儿童难治性肺炎支原体肺炎早期识别的多中心前瞻性研究

A multicenter prospective study on early identification of refractory Mycoplasma pneumoniae pneumonia in children

目的探索早期预测儿童难治性肺炎支原体肺炎(RMPP)的方法。方法前瞻性多中心研究,收集2019年5月1日至2020年1月31日在浙江13家医院就诊的1428例发热>48~<120 h患儿的临床资料,采集咽拭子检测肺炎支原体DNA,检测阳性者行胸部X线片、血常规、C反应蛋白、乳酸脱氢酶(LDH)和前降钙素等检测。根据随访时病情发展情况,将患儿分为RMPP组和普通肺炎支原体肺炎(GMPP)组。组间比较采用Mann-Whitney U检验。Logistic回归分析影响RMPP的相关因素,建立RMPP预报概率π的回归模型,受试者工作特征曲线分析预测RMPP的诊断价值。结果1428例患儿中男801例、女627例,年龄4.3(2.7,6.3)岁,肺炎支原体DNA阳性534例(37.4%),其中446例(83.5%)诊断为肺炎支原体肺炎。446例肺炎支原体肺炎患儿中男251例、女195例,就诊年龄5.2(3.3,6.9)岁。大环内酯类抗菌药物耐药性变异位点检测阳性410例(91.9%)。RMPP组55例、GMPP组391例。RMPP组第1次就诊前的峰值体温与乳酸脱氢酶(LDH)水平均高于GMPP组[39.6(39.1,40.0)比39.2(38.9,39.7)℃、333(279,392)比311(259,359)U/L,均P<0.05]。Logistic回归示RMPP的预报概率π=exp[-29.7+0.667×最高体温(℃)+0.004×LDH(U/L)]/{1+exp[-29.7+0.667×最高体温(℃)+0.004×LDH(U/L)]},截断值为0.12,预报一致性为0.89,灵敏度0.89,特异度0.67。预报概率π的受试者工作特性曲线下面积为0.682(95%CI 0.593~0.771,P<0.01)。结论发热>48~<120 h的肺炎支原体肺炎患儿,可根据首次就诊前的最高体温和LDH水平计算RMPP的预报概率,以期达到早期预测RMPP的目的。

Objective To explore potential predictors of refractory Mycoplasma pneumoniae pneumonia(RMPP)in early stage.Methods The prospective multicenter study was conducted in Zhejiang,China from May 1st,2019 to January 31st,2020.A total of 1428 patients with fever>48 hours to<120 hours were studied.Their clinical data and oral pharyngeal swab samples were collected;Mycoplasma pneumoniae DNA in pharyngeal swab specimens was detected.Patients with positive Mycoplasma pneumoniae DNA results underwent a series of tests,including chest X-ray,complete blood count,C-reactive protein,lactate dehydrogenase(LDH),and procalcitonin.According to the occurrence of RMPP,the patients were divided into two groups,RMPP group and general Mycoplasma pneumoniae pneumonia(GMPP)group.Measurement data between the 2 groups were compared using Mann-Whitney U test.Logistic regression analyses were used to examine the associations between clinical data and RMPP.Receiver operating characteristic(ROC)curves were used to analyse the power of the markers for predicting RMPP.Results A total of 1428 patients finished the study,with 801 boys and 627 girls,aged 4.3(2.7,6.3)years.Mycoplasma pneumoniae DNA was positive in 534 cases(37.4%),of whom 446 cases(83.5%)were diagnosed with Mycoplasma pneumoniae pneumonia,including 251 boys and 195 girls,aged 5.2(3.3,6.9)years.Macrolides-resistant variation was positive in 410 cases(91.9%).Fifty-five cases were with RMPP,391 cases with GMPP.The peak body temperature before the first visit and LDH levels in RMPP patients were higher than that in GMPP patients(39.6(39.1,40.0)vs.39.2(38.9,39.7)℃,333(279,392)vs.311(259,359)U/L,both P<0.05).Logistic regression showed the prediction probabilityπ=exp(-29.7+0.667×Peak body temperature(℃)+0.004×LDH(U/L))/(1+exp(-29.7+0.667×Peak body temperature(℃)+0.004×LDH(U/L))),the cut-off value to predict RMPP was 0.12,with a consensus of probability forecast of 0.89,sensitivity of 0.89,and specificity of 0.67;and the area under ROC curve was 0.682(95%CI 0.593-0.771,P<0.01).Conclusion In MPP patients with fever over 48 to<120 hours,a prediction probabilityπof RMPP can be calculated based on the peak body temperature and LDH level before the first visit,which can facilitate early identification of RMPP.