儿童难治性细菌性脑膜炎临床分析Clinical analysis of refractory bacterial meningitis in children
李栋方;邓巧儿;何展文;唐丹霞;孙怡;罗向阳;
摘要(Abstract):
目的回顾性分析儿童难治性细菌性脑膜炎患儿的临床数据,以期提高儿童细菌性脑膜炎的诊治经验。方法回顾性分析31例儿童难治性细菌性脑膜炎及病程>1个月的住院患儿的临床资料。结果在抗生素治疗的基础上,大部分病例联合应用免疫治疗,发病后1 a成功随访23例,预后不良率高(69.57%);患儿住院期间血淋巴细胞亚群以CD19+、NK、CD20出现异常率较高(>50%),50%以上的患儿停用抗生素时不符合国内常见停药标准,应用免疫治疗对患儿预后的影响差异无统计学意义(P>0.05)。结论儿童难治性细菌性脑膜炎常出现外周血淋巴细胞亚群比例异常,临床应重视加强免疫方面的检查及治疗。临床决定患儿是否停用抗生素应多因素综合考虑及个体化治疗,为患儿制定最佳停用抗生素时间点。免疫调节治疗的长期效果仍待观察。
关键词(KeyWords): 难治性细菌性脑膜炎;血淋巴细胞亚群;抗生素治疗;免疫治疗;儿童
基金项目(Foundation): 2020年广东省自然科学基金(编号:2020A1515010312)
作者(Authors): 李栋方;邓巧儿;何展文;唐丹霞;孙怡;罗向阳;
参考文献(References):
- [1]VAN ETTEKOVEN C N,VAN DE BEEK D,BROUWERM C,et al.Update on community-acquired bacterial meningitis:guidance and challenges[J].Clin Microbiol Infect,2017,23(9):601-606.DOI:10.1016/j.cmi.2017.04.019.
- [2]KIM K S.Acute bacterial meningitis in infants and children[J].Lancet Infect Dis,2010,10(1):32-42.DOI:10.1016/S1473-3099(09)70306-8.
- [3]OUCHENIR L,RENAUD C,KHAN S,et al.The Epidemiology,Management,and Outcomes of Bacterial Meningitis in Infants[J].Pediatrics,2017,140(1):e20170476.DOI:10.1542/peds.2017-0476.
- [4]LUNDBO L F,BENFIELD T.Risk factors for communityacquired bacterial meningitis[J].Infect Dis(Lond),2017,49(6):433-444.DOI:10.1080/23744235.2017.1285046.
- [5]BROUWER M C,VAN DE BEEK D.Epidemiology of community-acquired bacterial meningitis[J].Curr Opin Infect Dis,2018,31(1):78-84.DOI:10.1097/QCO.0000000000000417.
- [6]DE ALMEIDA S M,BARROS N C,PETTERLE R,et al.Comparison of cerebrospinal fluid lactate with physical,cytological,and other biochemical characteristics as prognostic factors in acute bacterial meningitis[J].Arq Neuropsiquiatr,2019,77(12):871-880.DOI:10.1590/0004-282X20190185.
- [7]DI MAURO A,CORTESE F,LAFORGIA N.Neonatal bacterial meningitis:a systematic review of European available data[J].Minerva Pediatr,2019,71(2):201-208.DOI:10.23736/S0026-4946.17.05124-6.
- [8]李雪琴,王勤,王江涛,等.0~3月龄婴儿细菌性脑膜炎脑脊液病原菌分布及耐药性分析[J].中国实用神经疾病杂志,2020,23(6):534-539.DOI:10.12083/SYSJ.2020.06.035.
- [9]KRALIK S F,KUKREJA M K,PALDINO M J,et al.Comparison of CSF and MRI Findings among Neonates and Infants withE colior Group B Streptococcal Meningitis[J].AJNR Am J Neuroradiol,2019,40(8):1413-1417.DOI:10.3174/ajnr.A6134.
- [10]MEN X,ZHAO G,ZHAO W,et al.Pathogen identification in culture-negative cerebrospinal fluid specimens of patients with purulent meningitis using next-generation sequencing technology[J].Int J Clin Exp Pathol,2020,13(9):2427-2438.
- [11]PENG H L,HU Y,CHEN H J,et al.Risk factors for poor prognosis in children with refractory purulent meningitis and the discharge criteria[J].J Infect Public Health,2018,1(2):238-242.DOI:10.1016/j.jiph.2017.07.007.
- [12]SHI G,HAN J,LIU G,et al.Expansion of activated regulatory T cells by myeloid-specific chemokines via an alternative pathway in CSF of bacterial meningitis patients[J].Eur J Immunol,2014,44:420-430.DOI:10.1002/eji.201343572.
- [13]JAFARI M,JAHANI P M,CHOOPANIZADEH M,et al.Investigating the role of T helper related cytokines in cerebrospinal fluid for the differential diagnosis of bacterial meningitis in pre-treated paediatric patients[J].Biomarkers,2020,25(2):171-178.DOI:10.1080/1354750X.2020.1714737.
- [14]YU N,ZHANG Q,ZHANG K,et al.Comparative study of CD4 and CD45RO T cells and CD20 B cells in cerebrospinal fluid of syphilitic meningitis and tuberculous meningitis patients[J].APMIS,2016,124(9):764-769.DOI:10.1111/apm.12572.
- [15]MARTINOT M,GREIGERT V,SOUPLY L,et al.Cerebrospinal fluid monocytes in bacterial meningitis,viral meningitis,and neuroborreliosis[J].Med Mal Infect,2018,48(4):286-290.DOI:10.1016/j.medmal.2018.03.002.
- [16]KAPLAN S L,EDWARDS M S.Bacterial meningitis in children older than one month:Treatment and prognosis[DB/OL].https://www.uptodate.com/contents/bacterialmeningitis-in-children-older-than-one-month-treatment-and-prognosis.2018-04-03.
- [17]梁琰,郭大川,刘玉莹,等.病毒性脑炎及细菌性脑膜炎患儿血清血管内皮细胞钙黏蛋白降钙素原的变化及意义[J].中国实用神经疾病杂志,2020,23(12):1072-1076.DOI:10.12083/SYSJ.2020.12.245.
- [18]ZENG Y,ZHANG W.Ameliorative effects of ceftriaxone sodium combined with dexamethasone on infantile purulent meningitis and associated effects on brain-derived neurotrophic factor levels[J].Exp Ther Med,2020,20(2):945-951.DOI:10.3892/etm.2020.8769.
- [19]VILNITS A A,SKRIPCHENKO N V,GORELIK E Y,et al.Possibilities for optimizing the pathogenetic therapy of purulent meningitis in children[J].Zh Nevrol Psikhiatr Im S S Korsakova,2019,119(12):46-50.DOI:10.17116/jnevro201911912146.
- [20]YGBERG S,BRAUNER A,CHAAMBERS B J,et al.A ten-year retrospective case series of glucocorticoid treatment of bacterial meningitis in children[J].Acta Paediatr,2016,105(8):979-82.DOI:10.1111/apa.13443.
- [21]MOUNT H R,BOYLE S D.Aseptic and Bacterial Meningitis:Evaluation,Treatment,and Prevention[J].Am Fam Physician,2017,96(5):314-322.
- [22]COSTERUS J M,BROUWER M,BIJLSMA M W,et al.Community-acquired bacterial meningitis[J].Curr Opin Infect Dis,2017,30(1):135-141.DOI:10.1097/QCO.0000000000000335.
- [23]MORMILE R.Dexamethasone treatment for bacterial meningitis in children:what is the truth?[J].Minerva Pediatr,2017,69(6):557-559.DOI:10.23736/S0026-4946.16.04598-9.
- [24]SIGFRID L,PERFECT C,ROJEK A,et al.A systematic review of clinical guidelines on the management of acute,community-acquired CNS infections[J].BMC Med,2019,17(1):170.DOI:10.1186/s12916-019-1387-5.
- [25]SAUX N L,Canadian Paediatric Society,Infectious Diseases and Immunization Committee.Guidelines for the management of suspected and confirmed bacterial meningitis in Canadian children older than one month of age[J].Paediatr Child Health,2014,19(3):141-252.DOI:10.1093/pch/19.3.141.
- [26]VAN DE BEEK D,CABELLOS C,DZUPOVA O,et al.ESCMID guideline:diagnosis and treatment of acute bacterial meningitis[J].Clin Microbiol Infect,2016,22(3):37-62.DOI:10.1016/j.cmi.2016.01.007.
- [27]KU L C,BOGGESS K A,COHEN-WOLKWIEZ M.Bacterial meningitis in infants[J].Clin Perinatol,2015,42(1):29-45.DOI:10.1016/j.clp.2014.10.004.
- [28]XIE Y P,HUA C Z,WANG H J,et al.Diagnostic Yield of Pneumococcal Antigen Detection in Cerebrospinal Fluid for Diagnosis of Pneumococcal Meningitis Among Children in China[J].Indian Pediatr,2020,57(1):39-42.
- [29]GARCIA P C R,BARCELOS A L M,TONIAL C T,et al.Accuracy of cerebrospinal fluid ferritin for purulent meningitis[J].Arch Dis Child,2020 Feb 28:archdischild-2019-317960.DOI:10.1136/archdischild-2019-317960.
- [30]GOTO R,INUZUKA R,SHINDO T,et al.Relationship between post-IVIG IgG levels and clinical outcomes in Kawasaki disease patients:new insight into the mechanism of action of IVIG[J].Clin Rheumatol,2020,39(12):3747-3755.DOI:10.1007/s10067-020-05153-w.
- [31]NORRIS P A A,KAUR G,LAZARUS A H.New insights into IVIg mechanisms and alternatives in autoimmune and inflammatory diseases[J].Curr Opin Hematol,2020,27(6):392-398.DOI:10.1097/MOH.0000000000000609.
- [32]LUO Y,LIAO Z,SHU J,et al.Observation and analysis of the efficacy of dexamethasone in combination with anti-infectious treatment on the pediatric refractory purulent meningitis[J].Pak J Pharm Sci,2020,33(1(Special)):489-494.