram-negative bacterial bloodstream infection is more serious than Gram-positive bacterial bloodstream infection complications, which mostly occurs in the stage of severe granulocyte deficiency. Bloodstream infection combined with septic shock is an independent risk factor for FN death.