Clin Infect Dis:2-59月龄重症肺炎患儿治疗失败率低

2013-01-04 Clin Infect Dis 互联网 陈郁婷

自1990年以来,儿童肺炎管理取得了相当的进展。然而,在世界范围内,肺炎仍然是导致儿童死亡的一大杀手。每年约有140万儿童死于肺炎。其中,大部分死亡发生于患有WHO(世界卫生组织)定义的严重或非常严重肺炎的患儿,常常发生于那些没有及时进行治疗的儿童患者。基于上述情况,来自美国波士顿大学全球卫生和发展中心的Matthew P Fox等人展开一项研究,研究结果在线发表在2012年12月21日的《临床感

自1990年以来,儿童肺炎管理取得了相当的进展。然而,在世界范围内,肺炎仍然是导致儿童死亡的一大杀手。每年约有140万儿童死于肺炎。其中,大部分死亡发生于患有WHO(世界卫生组织)定义的严重或非常严重肺炎的患儿,常常发生于那些没有及时进行治疗的儿童患者。基于上述情况,来自美国波士顿大学全球卫生和发展中心的Matthew P Fox等人展开一项研究,研究结果在线发表在2012年12月21日的《临床感染性疾病》(Clincal Infectious Diseases)杂志上。作者发现,随着抗生素治疗的推广,重症肺炎几乎不再导致儿童发生严重并发疾病或者死亡。

本研究旨在评估全球患有WHO定义的重症肺炎且月龄在2-59之间儿童患者的治疗失败率,并找出能够有效预测治疗效果的因素。研究人员汇聚分析了4项针对重症肺炎的研究数据,均开展于1999年-2009年期间且使用类似的方法学。他们将治疗失败定义为治疗的前6天出现以下症状:死亡、危险体征(无法饮用液体、抽搐、异常嗜睡)、发烧(大于或等于38°C)、胸腔下部收缩(LCI)(第2-3天)、LCI或发烧(第6天)或者抗生素疗效改变。

研究结果如下,在治疗的前6天,来自10个不同国家的6398例重症肺炎患儿中,495例出现治疗失败(7.7%,95%置信区间[CI]:7.1-8.4%)。临床治疗失败的最常见原因是出现持续高烧和LCI(第2-3天),或者是单独出现LCI或高烧(第6天),这二者共造成了71%的失败。17例(0.3%)患儿死亡。极少出现危险体征(<1%)。6-11月龄和2-5月龄婴幼儿更易出现治疗失败,分别高达12-59月龄儿童的2和3倍(aOR:2.0,95%CI:1.5-2.6;aOR:3.5,95%CI:2.7-4.6)。患儿出现呼吸急促与失败几率的翻倍增加有关(aOR:2.1,95%CI:1.4-3.2)。在年龄和呼吸频率相互作用的模型中,与12-59月龄且呼吸正常的患儿相比,2-5月龄且呼吸急促患儿的治疗失败率为前者的7倍(aOR:6.8,95%CI:4.5-10.2)。

这项大规模汇聚分析的结果表明:在不同地理区域(10个不同国家),重症肺炎治疗失败率低以及极少出现严重并发疾病或死亡,主要得益于医疗机构医生或是社区卫生工作者(CHWs)针对WHO定义的重症肺炎使用抗生素(口服阿莫西林)进行治疗管理。这些发现支持了在基层以及社区卫生机构使用口服抗生素治疗重症肺炎的举措,正如全球控制和预防肺炎行动计划所倡议的一样,通过提高治疗的覆盖率以减少婴幼儿及儿童的死亡。

肺炎相关的拓展阅读:

doi: 10.1093/cid/cis1201
PMC:
PMID:

Low Rates of Treatment Failure in Children 2‐59 Months Treated for Severe Pneumonia: A Multi‐site Pooled Analysis

Fox MP, Thea DM, Sadruddin S, Bari A, Bonawitz R, Hazir T, Bin Nisar Y, Qazi SA; for the Pneumonia Studies Group.

Background. Despite advances childhood pneumonia management, it remains a major killer of children worldwide. We sought to estimate global treatment failure rates in children 2-59 months with WHO-defined severe pneumonia and identify factors requiring referral for supportive care.Methods. We pooled data from four severe pneumonia studies conducted 1999-2009 using similar methodologies. We defined treatment failure by day 6 as: death, danger signs (inability to drink, convulsions, abnormally sleepy), fever (≥38°C), lower chest indrawing (LCI) (day 2-3), LCI or fever (day 6), or antibiotic change.Results. Among 6398 cases of severe pneumonia from ten countries, 495 (7.7%;95%CI:7.1-8.4%) failed treatment by day 6. The most common clinical failure reasons was persistence of fever and LCI (day 2-3) or LCI or fever alone (day 6)(71% of failures). 17 (0.3%) children died. Danger signs were uncommon (<1%). Infants 6-11 months and 2-5 months were two- and three-fold more likely to fail (aOR:2.0; 95%CI:1.5-2.6 and aOR:3.5; 95%CI:2.7-4.6) as children 12-59 months. Very fast breathing was associated with two-fold increased odds (aOR:2.1; 95%CI:1.4-3.2). In models with interactions between age and respiratory rate, failure was increased seven-fold (aOR 6.8; 95%CI:4.5-10.2) comparing infants 2-5 months with very fast breathing to children 12-59 months with normal breathing.Conclusions. Our findings demonstrate severe pneumonia case management with antibiotics at health facilities or in the community is associated with few serious morbidities or deaths across diverse geographic settings and support moves to shift management of severe pneumonia with oral antibiotics to outpatients and in the community.

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