儿童嗜麦芽窄食单胞菌感染临床特征分析

The clinical features of stenotrophomonas maltophili infection in children

目的了解儿童嗜麦芽窄食单胞菌(SMA)感染的特征。方法回顾性队列研究选取2018年1月至2023年6月就诊于上海儿童医学中心诊断SMA感染的患儿为研究对象,分析患儿的各类临床特征。根据最终治疗的转归分为存活组和死亡组,并比较两组患儿的临床特征。结果共70例患儿纳入研究,其中女23例,男47例,发病年龄9.0(3.0,12.6)岁。65例(92.9%)患儿系血液系统及实体肿瘤患儿,其中24例(34.3%)患儿进行了骨髓造血干细胞移植,18例(25.7%)进行了嵌合抗原受体T细胞免疫疗法(CAR-T)。SMA感染部位40例(57.1%)为呼吸道感染,19例(27.1%)为血流感染,11例(15.7%)为软组织感染。感染前33例(47.1%)患儿接受糖皮质激素治疗,63例(90.0%)接受碳青霉烯类药物。最终39例(55.7%)患儿好转出院,31例死亡,病死率达44.3%。培养出的SMA对米诺环素、左氧氟沙星、复方新诺明、头孢哌酮/舒巴坦的敏感率分别为100.0%、98.1%、96.2%、94.0%。对比存活组患儿,死亡组患儿年龄更大[11.9(8.4,13.8)岁比6.3(2.1,10.0)岁],感染前住院时间及干细胞移植后时间更长[28(23,46)d比25(16,34)d,140(93,221)d比24(12,49)d],感染前入住ICU、感染前使用激素、接受CAR-T治疗及基础疾病系淋巴瘤的患儿比例更高[26例(83.9%)比15例(38.46%),22例(71.0%)比11例(28.2%),13例(41.9%)比5例(12.8%),11例(35.5%)比3例(7.7%)],差异均有统计学意义(P<0.05)。结论SMA感染主要出现在恶性肿瘤、免疫受损、应用广谱抗生素的患儿中。在儿童患者中,SMA对复方新诺明、米诺环素、左氧氟沙星及头孢哌酮/舒巴坦保持着良好的敏感率。SMA感染后病死率高,发病年龄大、较长的感染前住院时间、干细胞移植后时间长、感染前入住ICU、感染前使用激素、接受CAR-T治疗及基础疾病系淋巴瘤可能与感染后死亡有关。

Objective To understand the clinical characteristics of stenotrophomonas maltophilia(SMA)infections in pediatric patients.Methods This was a retrospective observational study.The children diagnosed with SMA infections between January 2018 and June 2023 at Shanghai Children's Medical Center were selected as the study population.The clinical characteristics of patients were analyzed.According to the outcome,the patients were categorized into survival and death groups to compare the clinical characteristics.Results A total of 70 patients were included in the study,including 23 females and 47 males,with an onset age of 9.0(3.0,12.6)years old.Sixty-five(92.9%)patients had underlying malignancies,primarily hematologic and solid tumors,of which 24(34.3%)cases underwent bone marrow hematopoietic stem cell transplantation,and 18(25.7%)cases underwent chimeric antigen receptor T cell immunotherapy(CAR-T).Forty(57.1%)cases of SMA infection sites were respiratory infections,19(27.1%)cases were bloodstream infections,and 11(15.7%)cases were soft tissue infections.Prior to infection,33(47.14%)patients were treated with glucocorticoids and 63(90.0%)patients with carbapenems.Eventually,39(55.7%)patients were discharged,while 31 patients died,with a mortality rate of 44.3%.Minocycline(100.0%),levofloxacin(98.1%),co-trimoxazole(96.2%),and cefoperazone/sulbactam(94.0%)showed high sensitivity rates to SMA.Compared with the survival group,the death group had a younger age[11.9(8.4,13.8)years vs.6.3(2.1,10.0)years],longer hospitalization before infection and duration after stem cell transplantation[28(23,46)d vs.25(16,34)d,140(93,221)d vs.24(12,49)d],and a higher proportion of pre-infection ICU admission,preinfection glucocorticoids usage,receiving CAR-T treatment and lymphoma as the underlying disease[26(83.9%)cases vs.15(38.46%)cases,22(71.0%)cases vs.11(28.2%)cases,13(41.9%)cases vs.5(12.8%)cases,11(35.5%)cases vs.3(7.7%)cases],and the differences were all statistically significant(P<0.05).Conclusion SMA infection pose a serious risk to pediatric patients with malignancies,compromised immune systems and exposured to broad-spectrum antibiotics.SMA maintains excellent sensitivity to compound sulfamethoxazole,minocycline,levofloxacin,and cefoperazone/sulbactam in pediatric patients.The mortality rate of SMA infection is very high,with longer pre-infection hospitalization,pre-infection ICU admission,pre-infection glucocorticoids usage,older onset age,longer duration after stem cell transplantation,receiving CAR-T treatment and lymphoma as the underlying disease possibly associated with post infection mortality.