脓毒性休克患儿临床特征与病原构成多中心研究

A multicenter retrospective study on clinical features and pathogenic composition of septic shock in children

目的了解我国儿童重症监护病房脓毒性休克患儿主要临床特征、病原构成和预后。方法多中心回顾性队列研究。回顾性收集我国10家医院2018年1月至2021年12月收治于儿童重症监护病房脓毒性休克患儿的病例资料,分析其临床特征、病原构成和预后。根据是否存在恶性肿瘤基础病和预后将患儿分为恶性肿瘤组和非恶性肿瘤组,存活组和死亡组,采用两独立样本t检验、Mann-WhitneyU检验和χ^(2)检验比较组间临床特征和预后情况,利用多因素Logistic回归分析死亡相关危险因素。结果共纳入脓毒性休克患儿1247例,其中男748例(59.9%),年龄3.1(0.9,8.8)岁,住院病死率23.2%(289例)。总体病原阳性率为68.2%(851例)。共获得阳性病原体1229个,754个(61.4%)为细菌,305个(24.8%)为病毒。全部细菌中,革兰阴性菌484个(64.2%),前2位为铜绿假单胞菌[108个(22.3%)]和肠杆菌[102个(21.1%)];革兰阳性菌270个(35.8%),前2位为链球菌属[88个(32.6%)]和葡萄球菌[65个(24.1%)]。病毒中,前3位为流感病毒[86个(28.2%)]、EB病毒[53个(17.4%)]、呼吸道合胞病毒[46个(15.1%)]。与非恶性肿瘤组相比,肿瘤组患儿更年长,第三代小儿死亡危险(PRISMⅢ)和儿童序贯器官衰竭评分(pSOFA)均更高[7.9(4.3,11.8)比2.3(0.8,7.5)岁、22(16,26)比16(10,24)分、10(5,14)比8(4,12)分、Z=11.32、0.87、4.00,均P<0.05],且病原阳性率和住院病死率均更高[77.7%(240/309)比65.1%(611/938),29.7%(92/309)比21.0%(197/938),χ^(2)=16.84、10.04,均P<0.05]。病死组PRISMⅢ评分、pSOFA评分均更高[16(22,29)比14(10,20)分,8(12,15)比6(3,9)分,Z=4.92、11.88,均P<0.05],且存在肿瘤性疾病、病原阳性率和有创机械通气比例均高于存活组[29.7%(87/289)比23.2%(222/958),77.8%(225/289)比65.4%(626/958),73.7%(213/289)比50.6%(485/958),χ^(2)=5.72、16.03、49.98,均P<0.05]。PRISMⅢ和pSOFA评分、存在恶性肿瘤疾病均与病死相关(OR=1.04、1.09、0.67,95%CI 1.01~1.05、1.04~1.12、0.47~0.94,均P<0.05)。结论脓毒性休克患儿以细菌感染为主,但病毒阳性率也相对较高;存在恶性肿瘤基础病的患儿病情更重、对有创呼吸支持的依赖度更高;儿童重症监护病房脓毒性休克患儿总体住院病死率仍偏高,PRISMⅢ和pSOFA评分、存在恶性肿瘤性疾病与病死正相关。

ObjectiveTo investigate the clinical features,pathogen composition,and prognosis of septic shock in pediatric intensive care units(PICU)in China.MethodsA multicenter retrospective cohort study.A retrospective analysis was conducted on the clinical data of children with septic shock from 10 hospitals in China between January 2018 and December 2021.The clinical features,pathogen composition,and outcomes were collected.Patients were categorized into malignant tumor and non-malignant tumor groups,as well as survival and mortality groups.T test,Mann Whitney U test or Chi square test were used respectively for comparing clinical characteristics and prognosis between 2 groups.Multiple Logistic regression was used to identify risk factors for mortality.ResultsA total of 1247 children with septic shock were included,with 748 males(59.9%)and the age of 3.1(0.9,8.8)years.The in-patient mortality rate was 23.2%(289 cases).The overall pathogen positive rate was 68.2%(851 cases),with 1229 pathogens identified.Bacterial accounted for 61.4%(754 strains)and virus for 24.8%(305 strains).Among all bacterium,Gram negative bacteria constituted 64.2%(484 strains),with Pseudomonas aeruginosa and Enterobacter being the most common;Gram positive bacteria comprised 35.8%(270 strains),primarily Streptococcus and Staphylococcus species.Influenza virus(86 strains(28.2%)),Epstein-Barr virus(53 strains(17.4%)),and respiratory syncytial virus(46 strains(17.1%))were the top three viruses.Children with malignant tumors were older and had higher pediatric risk of mortality(PRISM)Ⅲscore,paediatric sequential organ failure assessment(pSOFA)score(7.9(4.3,11.8)vs.2.3(0.8,7.5)years old,22(16,26)vs.16(10,24)points,10(5,14)vs.8(4,12)points,Z=11.32,0.87,4.00,all P<0.05),and higher pathogen positive rate,and in-hospital mortality(77.7%(240/309)vs.65.1%(611/938),29.7%(92/309)vs.21.0%(197/938),χ^(2)=16.84,10.04,both P<0.05)compared to the non-tumor group.In the death group,the score of PRISMⅢ,pSOFA(16(22,29)vs.14(10,20)points,8(12,15)vs.6(3,9)points,Z=4.92,11.88,both P<0.05)were all higher,and presence of neoplastic disease,positive rate of pathogen and proportion of invasive mechanical ventilation in death group were also all higher than those in survival group(29.7%(87/289)vs.23.2%(222/958),77.8%(225/289)vs.65.4%(626/958),73.7%(213/289)vs.50.6%(485/958),χ^(2)=5.72,16.03,49.98,all P<0.05).Multiple Logistic regression showed that PRISMⅢ,pSOFA,and malignant tumor were the independent risk factors for mortality(OR=1.04,1.09,0.67,95%CI 1.01-1.05,1.04-1.12,0.47-0.94,all P<0.05).ConclusionsBacterial infection are predominant in pediatric septic shock,but viral infection are also significant.Children with malignancies are more severe and resource consumptive.The overall mortality rate for pediatric septic shock remains high,and mortality are associated with malignant tumor,PRISMⅢand pSOFA scores.