Jones P D, Henry R L, Stuart J, Francis L
Department of Paediatrics, The University of Newcastle, John Hunter Hospital, NSW, Australia.
J Qual Clin Pract. 1998 Dec;18(4):275-84. doi: 10.1046/j.1440-1762.1998.00284.x.
The microbiology and severity of suspected infections in children with cancer admitted to the John Hunter Children's Hospital was determined in order to assess whether any alteration to the infection treatment protocol was required. All children with cancer aged 1-17 years who had an episode of suspected or proven infection that required parenteral treatment at John Hunter Children's Hospital (JHCH) during 1994/95 were reviewed. Thirty-seven children were treated for cancer at JHCH; 62 admissions for suspected infection which involved 26 children were reviewed. Sixteen of these children had a permanent central line. Children with a central line had an increase in the number of days of inpatient treatment required for the treatment of suspected infection, and they had more episodes of infection. A pathogen was isolated more frequently with blood cultures being positive more often and gram-positive species were methicillin resistant more often. These differences were not statistically significant. A pathogen was isolated in 52% of admissions. Sixteen pathogens were gram positive; 12 were gram negative, two were fungal and two were viral. Blood cultures were positive in 21 of 62 admissions, skin swabs in four admissions, urine cultures in three admissions, stool in two admissions and one species was isolated from an epidural catheter tip and from the sputum. In 16% of admissions, the identified organism was resistant to the initial empirical therapy of tobramycin and piperacillin. In a further 13%, flucloxacillin was added to the empirical regimen when a sensitive Staphylococcus was identified. No significant differences between the culture-negative and culture-positive groups were observed in admission pulse, fever or admission neutrophil count. However, those patients with a central line had a higher incidence of having a pathogen isolated if their temperature was > 39.5 degrees C. The median length of stay was longer for patients with a pathogen isolated on blood culture. Admission blood cultures were positive in 53% of admissions with an initial neutrophil count > 1000 x 10(9)/mL. Each of these children had a central line. Only one child died of infection during the 2-year study period. This review supports the observations that gram-positive infection is now more common than gram-negative infection in children with cancer. Despite the management advantages a permanent central line affords it is clear those children with a central line have an increased rate of infection and there needs to be caution in their use. The most important is the observation that any fever > 39.5 degrees C in a child with a central line is likely to be associated with a documented infection irrespective of the neutrophil count. The clinical outcomes observed in the present study indicate that tobramycin and piperacillin are effective empirical treatments for suspected infection in children with cancer.
为评估是否需要对感染治疗方案进行调整，对入住约翰·亨特儿童医院的癌症患儿疑似感染的微生物学特征及严重程度进行了测定。对1994/95年间在约翰·亨特儿童医院（JHCH）因疑似或确诊感染而需要接受肠外治疗的所有1 - 17岁癌症患儿进行了回顾性研究。37名患儿在JHCH接受癌症治疗；对62例涉及26名患儿的疑似感染入院病例进行了回顾。其中16名患儿有永久性中心静脉导管。有中心静脉导管的患儿在治疗疑似感染时所需的住院天数增加，且感染发作次数更多。病原体分离更为频繁，血培养阳性更为常见，革兰氏阳性菌对甲氧西林耐药更为常见。这些差异无统计学意义。52%的入院病例中分离出病原体。16种病原体为革兰氏阳性菌；12种为革兰氏阴性菌，2种为真菌，2种为病毒。62例入院病例中，21例血培养阳性，4例皮肤拭子培养阳性，3例尿培养阳性，2例粪便培养阳性，1例从硬膜外导管尖端和痰液中分离出一种病原体。16%的入院病例中，鉴定出的病原体对妥布霉素和哌拉西林的初始经验性治疗耐药。另外13%的病例中，当鉴定出敏感葡萄球菌时，在经验性治疗方案中加用了氟氯西林。在入院时的脉搏、发热或入院时中性粒细胞计数方面，培养阴性组和培养阳性组之间未观察到显著差异。然而，有中心静脉导管的患儿如果体温>39.5℃，分离出病原体的发生率更高。血培养分离出病原体的患者中位住院时间更长。初始中性粒细胞计数>1000×10⁹/L的入院病例中，53%的入院血培养阳性。这些患儿均有中心静脉导管。在为期2年的研究期间，只有1名患儿死于感染。该综述支持了以下观察结果：在癌症患儿中，革兰氏阳性菌感染现在比革兰氏阴性菌感染更常见。尽管永久性中心静脉导管具有管理优势，但显然有中心静脉导管的患儿感染率增加，使用时需要谨慎。最重要的是观察到，有中心静脉导管的患儿体温>39.5℃时，无论中性粒细胞计数如何，都可能与有记录的感染相关。本研究中观察到的临床结果表明，妥布霉素和哌拉西林是治疗癌症患儿疑似感染的有效经验性治疗药物。
