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JAMA子刊：在社区发病的儿童严重细菌感染的管理中，“次优护理”的发生率、特点和决定因素是什么?

2022-06-27 liangying MedSci原创

社区管理儿童严重细菌感染次优护理
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可以通过提高初级保健，特别是幼儿初级保健的质量来优化管理。

2017年，世界卫生组织通过了一项决议以改进脓毒症的预防、诊断和管理，减轻其负担。在高收入国家，严重细菌感染（SBI）是儿童发病率和死亡率的主要原因，约占儿科重症监护病房（PICU）死亡人数的25%。大约30%的幸存者会经历严重的后遗症，如截肢、神经发育障碍或听力损失。

为了防止感染的不良进展并降低其发病率和死亡率，优化管理是必要的，关键依赖于三个步骤：第一，一旦出现严重症状，立即寻求家庭护理；第二，医生应认识到感染的严重程度并适当转诊；第三，根据败血症国际指南进行治疗。一些作者假设，目前SBI的剩余死亡率与这些步骤中的一个或多个步骤中的次优护理有关。其中，有必要评估初级保健的质量，从而减少儿童社区严重细菌感染（COSBIs）引起的高发病率和死亡率。

这项前瞻性的、以人群为基础的队列研究和保密调查于2009年8月至2014年1月在法国西部进行，该地区占法国儿科人口的15%(1个月至16岁的儿童为1968474名)，包括6个儿科重症监护室(PICUs)和35个急诊科。参与者包括所有在PICU入院前死亡的1个月至16岁的儿童，或因COSBI(即细菌性败血症，包括脑膜炎、富紫癜，以及肺部、骨关节、腹腔内、心脏和软组织严重感染)入院的PICU。分析了2020年3月至6月的数据。

通过对8种护理类型的评估确定次优护理:(1)家属求医的延迟，(2)医生对严重程度的评估，(3)有严重症状的患者在首次会诊时的转诊，(4)抗生素治疗的时机和剂量，(6)时间，(7)液体给药量，(8)液体给药后的临床重新评估。通过多项逻辑回归和广义线性混合模型确定了肯定次优护理的后果和决定因素。

在纳入的儿童中有259名死亡，25名（9.6%）在PICU出院时有严重后遗症。89例（34.4%）的护理质量肯定不理想。与无后遗症存活的儿童相比，后遗症儿童的次优护理更频繁，死亡儿童的次优护理更少。与次优护理相关的独立因素包括年龄小于5岁、诊断为无来源败血症或脑膜炎与其他严重感染、初级保健医生的护理与儿科医院服务。

社区严重起病的细菌感染儿童入住重症监护病房前，全球管理质量的潜在决定因素的多变量分析

这项研究发现，在COSBI的初始治疗中，不理想的护理是常见的，并且与严重的后遗症有关。降低死亡风险的矛盾关联可能是由于对细菌或宿主内在因素的调整不足。可以通过提高初级保健，特别是幼儿初级保健的质量来优化管理。

参考文献：Lorton F, Chalumeau M, Martinot A, et al. Prevalence, Characteristics, and Determinants of Suboptimal Care in the Initial Management of Community-Onset Severe Bacterial Infections in Children. JAMA Netw Open. 2022;5(6):e2216778. doi:10.1001/jamanetworkopen.2022.16778

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    2022-09-02 一叶知秋

    #发生率#

    0

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    2023-05-21 mfx799

    #严重细菌感染#

    0

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    2023-02-12 wushaoling

    #决定因素#

    0

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    2022-06-27 liuhuangbo

    #细菌感染#

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1826806, encodeId=641c1826806a6, content=<a href='/topic/show?id=e5283e89970' target=_blank style='color:#2F92EE;'>#发生率#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=37899, encryptionId=e5283e89970, topicName=发生率)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=30bd35, createdName=一叶知秋, createdTime=Fri Sep 02 19:36:43 CST 2022, time=2022-09-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1967999, encodeId=fca7196e9997c, content=<a href='/topic/show?id=9e6021209b6' target=_blank style='color:#2F92EE;'>#严重细菌感染#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=21209, encryptionId=9e6021209b6, topicName=严重细菌感染)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6411176, createdName=mfx799, createdTime=Sun May 21 11:36:43 CST 2023, time=2023-05-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1671064, encodeId=3d2e16e1064b1, content=<a href='/topic/show?id=bd58310846e' target=_blank style='color:#2F92EE;'>#决定因素#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31084, encryptionId=bd58310846e, topicName=决定因素)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6e7726816052, createdName=wushaoling, createdTime=Sun Feb 12 02:36:43 CST 2023, time=2023-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1280701, encodeId=7a681280e0187, content=<a href='/topic/show?id=beefe810798' target=_blank style='color:#2F92EE;'>#细菌感染#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=78107, encryptionId=beefe810798, topicName=细菌感染)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6779163, createdName=liuhuangbo, createdTime=Mon Jun 27 00:36:43 CST 2022, time=2022-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1395928, encodeId=55ec139592889, content=<a href='/topic/show?id=7a89e4036eb' target=_blank style='color:#2F92EE;'>#社区#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74036, encryptionId=7a89e4036eb, topicName=社区)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=96f62500201, createdName=12498e67m28暂无昵称, createdTime=Mon Jun 27 00:36:43 CST 2022, time=2022-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1243577, encodeId=6b1912435e792, content=JAMA上文章都是顶级的，谢谢梅斯及时上新, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=肿瘤克星, createdTime=Sat Jun 25 12:36:43 CST 2022, time=2022-06-25, status=1, ipAttribution=)]
    2022-06-27 12498e67m28暂无昵称

    #社区#

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1826806, encodeId=641c1826806a6, content=<a href='/topic/show?id=e5283e89970' target=_blank style='color:#2F92EE;'>#发生率#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=37899, encryptionId=e5283e89970, topicName=发生率)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=30bd35, createdName=一叶知秋, createdTime=Fri Sep 02 19:36:43 CST 2022, time=2022-09-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1967999, encodeId=fca7196e9997c, content=<a href='/topic/show?id=9e6021209b6' target=_blank style='color:#2F92EE;'>#严重细菌感染#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=21209, encryptionId=9e6021209b6, topicName=严重细菌感染)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6411176, createdName=mfx799, createdTime=Sun May 21 11:36:43 CST 2023, time=2023-05-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1671064, encodeId=3d2e16e1064b1, content=<a href='/topic/show?id=bd58310846e' target=_blank style='color:#2F92EE;'>#决定因素#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31084, encryptionId=bd58310846e, topicName=决定因素)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6e7726816052, createdName=wushaoling, createdTime=Sun Feb 12 02:36:43 CST 2023, time=2023-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1280701, encodeId=7a681280e0187, content=<a href='/topic/show?id=beefe810798' target=_blank style='color:#2F92EE;'>#细菌感染#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=78107, encryptionId=beefe810798, topicName=细菌感染)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6779163, createdName=liuhuangbo, createdTime=Mon Jun 27 00:36:43 CST 2022, time=2022-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1395928, encodeId=55ec139592889, content=<a href='/topic/show?id=7a89e4036eb' target=_blank style='color:#2F92EE;'>#社区#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74036, encryptionId=7a89e4036eb, topicName=社区)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=96f62500201, createdName=12498e67m28暂无昵称, createdTime=Mon Jun 27 00:36:43 CST 2022, time=2022-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1243577, encodeId=6b1912435e792, content=JAMA上文章都是顶级的，谢谢梅斯及时上新, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=肿瘤克星, createdTime=Sat Jun 25 12:36:43 CST 2022, time=2022-06-25, status=1, ipAttribution=)]
    2022-06-25 肿瘤克星

    JAMA上文章都是顶级的，谢谢梅斯及时上新

    0