目的 探讨肺炎支原体核糖核酸恒温扩增技术(MP RNA-SAT)对儿童社区获得性肺炎(CAP)诊治的价值。方法 选择310例CAP的临床资料进行回顾性分析,其中肺炎支原体肺炎(MPP)和非肺炎支原体肺炎各155例,比较这两组的MP RNA-SAT和MP-IgM的检测结果。结果 以临床诊断为标准,RNA-SAT的特异度(97.4%)及阳性预测值(92.2%)高于IgM(分别为72.3%、74.4%),而敏感度(30.3%)及阴性预测值(58.3%)则低于IgM(分别为80.6%、78.9%),差异有统计学意义(P＜0.05);年龄＞3岁、检测前不使用大环内酯类药物以及选择肺泡灌洗液作为检测标本均能提高RNA-SAT的检出率(P＜0.05)。结论 RNA-SAT能特异度识别出MP的活动性感染,联合使用RNA-SAT和IgM检测,能更加快速、准确地诊断MP感染,对儿童肺炎的诊治具有较高的价值。尽量在使用大环内酯类药物治疗前进行RNA-SAT检测,必要时可选择肺泡灌洗液作为检测标本以提高检出率。

Objective To investigate the value of Mycoplasma pneumoniae RNA simultaneous amplification and testing(MP RNA-SAT)in the diagnosis and treatment of community acquired pneumonia(CAP) in children. Methods The clinical data of 310 children with CAP were selected for retrospective analysis,including 155 Mycoplasma pneumonia pneumonia(MPP)and 155 non-MPP,and the results of MP RNA-SAT and MP-IgM in both groups were compared. Results With the results of clinical diagnosis as reference, the specificity (97.4%)or positive predictive value (92.2%)by RNA-SAT was higher than that by IgM (72.3% and 74.4%, respectively), while the sensitivity (30.3%)or negative predictive value (58.3%)was lower than that by IgM (80.6% and 78.9%, respectively).The difference was statistically significant (P<0.05). Age>3 years, no macrolide treatment before testing, or choosing bronchoalveolar lavage fluid as testing samples, that can improve the detection rate of RNA-SAT(P<0.05). Conclusion RNA-SAT may specifically identify active infection of MP, and the combined use of RNA-SAT and IgM test may more quickly and accurately diagnose infection of MP.It has high value for the diagnosis and treatment of community acquired pneumonia in children. RNA-SAT should be performed before the application of macrolide treatment as early as possible. If necessary, bronchoalveolar lavage fluid could be chosen as testing samples to improve the detection rate of RNA-SAT.

目的 探讨及比较CURB-65、PSI、SMART-COP及APACHEⅡ 4种临床评分对重症社区获得性肺炎(SCAP)患者的早期诊断价值。方法 采用前瞻性研究方法,收集2011年10月—2014年2月广州市第一人民医院呼吸内科收治的67例SCAP及同期33例普通CAP患者的临床资料,记录入组后24小时内CURB-65、PSI、SMART-COP及APACHEⅡ评分的最差值,比较4种临床评分系统对SCAP的早期诊断价值。结果 SCAP组CURB-65、PSI、SMART-COP及APACHEⅡ评分均高于普通CAP组患者[CURB-65(分):3.06±1.10 比0.85±0.79,P<0.001;PSI(分):144.93±36.48比73.94±27.17,P<0.001; SMART-COP(分):6.54±1.41比 1.67±1.02,P<0.001; APACHEⅡ(分):20.79±5.69比7.94±3.87,P<0.001]。CURB-65≥3分、PSI≥130分、SMART-COP≥3分及APACHEⅡ≥15分诊断SCAP的受试者工作特征曲线(ROC)下面积(AUC)分别为0.940[95% CI:0.89~0.98, P<0.001],0.933[95%CI:0.88~0.97,P<0.001],0.999[95%CI:0.99~1.0,P<0.001],0.976[95%CI:0.95~0.99,P<0.001],敏感度分别为65.6%、71.6%、100%、88.1%,特异度分别为100%、100%、78.7%、93.9%。结论 CURB-65及PSI评分特异度好,但敏感度低,易漏诊,SMART-COP和APACHE Ⅱ评分诊断效能更佳。

Objective To evaluate and compare the early diagnosis value of CURB-65,PSI,SMART-COP and APACHEⅡin patients with severe community-acquired pneumonia. Methods This was a prospective study conducted in department of respiratory in Guangzhou First People's Hospital. We included 67 SCAP patients and 33 CAP patients between October of 2011and February of 2014. The lowest scores within 24 hours of CURB-65 score,PSI score,SMART-COP score,APACHE Ⅱ score,respectively,for each patients were recorded. Prediction of SCAP as made in four scoring systems was compared. Results CURB-65 score,PSI score,SMART-COP score,APACHE Ⅱ score were higher in SCAP as compared with that of CAP(CURB-65:3.0±1.1 vs 0.9±0.8,P<0.001;PSI:144.6±36.4 vs 73.9±27.1,P<0.001; SMART-COP:6.5±1.4 vs 1.6±1.0,P<0.001; APACHEⅡ:20.6±5.6 vs 7.9±3.8,P<0.001). ROC curve for CURB-65 score≥ 3 scores,PSI score≥ 130 scores,SMART-COP score≥3 scores and APACHE Ⅱ score ≥ 15 scores in the early diagnosis SCAP were 0.940[95%CI:0.89~0.98,P<0.001],0.933[95%CI:0.88~0.97,P<0.001],0.999[95%CI:0.99~1.0,P<0.001],0.976[95%CI:0.95~0.99,P<0.001]. Sensitivity of four kinds of scoring system was 65.6%,71.6%,100%,88.1%, with specificity of 100%,100%,78.7%,93.9% respectively. Conclusion The specificity of diagnosis was better in the CURB-65 and PSI score,but the sensitivity was low and easy to miss diagnosis. SMART-COP and APACHEⅡscore systems had a better diagnostic value on SCAP.

目的 了解中山市儿童社区获得性肺炎病原学特点及其与年龄、抗生素使用的相关性,为疾病诊断和抗生素合理使用提供参考依据。方法 对中山市妇幼保健院儿科住院部2016年1月—2016年4月收治的小儿社区获得性肺炎临床资料、入院前使用抗生素和病原学检测结果进行回顾性分析。结果 共有155例研究对象纳入研究,细菌检出95株,其中革兰氏阴性菌61株,革兰氏阳性菌34株。流感嗜血杆菌,金黄色葡萄球菌,肺炎链球菌,大肠埃希氏菌,副流感嗜血杆菌的占构成比前五位。支原体和衣原体现症感染率约7.7%～8.4%。RSV检出率达25.8%。年龄在3 a以上、入院前使用过抗生素者,革兰阳性菌检出率较低(P<0.05)。入院前使用过抗生素者,革兰阴性菌检出率较高,且使用4 d及以上者高于使用3 d及以下者(P<0.05)。结论 住院儿童CAP的治疗,应综合考虑病人的年龄、入院前的抗生素使用情况,结合当地CAP 的可能优势病原选择合适的治疗方案。

Objective To explore the etiological characteristics and factors of community-acquired pneumonia(CAP) in children in Zhongshan for providing reference for the diagnosis and rational use of antibiotics for CAP. Methods Retrospective analysis were applied on clinical data and etiology results of CAP in children admitted to the pediatric inpatient department of Maternal and Child Health Hospital in Zhongshan from January to April, 2016. Results 155 children were enrolled. The number of bacteria detected was 95, including 61 Gram-negative bacteria, 34 Gram-positive bacteria. Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Haemophilus parainfluenzae accounted the top five. The recent infection rate of Mycoplasma and Chlamydia were from 7.7% to 8.4%. RSV detection rate was 25.8%.The Children who were over 3 years old, pre-use of antibiotics, associated with lower detection rate of Gram-positive bacteria (P<0.05). The Children who were the pre-use of antibiotics, associated with higher detection rate of Gram-negative bacteria, and the use of four days and more higher than three days or less(P<0.05). Conclusion For the treatment of CAP in children, the patient's age and pre-use history of antibiotics should be considered, combined with local common type of disease pathogens, to select the appropriate treatment.

目的 探讨红细胞分布宽度(RDW)与老年重症社区获得性肺炎(CAP)患者病情严重程度及预后的相关性。方法 将103例老年重症CAP患者按照近期预后分为存活组(n=83例)及死亡组(n=20例),按照RDW的水平分为RDW≥14.5%组(n=83例)和RDW＜14.5%组(n=20例);记录患者的一般临床资料及相关实验室检查指标,比较各组之间的差异,并利用Logistic回归模型分析老年重症CAP患者近期死亡的危险因素。结果 死亡组中的患者入院APACHEⅡ评分、CRP、PCT、RDW水平均高于存活组,差异有统计学意义(P＜0.05)。RDW 异常率随着PSI 级别的增高而增高,RDW 异常率分别为PSIⅠ-Ⅱ级7.32%(3/41、 PSI Ⅲ级16.67%(6/36)、PSI Ⅳ级39.13%(9/23)、PSIⅤ级 66.67%(2/3),差异有统计学意义(P＜0.05)。Spearsman相关性分析显示:RDW与APACHEⅡ评分、CRP、PCT、PSI评分呈正相关(r_s分别为=0.353,0.363,0.432,0.362,P均＜0.05)。多因素Logistic回归分析显示: RDW(OR=2.024,P＜0.05)是老年重症CAP患者近期死亡的独立危险因素。结论 RDW水平随着老年重症CAP患者病情严重程度的增加而增加,RDW增高亦是患者近期死亡的高危因素。

目的 探讨血浆D-二聚体及纤维蛋白原在社区获得性肺炎患者严重程度评估的应用价值。方法 收集110例社区获得性肺炎患者的临床资料,根据CURB-65评分标准对患者进行分组,分别测定患者血浆D-二聚体及纤维蛋白原水平,比较其在不同分组间的差异及通过ROC曲线了解其在重症社区获得性肺炎诊断中的价值。结果 不同CURB-65分组间D-二聚体、纤维蛋白原水平比较差异有统计学意义(P<0.05),重症肺炎组D-二聚体、纤维蛋白原水平明显高于非重症肺炎组(P<0.05)。ROC曲线显示入院D-二聚体、纤维蛋白原水平诊断重症肺炎曲线下面积(AUC)分别为0.815、0.777。结论 血浆D-二聚体及纤维蛋白原可以有效评估社区获得性肺炎患者病情的严重程度,其是诊断重症肺炎的一个良好指标。

Objective To evaluate the prediction and evaluation of plasma D-dimer and fibrinogen levels upon the severity of community acquired pneumonia(CAP). Methods Clinical variables of 180 patients with CAP were evaluated and divided into different groups by CURB65.Plasma D-dimer and fibrinogen were measured to compare their levels among different groups and evaluate the prediction in the diagnosis of the severe CAP by ROC curve. Results The mean D-dimer and fibrinogen level were different significantly among different CURB65 groups. D-dimer and fibrinogen level of severe CAP were significantly higher than non-serious pnrumonia group. The area under the curve of the D-dimer, fibrinogen in the diagnosis of severe pneumonia were 0.815, 0.777. Conclusion Plasma D-dimer and fibrinogen can effectively evaluate the severity of illness in patients with community acquired pneumonia and they could be useful for assessment of the severity of CAP.

目的 了解广州地区儿童患者分离的社区获得性耐甲氧西林金黄色葡萄球菌(CA-MRSA)临床分离株的分子特征。方法 收集2009年—2014年我院分离获得的65株CA-MRSA临床分离株,PCR法检测杀白细胞素(PVL)基因阳性菌株,多位点基因序列类型(MLST)测定MRSA菌株的序列类型,多重PCR法对MRSA菌株进行葡萄球菌mec盒式染色体(SCCmec)分型。结果 65株CA-MRSA分离株中PVL基因阳性31株,阳性率47.69%;MLST分型表明以ST5933.84%(22/65)及ST8823.07%(15/65)为主;SCCmec分型中发现3种类型,分别为SCCmecⅡ 32.30%(21/65)、SCCmecⅣ 49.23%(32/65)及SCCmecⅤ 18.46%(12/65),未存在未能分型菌株。结论 广州地区儿童患者分离的CA-MRSA临床分离株的PVL基因阳性率相对较高,SCCmecIV型、V型可形成小范围内的流行,其基因表型存在多种ST分型。

Objective To investigate the molecular characteristic of Community-acquired Methicillin-resistant Staphylococcus aureus(CA-MRSA) isolates from pediatric patients in Guangzhou. Methods 65 non-duplicate strains of Community-acquired Methicillin-susceptible Staphylococcus aureus(CA-MSSA) isolated from our hospital in 2009-2014 were investigated. Panton-valentine leukocidin(PVL) gene was detected by polymerase chain reaction(PCR). The sequence type (ST) of each strain was determined by muhilocus sequence typing (MLST). The genotypes of staphylococcal cassette chromosome mec(SCCmec) of the CA-MRSA isolates were confirmed by multiplex PCR. Results Among 65 isolates of CA-MRSA, the positive rate of PVL genes was 47.69%(31／65). The most common MLST type was ST59 (n=22, 33.84%), followed by ST88 (n=15, 23.07%). Three SCCmec types were found. The most common type was SCCmecIV (49.23%, 32/65), followed by SCCmecⅡ (32.30%, 21/65) and SCCmecV (8.46%, 12/65). Conclusion The PVL gene-positive rate of CA-MRSA isolates in our hospitals is at a relatively high level. SCCmec type IV and SCCmec type V could spread among hospitals and cause a small scale epidemic. Their phenotypes have a variety of ST types.