Clinical characteristics and drug resistance of children with septic shock during six years in a single center / 中国小儿急救医学

Objective:To explore the clinical characteristics of children with septic shock and analyze the drug resistance of blood culture positive bacteria.Methods:The clinical data,positive blood culture strains and drug sensitivity results of 127 children with septic shock admitted to the Department of Intensive Care Medicine of Hunan Children's Hospital from September 2015 to August 2021 were retrospectively analyzed.Results:A total of 134 strains of bacteria or fungi were isolated from the blood culture samples of 127 children with septic shock,and gram-negative strains were the main ones,accounting for 67.16% (90/134).Haemophilus influenzae and Escherichia coli were the main gram-negative bacteria,accounting for 38.81% (52/134) and 20.15% (27/134)，respectively,while Streptococcus pneumoniae was the main gram-positive bacteria,accounting for 8.21% (11/134),and Candida albicans was the main fungus,accounting for 10.45% (14/134).The number of white blood cells,the levels of serum C-reactive protein,procalcitonin,venous blood sugar and arterial blood lactic acid in patients were all significantly higher than normal values,and the white blood cells count and neutrophil percentage in gram-positive bacterial infections were significantly higher than those with gram-negative bacterial infections and fungal infections( P<0.05).Procalcitonin increased most obviously when infected by gram-negative bacteria,and the difference was statistically significant ( P<0.05).Gram-positive strains were sensitive to vancomycin,teicoplanin,and linezolid,but only 50% of Streptococcus pneumoniae were sensitive to penicillin.Gram-negative strains had relatively high drug resistance,among which Klebsiella pneumoniae were only highly resistant to imipenem,cilastatin and levofloxacin,reaching 50%.Haemophilus influenzae was resistant to cephalosporins and β-amides enzyme antibiotic,and the drug sensitivity rate of lactamase antibiotics was high,with a resistance rate of 50% only to ampicillin,cefuroxime,amikacin,and compound sulfamethoxazole.There were not many fungal strains,and most antifungal drugs were effective against blood culture-positive fungi. Conclusion:The main pathogens of infection in children with septic shock are gram-negative bacteria,and have high resistance to general antibiotics.We should pay attention to their drug resistance when using antibiotics empirically.

Clinical features of pertussis in 248 hospitalized children and risk factors of severe pertussis / 中华实用儿科临床杂志

Objective:To investigate the clinical features of pertussis in children and analyze the risk factors of severe pertussis.Methods:The clinical data of 248 children with pertussis hospitalized in Hunan Children′s Hospital from March 2018 to March 2022 were analyzed retrospectively.According to the age at admission, the patients were divided into two groups: ≤3 months and > 3 months.According to the patient′s condition, they were classified into ordinary group and severe group.According to the pathogens detected, the children were divided into single infection group and mixed infection group.The independent sample t-test, chi- square test were used to analyze the clinical indexes of the infants in above groups. Results:(1)Of 248 hospitalized children with pertussis, 204 cases (82.2%) were less than 1 year old, 92 cases (37.0%) had contact with a coughing family member before, and 169 cases (68.1%) were unvaccinated.Among 248 children, 193 cases (77.8%) had an elevated white blood cell count, and 145 cases (58.4%) had mixed infections.The most common pathogen was respiratory syncytial virus [29/248(11.6%)]. About 173 cases (69.7%) had concurrent pneumonia, and 35 cases (14.1%) had pulmonary consolidation.(2)Compared with the group > 3 months of age, more patients in the group ≤3 months of age had contact with a coughing family member before, and suffered from cyanosis, dyspnea, respiratory failure, heart failure and pertussis encephalopathy ( χ2=4.612, 20.810, 7.882, 16.617, 13.740, 7.846, all P<0.05). The proportions of patients in the group ≤3 months of age required intensive care unit(ICU) hospitalization and mechanical ventilation were higher than those in the group > 3 months of age ( χ2=14.810, 21.436, all P<0.05). The mortality of the group ≤3 months of age was higher than that of the group >3 months of age ( χ2=12.016, P<0.05). Children ≤3 months of age had a higher WBC level [(27.83±27.70)×10 9/L vs.(23.34±15.28)×10 9/L, t=22.244, P<0.001], longer duration of spasmodic cough [(16.56±9.33) d vs.(15.06±6.16) d, t=10.145, P=0.002] and longer hospitalization time [(11.47±10.48) d vs.(9.48±4.80) d, t=20.050, P<0.001] than those >3 months of age.(3)Compared with the ordinary group, a higher proportion of children in the severe pertussis group were under 3 months old, and had not been vaccinated against pertussis vaccine ( χ2=14.803, 4.475, all P<0.05). The ratio of patients with dyspnea, an lymphocyte count/neutral cell(LC/NC) ratio <1, mixed infections, lung consolidation and pleural effusion in the severe pertussis group was higher than that in the ordinary group ( χ2=116.940, 43.625, 13.253, 106.370, 11.874, all P<0.05). The patients in the severe pertussis group had a higher WBC [(61.66±29.63)×10 9/L vs.(18.83±10.00)×10 9/L, t=112.580, P<0.001] and a lower LC (0.494±0.186 vs.0.676±0.132, t=13.752, P<0.001) than those in the ordinary group.(4)Compared with the single infection group, the proportions of children with fever, dyspnea, fine moist lung rales, an LC/NC ratio <1, and lung consolidation were higher in the mixed infection group ( χ2=8.909, 6.804, 7.563, 8.420, 12.458, all P<0.05). More children in the mixed infection group required ICU hospitalization and mechanical ventilation than those in the single infection group ( χ2=11.677, 7.397, all P<0.05). The mixed infection group had higher respiratory failure and death rates than the single infection group ( χ2=7.980, 4.267, all P<0.05). Compared with the single infection group, the mixed infection group had a higher WBC level [(27.73±24.13)×10 9/L vs.(21.25±14.65)×10 9/L, t=13.318, P<0.001], longer hospitalization time [(11.593±9.010) d vs.(8.339±4.047) d, t=17.283, P<0.001], and a smaller LC ratio (0.626±0.165 vs.0.684±0.132, t=7.997, P=0.005). (5) Logistic regression analysis showed that age ≤3 months, peak WBC and dyspnea were risk factors of severe pertussis. Conclusions:Hospitalized pertussis children are prone to pneumonia and pulmonary consolidation.Patients aged ≤3 months with a large WBC and dyspnea easily develop into severe pertussis.Monitoring blood routine is helpful for judging the severity of the disease.Mixed infections increase the incidence of complications and can impair the treatment effect.

Significance of sputum heparin binding protein in prognostic evaluation of children with sepsis complicated with acute respiratory distress syndrome / 中国小儿急救医学

Objective:To investigate the predictive value of sputum heparin binding protein(HBP) in sepsis related acute respiratory distress syndrome(ARDS).Methods:This study was a prospective case-control study.A total of 134 children with sepsis who were admitted in PICU at Hunan Children′s Hospital from January 2020 to November 2021 were included, including 63 children who had completed fiberoptic bronchoscopy.The 63 children were divided into sepsis without ARDS group, sepsis with mild ARDS group, and sepsis with moderate to severe ARDS group according to the presence and severity of ARDS.Sputum was collected and HBP was detected in all children with sepsis when they were admitted to the hospital.The alveolar lavage fluid within 72 hours of admission was reserved for HBP.The levels of interleukin (IL)-6 and tumor necrosis factor (TNF)- α were detected, and the blood biochemistry, pulmonary imaging, pediatric critical case score and other data within 72 hours were collected.Results:(1) Among 63 children with fiberoptic bronchoscopy, 29 were in sepsis without ARDS group, 18 were in the sepsis with mild ARDS group, and 16 were in the sepsis with moderate to severe ARDS group.There was no significant difference in the pediatric critical case score and the location of primary infection focus among the three groups at admission.The primary infection focus was respiratory system in 36 cases, whose sputum HBP level was (42.1±9.8) ng/mL, and 27 children with other systems infection, whose sputum HBP level was (37.8±10.8) ng/mL, there was no significant difference between two groups ( t=1.65, P=0.104). (2) There were significant differences in sputum HBP, alveolar lavage fluid HBP, IL-6 and TNF-α levels among sepsis with mild ARDS group, sepsis with moderate and severe ARDS group and sepsis without ARDS group ( P<0.05). The sputum HBP of 34 children with sepsis combined with ARDS was positively correlated with alveolar lavage fluid HBP, IL-6, TNF-α levels and lung injury score, and negatively correlated with SpO 2/FiO 2 ( P<0.05). (3)Among the 34 children with sepsis combined with ARDS, the sputum HBP concentration of children with invasive ventilation was significantly higher than that of children with non-invasive ventilation ( P<0.05). The sputum HBP concentration in children with three or more organ damage was significantly higher than that of children with two or less organ damage ( P<0.05). The sputum HBP concentration of dead children was higher than that of surviving children ( P<0.05). (4) The area under curve of sputum HBP for predicting ARDS was 0.772 (95% CI: 0.655~0.889). When the cut-off point value of sputum HBP was 27.9 mU/L, whose sensitivity and specificity were 70.6% and 79.3%, respectively.The area under curve of sputum HBP for predicting moderate and severe ARDS was 0.793 (95% CI: 0.661~0.926). When the cut-off point value of sputum HBP was 51.55 mU/L, whose sensitivity and specificity were 81.3% and 76.6%, respectively. Conclusion:Sputum HBP is elevated in children with sepsis and ARDS, which is related with the severity of the disease.Sputum HBP has a good predictive value for the diagnosis and severity of children with sepsis and ARDS, and can be used as a clinically effective and convenient evaluation index for children with sepsis related ARDS.

The clinical significance of changes in plasma mitochondrial DNA in children with sepsis / 中华急诊医学杂志

Objective To observe the dynamic changes of plasma mitochondrial DNA (mtDNA) in children with sepsis in order to explore the clinical value of it in evaluation of these cases. Methods A total of 37 sepsis children admitted from June 2016 to January 2017 in the intensive care unit of Hunan Children's Hospital were enrolled for this prospectively study. And another 27 healthy children with similar age and gender were randomly selected as the control group. The venous blood samples were taken on the 1st, 3rd and 7th day after admission. Fluorescence quantitative PCR was used to detect the plasma mtDNA level. Meanwhile, the laboratory examinations such as detections of CRP and PCT were carried out. The diagnosis of sepsis and septic shock was based on Sepsis Criteria 3. Patients with genetic metabolic disease, liver and kidney disease, end-stage of tumors were excluded. Data of two groups were analyzed with Mann-Whitney U test. The sensitivity and specifi city were assessed by receiver operating curve (ROC). Results The plasma mtDNA level in the sepsis group 3 384.4(1 368.5, 6 857.5) pg/mL was higher than that in the healthy control group 1 904.8(1 267.9, 2 395.5) pg/mL with statistical signifi cance (P<0.05). The levels of plasma mtDNA in the sepsis multi-organ dysfunction group were higher than those in the single organ disorder group at day 1,3,7, with statistically signifi cant in three intervals (P <0.05). The level of plasma mtDNA in sepsis group were signifi cantly higher than those in non-shock group at day 1,3,7, with statistical difference (P <0.05). The plasma mtDNA levels in the non-survival group were higher than those in survival group 13 515.1(4 832.7,152 348.5)vs.2 780.0(1 226.8,5 261.2)on day 1;5 842.4(3 402.8,101 937.5)vs.1 450.5(710.6,2 481.6)on day 3 with statistical difference(P<0.05).there was no significant difference in mtDNA on day 7 was 1 045.1 vs.741.8(334.0,1 254.6)between survival group and non-survival group (P >0.05). In respect of diagnostic effi cacy of plasma mtDNA, PCT and CRP in predicting sepsis MODS, the largest area under the ROC curve of plasma mtDNA was 0.848 occurring on the 1st day, when the critical value was 2 176.2 pg/mL, the sensitivity and specifi city was 89% and 72%, respectively, and the difference was statistically signifi cant(P<0.01). When the critical value of CRP was 71.3 mg/L, the sensitivity and specifi city was 58% and 67% respectively. When the critical value of PCT was 7.24 ng/L, the sensitivity and specifi city were 84% and 61%, respectively. The plasma mtDNA peaked on day 1 followed by a downward changes. Conclusions The elevated level of plasma mtDNA in sepsis children was associated with organ dysfunction, indicating that it can be used as one of biomarkers for the diagnosis of sepsis MODS in children. The level of plasma mtDNA in children with sepsis was significantly high on the first and third day after admission, which was positively correlated with the severity of sepsis and it has certain value in assessment of the disease.

Research progress on biomarkers of sepsis in children / 中国小儿急救医学

Sepsis is defined as life-threatening organ dysfunction caused by the disorder of the body′s response to infection.Sepsis is the focus of critical illness medicine and difficult problems nowadays.At pres-ent,the incidence of sepsis in children is still high around the world.If the treatment is not timely,sepsis can develop into septic shock,multiple organ dysfunction syndrome,which is a serious threat to human health. Therefore,the early identification,diagnosis and treatment of sepsis is important for reducing mortality.And the biomarkers play an important role in the early diagnosis of sepsis,pathogenetic condition and prognosis as well as efficacy evaluation.This article summarized the biomarkers of sepsis in recent years.