- 學位論文
新生兒早發性菌血症分析及抗生素使用對氣喘發生率之影響
Analysis of neonatal early-onset bacteremia and the effect of antibiotic use on new-onset asthma
摘要
根據WHO 2013年的統計，大約有一百萬新生兒因為感染而死亡。新生兒敗血症的臨床表徵跟症狀並不容易確認，例如，餵食困難、可自行恢復的呼吸暫停或心跳下降、輕微呼吸急促或心跳過快，或是活動力下降都有可能是新生兒敗血症的一個表徵。目前臨床上對於疑似新生兒敗血症的病人處置準則是檢測全血球計量、白血球分類、C反應蛋白、血液及尿液培養，胸腔X光片以及腦瘠髓液檢查。C反應蛋白對於新生兒敗血症有特異性但卻不是早期的生物指標。現階段，新生兒菌血症必須透過血液培養陽性來確定診斷，這通常要花5-7天的時間，因此，在獲得血液培養報告之前會常規使用廣泛經驗性抗生素來治療可能常見的病原體。 然而，在嬰幼兒時期使用抗生素可能會增加孩童時期氣喘的發生。我們根據國家研究資料庫的資料去評估罹患細支氣管炎嬰幼兒使用抗生素和孩童時期氣喘的相關性，研究中發現在罹患氣喘前五年內使用高累績劑量抗生素和孩童時期氣喘有強烈相關，並且在抗生素種類中，以azithromycin影響最大。因此，如何適當使用抗生素以及減少使用抗生素的頻率在嬰幼兒時期是非常重要的。 在早產兒早發性菌血症中，抗藥性菌株例如ESBL腸內桿菌時常出現並且造成高致死率。因此，當臨床工作者面對一個感染ESBL-producing E.coli的嬰兒，接受經驗性抗生素治療無效而可能致死時，是一個極大的挑戰。 我們回朔分析了2004年到2015年出生，並在出生3天內罹患E.coli菌血症的早產兒，比較其存活跟無存活組，以及ESBL-producing E.coli跟非ESBL-producing E.coli組之間母體因子跟周產期因子的差異。我們發現嬰兒出生後出現收縮壓以及絕對嗜中性白血球下降是死亡的預測因子，並且，ALT是可以用來預測嬰兒可能受到ESBL-producing E.coli感染的指標。
並列摘要
According to the data from the World Health Organization (WHO) 2013, approximately one million neonatal deaths resulting from infections. The clinical signs and symptoms of neonatal sepsis are not easy to define. For example, the presence of difficult feeding, self-resolving apnea or bradycardia, mild tachypnea or tachycardia, or decreased activity may be the one of the indicators of neonatal sepsis. Current clinical guidelines is to analyze complete blood count (CBC), differential count (DC), C-reactive protein (CRP) levels, blood and urine cultures, chest x-ray, and cerebral spinal fluid (CSF) study for clinically suspected cases. CRP is a specific but not early biomarker of neonatal sepsis. Currently, definitive diagnosis of bacteremia in neonates is based on a positive blood culture that may take 5-7 days. Thus, empiric antibiotics are routinely prescribed before the proven culture for covering the common pathogens. However, use of antibiotics during infancy may increase the risk of childhood asthma. We assessed the relationship of early-life antibiotic use on children with bronchiolitis and new-onset asthma in children according to the Taiwan National Health Insurance Research Database (NHIRD) 2010. There was a relationship between the risk of new-onset asthma and using a high dose of antibiotics within five years before the diagnosis of asthma. Among the different antibiotics, macrolides, azithromycin specifically had the greatest effect of development of asthma. Therefore, how to use antibiotics properly and reduce the frequency of using antibiotics were very important in infant period. In early-onset bacteremia among preterm neonates, antimicrobial resistance such as extended -spectrum β-lactamase (ESBL)-producing Enterobacteriaceae is the main pathogen and can cause a high mortality rate. Thus, it is a big challenge to clinicians to face an infant who received empiric antibiotics expired from ESBL-producing E.coli sepsis. We retrospectively reviewed preterm neonates who had E. coli bacteremia occurring within 3 days after birth from 2004 to 2015 and compared their maternal and perinatal information between survival and non-survival groups, as well as the ESBL-producing and non-ESBL-producing E. coli bacteremia groups. We found that the lower systolic blood pressure and absolute neutrophil count were the predicting factors of mortality in preterm babies with early-onset E. coli bacteremia, and alanine aminotransferase (ALT) could be a significant factor in predicting ESBL-producing E. coli.