Alt solunum yolu enfeksiyonu tanılı hastaların klinik ve laboratuvar bulguları ile prognoz öngörülebilir mi?
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Dosyalar
Tarih
2019
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Giriş: Alt solunum yolu enfeksiyonları; özellikle gelişmekte olan ülkelerde, 5 yaşın altındaki çocuklarda mortalitenin en önemli nedenlerinden biridir. Dünya Sağlık Örgütü'nün 2005 yılı raporuna göre de, alt solunum yolu enfeksiyonları 5 yaş altı çocuklarda en sık ölüm nedeni olmakla birlikte çocuk ölümlerinin %19' undan sorumludur. Hem gelişmiş hem de gelişmekte olan ülkelerdeki okul öncesi çocuklarda yapılan çalışmalar, solunum yolu enfeksiyonlarının çoğunun genel olarak viral etiyolojiye sahip olduğunu göstermektedir. Viral etkenlerden de en sık respiratuar sinsityal virüs görülmekte, onu human rinovirüs ve parainfluenza virüs izlemektedir. Son yıllarda moleküler tanı testlerinin gelişmesi kullanım sıklığının da artması ile birlikte, viral etkenlerin tespit edilmesi kolaylaşmıştır. Viral etkenlerin ve hastanın başvuru anındaki semptom ve fizik muayene bulgularının hastalık şiddeti ve kliniği üzerine etkisi daha iyi anlaşılırsa, hastaların klinik seyirlerinin de tahmin edilebileceği düşünülmektedir. Amaç: Çalışmamızın amacı; alt solunum yolu enfeksiyonu nedeniyle hastanede yatışı gereken, özellikle de ağır seyreden hasta grubunda saptanmış olan viral etken ile birlikte, hastanın başvuru anındaki klinik ve laboratuvar bulgularının birlikte değerlendirilerek, klinik seyirin ve prognozun nasıl gelişeceğini öngörebilmektir. Yöntem: Ocak 2014 – Aralık 2018 tarihleri arasında; Ege Üniversitesi Çocuk Hastanesi'nde alt solunum yolu enfeksiyonu (akut bronşiyolit ve pnömoni) tanısı ile yatırılmış, nazofaringeal sürüntü örneği alınarak solunum viral paneli gönderilen ve etken pozitif olarak saptanan, 5 yaş altı (yenidoğan dönemi hariç) hastalar retrospektif olarak incelendi. Hastaların demografik, klinik ve laboratuvar bilgilerine hastane bilgi sistemi ve sisteme kayıtlı hasta dosyası bilgilerinden ulaşıldı. Hastalardan alınmış olan nazofaringeal ve nazal sürüntü örnekleri Ege Üniversitesi Tıp Fakültesi Hastanesi Mikrobiyoloji Anabilim Dalı laboratuvarında, gerçek zamanlı polimeraz zincir reaksiyon (RT-PCR) yöntemi ile, FTD Respiratory pathogens 21 ov kit (Fast Track Diagnosis, Lüksemburg) kullanılarak, RotorGene isimli cihazda çalışıldı. Çalışmaya dahil edilen olguların; yaş (ay olarak), cinsiyet, doğum haftası ve doğum kilosu, başvurduğu ay ve yıl, başvuru anında bakılan vücut sıcaklığı, oksijen saturasyonu değeri (% olarak), burun akıntısı, öksürük, hışıltı, solunum güçlüğü, morarma, interkostal çekilmelerinin olup olmadığı gibi klinik semptomları, kaçıncı alt solunum yolu enfeksiyonu atağı olduğu, eşlik eden kronik hastalığı olup olmadığı, hışıltılı infant olarak değerlendirilip değerlendirilmediği, ilk başvuru anında bakılan akut faz reaktanı değerleri (C-reaktif protein, prokalsitonin total lenfosit ve nötrofil sayısı), gönderilen örnekte PCR ile pozitif olarak saptanan viral etken ve/veya etkenlerin sayısı ile saptanan etkenler, hastaneye yatışından itibaren ilk 48 saat içinde gönderilen ve üreme saptanan bakteriyel kan, balgam, transtrakeal aspirasyon ve idrar kültürü sonuçları, hastanede yatış süresi, almış olduğu medikal tedaviler (inhaler, intravenöz steroid ve magnezyum sülfat, antibiyotik), aldığı solunum desteği (oksijen, HFNC, BİPAP, İMV, ECMO) ve tedavi sonucu (taburcu ya da exitus) değerlendirildi. Tüm bu klinik ve laboratuvar bilgilerin değerlendirilmesi ile, klinik seyirin ağırlığının öngörülebilmesi amaçlandı. Bu amaçla DSÖ'nün sınıflaması dikkate alınarak hastalar ağır, orta- ağır ve hafif klinik seyir olacak şekilde üç gruba ayırıldı. Ağır klinik gruba dahil edilme kriterleri; çocuk yoğun bakım ünitesine alınarak, invaziv ve non- invaziv mekanik ventilasyon desteği gereken hastalar ile, tedavi sonucu eksitus olan hastalar ağır grup olarak değerlendirildi. Orta- ağır grup için de başvuru oksijen saturasyonu %92'nin altında olup, oksijen ya da yüksek akımlı nazal oksijen (HFNC) desteği almış olan hastalar alındı. Bunların dışında kalan hastalar ise hafif grup olarak değerlendirildi. Bulgular: Ocak 2014 – Aralık 2018 ayları arasında EÜTF Çocuk Hastanesi'nde, 5 yaşın altında "Alt Solunum Yolu Enfeksiyonu" tanısı ile hastaneye yatırılan, etken saptamak amacıyla alınan nazofaringeal sürüntü örneğinde viral etken pozitif olarak saptanan ve dosya verilerine ulaşılabilen toplam 1242 hasta ile çalışıldı. Hastalarımızın 459'u (%37) kız, 783'ü (%63) erkek çocuktan oluşmaktaydı. Yaş ortalaması 13.9 (min:1- max:62) ay olarak hesaplandı. Yaş gruplarına ayırıldığında ise; 1-6 ay arası olan 535 hasta (%43.1), 7-12 ay arası 239 hasta (%19.2), 13-24 ay arası 256 hasta (%20.6), 25-36 ay arası 83 hasta (%6.7), 37-60 ay arası da 129 hasta (%10.4) olarak dağılımın olduğu görüldü. Çalışmaya dahil edilen 1242 hastadan; 746'sı (%60.1) hafif, 378'i (%30.4) orta-ağır, 118'i de (%9.5) ağır grup içerisinde olarak saptandı. Klinik ağırlık gruplarına göre hastaların ortalama yaşları karşılaştırıldığında; ağır grupta yaş ortalama 13 ay (min:1- max:53), orta – ağır grupta 8 ay (min:1- max:60), hafif grupta ise 8 ay (min:1- max:62) olarak görüldü. Hastaların hastaneye başvurularında bakılan oksijen saturasyonları (SpO2) da; ağır grupta %89 (min:60- max:100), orta- ağır grupta %90 (min:60- max:100), hafif grupta ise %97.5 (min:89- max:100) olarak saptandı ve ağır klinik seyir açısından istatistiksel olarak anlamlı olarak değerlendirildi. Başvuru anında eşlik eden kronik hastalığı bulunanlar 1242 hastanın 403'ünü (%32.4), komorbid hastalığı bulunmayanlar ise 839'unu (%67.6) oluşturmaktaydı. Komorbid hastalılar arasında da; kronik akciğer hastalıkları (KAH) 125 hastada (%10.1), konjenital kalp hastalıkları (KKH) 96 hastada (%7.7), nörometabolik hastalıklar 94 hastada (%7.6), immun yetmezlikler 73 hastada (%5.9) ve diğer grubu olarak belirlenenler (gastrointestinal sistem hastalıkları, genetik hastalıklar, renal yetmezlik) 158 hastada (%12.7) şeklinde dağılım göstermekteydi. Komorbid hastalığı olanlarda ASYE kliniğinin daha ağır seyredebileceği istatistiksel olarak da anlamlı olarak değerlendirildi. Hastaların daha önceki ASYE atak sayıları değerlendirildiğinde, tüm hasta grubu içinde %54.5'inde ilk atak olduğu görüldü. Ağırlık grupları arasında atak sayısı ile kıyaslama yapıldığında ise; artan atak sayısının ağır klinik seyir açısından hafif ve ağır grup arasında anlamlı şekilde ağır grupta daha fazla olduğu görüldü. Çalışmamızdaki izlem sonucunda eksitus olan toplam 11 hastanın da ağır klinik grup içerisinde seyretmiş ve ÇYBÜ'nde izlenmiş olduğu görüldü. Pozitif olarak saptanmış olan viral etkenlerin dağılımına bakıldığında ise; RSV (n:579, % 46.6), HRV (n:439, %35.3), FLU (n:116 %9.3), PIF(n:119 %9.6), HBoV (n:138, %11.1), HMpV (n:85 %6.8), enterovirüs (n:29 %2.3), coronavirüs (n:67 %5.4), adenovirüs (n:81 %6.5) ve toplamda 349 hastada da (% 28.1) birden fazla virüs birlikte (koenfeksiyon) olarak belirlendi. Ağır klinik seyir açısından riskin en fazla olduğu virüsler FLUB, HBoV ve adenovirüs olarak belirlendi. Laboratuvar değerlerine bakıldığında ise nötrofili ve lenfopeni ile; CRP ve prokalsitonin düzeylerinin ağır seyreden klinik gruba daha sık eşlik ettiği görüldü. Klinik ağırlık gruplarına göre değerlendirilen hastaların, servis ya da çocuk yoğun bakım ünitesi (ÇYBÜ) yatışları incelendiğinde ise; ağır grup olarak değerlendirilen 118 hastanın 13'ü (%11) serviste, 105'i ÇYBÜ'nde; orta- ağır grupta yer alan 378 hastanın 352'si (%93.1) serviste, 26'sı (%6.9) ÇYBÜ'nde; hafif grupta yer alan 746 hastanın da 740'ı (%99.2) servis, 6'sı (%0.8) da ÇYBÜ'nde yatırılarak izlenmişti. Gruplar arasında istatistiksel değerlendirme ile de anlamlı şekilde klinik ağır gidişte ÇYBÜ yatışı risk faktörü olarak yorumlandı. Sonuç: Çalışmamızda; Ocak 2014 – Aralık 2018 tarihleri arasında kliniğimizde ASYE tanısı ile yatırılan, 5 yaşın altındaki, alınan nazal sürüntü örneğinde PCR yöntemi ile viral etken pozitif saptanan hastalar, etken, klinik ve laboratuvar bulguları ile birlikte klinik seyir ağırlık gruplarına göre değerlendirildiğinde; yaş, saptanan virüs tipi, ateş, daha önce geçirilen ASYE, nötrofili, lenfopeni, başvuru anında SpO2 düşüklüğü, dispne ve takipne ve eşlik eden kronik hastalığın olması klinik olarak ağır seyir açısından anlamlı bulundu.
Introduction: Lower respiratory tract infections; It is one of the most important causes of mortality in children under 5 years of age, especially in developing countries. According to the 2005 report of the World Health Organization, lower respiratory tract infections are the most common cause of death in children under 5 years of age and responsible for 19% of child deaths. Studies in preschool children in both developed and developing countries show that most respiratory infections generally have viral etiology. The most common viral agents are respiratoryatuarsinsial virus, followed by humannrinovirus and parainfluenza virus. With the development of molecular diagnostic tests in recent years, the frequency of use has increased and the detection of viral agents has become easier. If the effects of viral agents, symptoms and physical examination findings on the severity and clinical presentation of the patient are better understood, it is thought that the clinical course of the patients can be predicted. Objective: The aim of this study; The aim of this study is to evaluate the clinical and laboratory findings of the patient at the time of admission together with the viral agent detected especially in the severely ill group requiring hospitalization for lower respiratory tract infection and to predict how the clinical course and prognosis will improve. Method: Between January 2014 and December 2018; Patients under the age of 5 years (except neonatal period) who were hospitalized in Ege University Children's Hospital with the diagnosis of lower respiratory tract infection (acute bronchiolitis and pneumonia), were sent to the respiratory viral panel with a nasopharyngeal specimen. Demographic, clinical and laboratory data of the patients were obtained from the hospital information system and patient files. Nasopharyngeal and nasal swab samples obtained from the patients were studied in the laboratory of Ege University Medical Faculty Department of Microbiology by using real-time polymerase chain reaction (RT-PCR) method using FTD Respiratorypathogens 21 ov kit (FastTrackDiagnosis, Luxembourg). The cases included in the study; age (in months), sex, birth week and birth weight, month and year of admission, body temperature, oxygen saturation value (in%), nasal discharge, cough, wheezing, difficulty in breathing, bruising, intercostal withdrawal clinical symptoms, number of attacks of lower respiratory tract infection, concomitant chronic disease, wheezing infant, acute phase reactant values (C-reactive protein, procalcitonin total lymphocyte and neutrophil count), positive bacterial blood, sputum, transtrakealaspiration and urine culture results sent within the first 48 hours of hospitalization, duration of hospitalization, medical treatments (inhaler, intravenoussteroid) and magnesium sulphate, antibiotic), respiratory support (oxygen, HFNC, BIPAP, IMV, ECMO) and treatment result (discharged or exitus). All these clinical and laboratory data were evaluated to predict the severity of the clinical course. For this purpose, the patients were divided into three groups according to WHO classification as severe, moderate-severe and mild clinical course. Criteria for inclusion in the severe clinical group; The patients who required invasive and non-invasive mechanical ventilation support and those who died after the treatment were evaluated as severe group. Oxygen saturation at admission was below 92% for the moderate-heavy group and patients receiving oxygen or high-flow nasal oxygen (HFNC) support were included. Other patients were evaluated as mild group. Results: Between January 2014 and December 2018, a total of 1242 patients who were hospitalized under the age of 5 with the diagnosis of Lower Respiratory Tract Infection, at the Ege University Medical Faculty Children's Hospital for the purpose of detecting a causative agent were identified. 459 (37%) of our patients were female and 783 (63%) were male. The mean age was calculated as 13.9 (min: 1- max: 62) months. 459 (37%) of our patients were female and 783 (63%) were male. The mean age was calculated as 13.9 (min: 1- max: 62) months. When divided into age groups; 535 patients (43.1%) between 1-6 months, 239 patients (19.2%) between 7-12 months, 256 patients (20.6%) between 13-24 months, 83 patients (6.7%) between 25 and 36 months, 129 patients (10.4%) between 37 -60 months were seen. 1242 patients included in the study; 746 (60.1%) were mild, 378 (30.4%) were moderate-severe and 118 (9.5%) were in severe group. When the mean age of the patients was compared according to clinical weight groups; The mean age was 13 months (min: 1- max: 53) in the severe group, 8 months (min: 1- max: 60) in the moderate-severe group, and 8 months (min: 1- max: 62) in the mild group. Oxygen saturation (SpO2) at admission was as follows; 89% (min: 60- max: 100) in the severe group, 90% (min: 60- max: 100) in the moderate-severe group, 97.5% (min: 89- max: 100) in the mild group and was statistically significant for the severe clinical course. At the time of admission, 403 (32.4%) of the 1242 patients with concomitant chronic disease and 839 (67.6%) of those without comorbid disease. Among the comorbid diseases; chronic lung diseases (CAD) in 125 patients (10.1%), congenital heart disease (CHD) in 96 patients (7.7%), neurometabolic diseases in 94 patients (7.6%), immunodeficiencies in 73 patients (5.9%) and other group (gastrointestinal system diseases, genetic diseases, renal failure) in 158 patients (12.7%) were obtained. The presence of LRTI in patients with comorbid disease was evaluated as statistically significant. When the previous LRTI episodes of the patients were evaluated, it was seen that 54.5% of the patients had the first episode. When comparing the number of attacks between the groups; the number of episodes was significantly higher in the severe group between the mild and severe groups in terms of severe clinical course. As a result of the follow-up in our study, a total of 11 patients died and were observed in the severe clinical group and were observed in the PICU. When the distribution of positive viral agents was examined; RSV (n: 579, 46.6%), HRV (n: 439, 35.3%), FLU (n: 116 9.3%), PIF (n: 119 9.6%), HBoV (n: 138, 11.1%), HMpV ( n: 85 6.8%), enterovirus (n: 29 2.3%), coronavirus (n: 67 5.4%), adenovirus (n: 81 6.5%) and a total of 349 patients (28.1%) with more than one virus together (coinfection) determined. Viruses with the highest risk for severe clinical course were FLUB, HBoV and adenovirus. Laboratory values were evaluated with neutrophilia and lymphopenia; CRP and procalcitonin levels were more frequently associated with severe clinical group. When the service or pediatric intensive care unit (PICU) hospitalizations are examined; Of 118 patients evaluated as severe group, 13 (11%) were in the ward and 105 in the PICU; Of the 378 patients in the moderate-heavy group, 352 (93.1%) were in the ward and 26 (6.9%) were in the PICU; Of the 746 patients in the mild group, 740 (99.2%) were hospitalized and 6 (0.8%) were hospitalized in the PICU. Statistically significant clinical severity of ICU hospitalization was evaluated as risk factor between the groups. Conclusion: In our study, patients who were hospitalized in our clinic with the diagnosis of LRTI between January 2014 and December 2018, under the age of 5 years and who were found to be positive for viral agents by PCR method were evaluated according to the clinical course weight groups; Age, type of virus, fever, previous LRTI, neutrophilia, lymphopenia, low SpO2 at admission, dyspnea and tachypnea and accompanying chronic disease were clinically significant.
Introduction: Lower respiratory tract infections; It is one of the most important causes of mortality in children under 5 years of age, especially in developing countries. According to the 2005 report of the World Health Organization, lower respiratory tract infections are the most common cause of death in children under 5 years of age and responsible for 19% of child deaths. Studies in preschool children in both developed and developing countries show that most respiratory infections generally have viral etiology. The most common viral agents are respiratoryatuarsinsial virus, followed by humannrinovirus and parainfluenza virus. With the development of molecular diagnostic tests in recent years, the frequency of use has increased and the detection of viral agents has become easier. If the effects of viral agents, symptoms and physical examination findings on the severity and clinical presentation of the patient are better understood, it is thought that the clinical course of the patients can be predicted. Objective: The aim of this study; The aim of this study is to evaluate the clinical and laboratory findings of the patient at the time of admission together with the viral agent detected especially in the severely ill group requiring hospitalization for lower respiratory tract infection and to predict how the clinical course and prognosis will improve. Method: Between January 2014 and December 2018; Patients under the age of 5 years (except neonatal period) who were hospitalized in Ege University Children's Hospital with the diagnosis of lower respiratory tract infection (acute bronchiolitis and pneumonia), were sent to the respiratory viral panel with a nasopharyngeal specimen. Demographic, clinical and laboratory data of the patients were obtained from the hospital information system and patient files. Nasopharyngeal and nasal swab samples obtained from the patients were studied in the laboratory of Ege University Medical Faculty Department of Microbiology by using real-time polymerase chain reaction (RT-PCR) method using FTD Respiratorypathogens 21 ov kit (FastTrackDiagnosis, Luxembourg). The cases included in the study; age (in months), sex, birth week and birth weight, month and year of admission, body temperature, oxygen saturation value (in%), nasal discharge, cough, wheezing, difficulty in breathing, bruising, intercostal withdrawal clinical symptoms, number of attacks of lower respiratory tract infection, concomitant chronic disease, wheezing infant, acute phase reactant values (C-reactive protein, procalcitonin total lymphocyte and neutrophil count), positive bacterial blood, sputum, transtrakealaspiration and urine culture results sent within the first 48 hours of hospitalization, duration of hospitalization, medical treatments (inhaler, intravenoussteroid) and magnesium sulphate, antibiotic), respiratory support (oxygen, HFNC, BIPAP, IMV, ECMO) and treatment result (discharged or exitus). All these clinical and laboratory data were evaluated to predict the severity of the clinical course. For this purpose, the patients were divided into three groups according to WHO classification as severe, moderate-severe and mild clinical course. Criteria for inclusion in the severe clinical group; The patients who required invasive and non-invasive mechanical ventilation support and those who died after the treatment were evaluated as severe group. Oxygen saturation at admission was below 92% for the moderate-heavy group and patients receiving oxygen or high-flow nasal oxygen (HFNC) support were included. Other patients were evaluated as mild group. Results: Between January 2014 and December 2018, a total of 1242 patients who were hospitalized under the age of 5 with the diagnosis of Lower Respiratory Tract Infection, at the Ege University Medical Faculty Children's Hospital for the purpose of detecting a causative agent were identified. 459 (37%) of our patients were female and 783 (63%) were male. The mean age was calculated as 13.9 (min: 1- max: 62) months. 459 (37%) of our patients were female and 783 (63%) were male. The mean age was calculated as 13.9 (min: 1- max: 62) months. When divided into age groups; 535 patients (43.1%) between 1-6 months, 239 patients (19.2%) between 7-12 months, 256 patients (20.6%) between 13-24 months, 83 patients (6.7%) between 25 and 36 months, 129 patients (10.4%) between 37 -60 months were seen. 1242 patients included in the study; 746 (60.1%) were mild, 378 (30.4%) were moderate-severe and 118 (9.5%) were in severe group. When the mean age of the patients was compared according to clinical weight groups; The mean age was 13 months (min: 1- max: 53) in the severe group, 8 months (min: 1- max: 60) in the moderate-severe group, and 8 months (min: 1- max: 62) in the mild group. Oxygen saturation (SpO2) at admission was as follows; 89% (min: 60- max: 100) in the severe group, 90% (min: 60- max: 100) in the moderate-severe group, 97.5% (min: 89- max: 100) in the mild group and was statistically significant for the severe clinical course. At the time of admission, 403 (32.4%) of the 1242 patients with concomitant chronic disease and 839 (67.6%) of those without comorbid disease. Among the comorbid diseases; chronic lung diseases (CAD) in 125 patients (10.1%), congenital heart disease (CHD) in 96 patients (7.7%), neurometabolic diseases in 94 patients (7.6%), immunodeficiencies in 73 patients (5.9%) and other group (gastrointestinal system diseases, genetic diseases, renal failure) in 158 patients (12.7%) were obtained. The presence of LRTI in patients with comorbid disease was evaluated as statistically significant. When the previous LRTI episodes of the patients were evaluated, it was seen that 54.5% of the patients had the first episode. When comparing the number of attacks between the groups; the number of episodes was significantly higher in the severe group between the mild and severe groups in terms of severe clinical course. As a result of the follow-up in our study, a total of 11 patients died and were observed in the severe clinical group and were observed in the PICU. When the distribution of positive viral agents was examined; RSV (n: 579, 46.6%), HRV (n: 439, 35.3%), FLU (n: 116 9.3%), PIF (n: 119 9.6%), HBoV (n: 138, 11.1%), HMpV ( n: 85 6.8%), enterovirus (n: 29 2.3%), coronavirus (n: 67 5.4%), adenovirus (n: 81 6.5%) and a total of 349 patients (28.1%) with more than one virus together (coinfection) determined. Viruses with the highest risk for severe clinical course were FLUB, HBoV and adenovirus. Laboratory values were evaluated with neutrophilia and lymphopenia; CRP and procalcitonin levels were more frequently associated with severe clinical group. When the service or pediatric intensive care unit (PICU) hospitalizations are examined; Of 118 patients evaluated as severe group, 13 (11%) were in the ward and 105 in the PICU; Of the 378 patients in the moderate-heavy group, 352 (93.1%) were in the ward and 26 (6.9%) were in the PICU; Of the 746 patients in the mild group, 740 (99.2%) were hospitalized and 6 (0.8%) were hospitalized in the PICU. Statistically significant clinical severity of ICU hospitalization was evaluated as risk factor between the groups. Conclusion: In our study, patients who were hospitalized in our clinic with the diagnosis of LRTI between January 2014 and December 2018, under the age of 5 years and who were found to be positive for viral agents by PCR method were evaluated according to the clinical course weight groups; Age, type of virus, fever, previous LRTI, neutrophilia, lymphopenia, low SpO2 at admission, dyspnea and tachypnea and accompanying chronic disease were clinically significant.
Açıklama
Anahtar Kelimeler
Alt Solunum Yolu Enfeksiyonu, Solunum Virüsleri, Mortalite, Lower Respiratory Tract İnfection, Respiratory Viruses, Mortality
