复杂性先天性心脏病术后耐甲氧西林金黄色葡萄球菌所致儿童感染性心内膜炎的救治与思考

doi:10.12372/jcp.2024.23e1225

摘要/Abstract

摘要：

患儿，男，6岁10月龄，因“反复发热2个月，精神不佳半天”就诊于我院。患儿既往有先天性心脏病，改良体-肺循环分流术后出现发热，多次血培养提示耐甲氧西林金黄色葡萄球菌（methicillin-resistant Staphylococcus aureus，MRSA）阳性，超声心动图示管道不通畅，诊断为感染性心内膜炎，予万古霉素、利奈唑胺、美罗培南等抗感染，患儿用药后骨髓抑制明显，感染控制不佳，行急诊手术摘除赘生物、中央分流术后仍反复发热，改用康替唑胺抗感染治疗后患儿病情改善，感染稳定控制，随访半年患儿无反复感染，未见脏器损伤及骨髓抑制现象，超声心动图示血流通畅。本病例拟为临床医师应对此类复杂感染提供临床思路，并对儿童耐药菌抗感染治疗药物选择进行探讨。

关键词: 感染性心内膜炎, 耐甲氧西林金黄色葡萄球菌, 抗生素, 康替唑胺, 儿童

Abstract:

The patient, male, 6 years and 10 months old, was admitted to our hospital because of “repeated fever for 2 months and mental fatigue for half a day”. The patient had congenital heart disease in the past, and fever occurred after modified body to pulmonary circulation shunt. Multiple blood cultures indicated methicillin-resistant Staphylococcus aureus (MRSA), and echocardiography indicated that the tube was not smooth. The patient was diagnosed with infective endocarditis, and vancomycin, linezolid, meropenem and other anti-infective drugs were given. After the use of drugs, bone marrow suppression is obvious, infection control is poor. Emergency surgery was performed to remove the redundant organisms and recurrent fever after central shunt surgery. The patient’s condition improved and the infection was stably controlled, after switched to contizolamide anti-infective treatment with contezolid. Follow-up six months, the child has no recurrent infections, there is no organ damage and bone marrow suppression phenomenon, the echocardiogram showed that the blood flow is smooth. This case is intended to provide clinical ideas for clinicians to deal with this kind of complex infection, and to discuss the choice of drugs for anti-infection treatment of drug-resistant bacteria in children.

Key words: infective endocarditis, methicillin-resistant Staphylococcus aureus, antibiotic, contezolid, child

黄诗喻, 王薇, 朱荻绮, 沈捷, 曹清. 复杂性先天性心脏病术后耐甲氧西林金黄色葡萄球菌所致儿童感染性心内膜炎的救治与思考[J]. 临床儿科杂志, 2024, 42(8): 728-736.

HUANG Shiyu, WANG Wei, ZHU Diqi, SHEN Jie, CAO Qing. Treatment and reflection of infective endocarditis caused by methicillin-resistant Staphylococcus aureus in children after complex congenital heart disease[J]. Journal of Clinical Pediatrics, 2024, 42(8): 728-736.

图/表 5

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表1

患儿病程时间轴"

时间	临床表现及检查、抗菌药物治疗情况
入院前2个月	患儿因先天性心脏病于外院行改良体-肺循环分流术(B-T分流术)
入院前1个月	反复发热，三次血培养示MRSA，
	外院先后予哌拉西林他唑巴坦、万古霉素、达托霉素治疗，体温控制不佳
入院前半天	高热，精神不佳，血压下降，氧合不能维持
入院时	体格检查：T36℃，HR140次/分，RR22次/分，BP72/42 mmHg，体重13 kg，精神欠佳，口唇发绀，二尖瓣面容，鼻导管(2 L/分)吸氧下经皮血氧饱和度70 %，四肢末端凉，可见杵状指。
	血常规：WBC14.79×10⁹/L，PLT96×10⁹/L，中性粒细胞百分比96.8 %
	感染炎症指标：SAA395.09 mg/L，CRP84.3 mg/L，PCT>100.00 ng/mL
	心肌损伤标记物：pro-BNP 35 000 pg/mL，cTNI-Ⅰ 0.12 μg/L
	肝肾功能：钠128.0 mmol/L，ALT 86 U/L，AST 203 U/L，LDH 764U/L
	血培养：革兰阳性球菌
	影像学：胸部CT提示右位主动脉弓，左右支气管反位，左肺感染，骨密度欠均匀。
	彩色多普勒超声心动图：B-T管道无明显梗阻，主动脉端内径约0.37 cm，左向右分流速2.64 m/s。
	治疗：美罗培南500 mg q8h ivgtt+万古霉素200 mg q8h ivgtt+氟氯西林钠200 mgq8h ivgtt+利奈唑胺130 mg q8h ivgtt
入院第2天	复查WBC、PLT下降，停用利奈唑胺及氟氯西林钠
入院第10天	患儿热退，生命体征平稳，CRP、pro-BNP 下降，血培养阴性
	美罗培南降级为头孢他啶0.65g q8h ivgtt
入院第30天	血氧饱和度下降至45 %，次日体温38℃，连续两次血培养提示MRSA
	彩色多普勒超声心动图提示：B-T管道束宽降低(内径0.3 cm)，流速减慢(1.85 m/s)
	加用利奈唑胺0.14 g q8h po
入院第40天	面罩吸氧下氧合不能维持，予气管插管，呼吸机辅助通气
	万古霉素加量至225mg q8h ivgtt
入院第43天	心率30~40 次/分，血压33/24 mmHg，急诊手术，赘生物培养阴性
（手术）	术后予万古霉素225 mg q8h ivgtt+利奈唑胺0.14 g q8h po
术后第1天	PLT下降至30×10⁹/L，停用利奈唑胺，予头孢他啶0.75 g q8h ivgtt
术后第4天	复查感染指标较前升高，美罗培南300 mg q8h ivgtt+万古霉素225 mg q8h ivgtt
术后第20天	间断低热1周，感染指标进行性升高，血、尿培养阴性
	万古霉素药物浓度9.70 mg/L
	康替唑胺200 mg q12h po +万古霉素225 mg q8h ivgtt
术后第29天	感染指标正常，停用万古霉素
术后第38天	带药出院
出院后1个月	停用康替唑胺
出院后6个月	体温平稳，血常规、感染指标、肝肾功能正常
	彩色多普勒超声心动图提示管道通畅，无赘生物

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参考文献 36

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