甲型H1N1病毒论文：山东省甲型H1N1感染病例临床资料分析及奥司他韦疗效研究

甲型H1N1病毒论文：山东省甲型H1N1感染病例临床资料分析及奥司他韦疗效研究 【中文摘要】描述山东省甲型H1N1流感病毒感染入院患者的临床特征、治疗经过及预后,重点评价治疗过程中抗病毒药物奥司他韦在不同给药时机、剂量及疗程应用对患者预后的影响。方法：收集山东省3个市区4家医院从2009年3月至2010年3月入院的甲型H1N1感染确诊病例资料,从患者基本资料、既往疾病、伴随症状、早期常规辅助检查(了解各脏器损害情况)、治疗情况及最终转归等各方面进行回顾性观察分析,以起病2周、4周及8周死亡率为主要观察指标,需要辅助机械通气治疗时间及重症监护病房治疗时间为次要观察指标。重点描述各年龄组患者抗病毒治疗的临床疗效,对成人患者根据既往健康状况进行分组观察,系统评价抗病毒药物奥司他韦不同给药方案对预后的影响。结果：本次收集的238例确诊病例的平均年龄(SD)为28.2(16.1)岁,女性140例((58.8%)。部分患者在入院时即存在休克和肺部以外其他脏器的急性损伤(入院当天所有病例的平均SOFA评分为5.8)。起病至入院的平均时间为4天(IQR,3-6天),入院至转入ICU平均时间为1天(IQR,0-3天)。所有患者在治疗过程中均应用奥司他韦抗病毒治疗,13.4%(39／238)患者应用呼吸机辅助治疗,平均通气时间为7天(IQR,4-11天),转入重症监护病房平均治疗时间为8天(IQR,3-11天)。入院病例起病2周内死亡率为5.9%(95%可信区间,2.9%-8.9%；n=14),2-4周死亡率为2.5%(95%可信区间,0.5%-4.5%；n=6),4周-8周内死亡率为1.3%(95%可信区间,0.3%-3.7%；n=3)。死亡病例主要集中在既往无基础疾病的青中年人群,但是存在基础疾病的老年患者更容易死亡。对成人组不同奥司他韦应用方案研究表明：(1)起始剂量加倍组与推荐剂量组临床疗效相同(P>0.05)；(2)存在合并症患者起病48小时内给药能显著改善预后,提高生存率(P0.05)；疗程大于10天能降低存在合并症患者的死亡率,减少既往体健患者呼吸机的应用(P<0.05)。结论：本次甲型H1N1流感好发于中青年,女性略多于男性。咯血为H1N1感染早期较特异性的临床症状,但与病情危重程度无明显相关性,不能作为病情危重程度的判断标准。实验室检查结果缺少特异性,白细胞总数增多及中性粒比值升高不能排除H1N1病毒感染可能。90%以上的患者经治疗好转出院,死亡率较普通流行性感冒无明显差异。晚期妊娠、肥胖、存在两种及两种以上合并症是引起患者死亡的高危因素(P<0.05)。本次H1N1感染治疗的关键在于尽可能早的给予奥司他韦抗病毒治疗,而无需等待实验室核酸检查结果,给予常规剂量即有效,当病情持续进展或出现严重并发症时,可将剂量加倍,疗程适当延长。 【英文摘要】To describe characteristics, treatment, and outcomes of confirmed patients in Shandong of China with 2009 influenza A(H1N1) infection.DESIGN A prospective observational study of 238 RT-PCR confirmed patients with 2009 influenza A(H1N1) infection in 4 adult and pediatric intensive care units (ICUs) in Shandong of China between March 2009 and March,2010. The primary outcome measures were 14-day,28-day and 56-day mortality, and the secondary outcomes included frequency and duration of mechanical ventilation and duration of ICU stay. Describe the clinical effect of oseltamivir in different groups of health condition.RESULTS Among the 238 patients with confirmed community-acquired 2009 influenza A(H1N1) infection, the mean(SD) age was 28.2(16. 1)years, 58.8%(140/238)were female, range 2-68years, mean (SD) age was 27.6(14.1)years; 41.2%(98/238)were male, range 0.5-73years, mean (SD) age was 29.1(18.7)years. The median time from symptom onset to hospital admission was 4 days (interquartile range [IQR],3-6 days) and from hospitalization to ICU admission was 1 day (IQR,0-3 days). Shock and nonpulmonary acute organ dysfunction was common (Sequential Organ Failure Assessment mean [SD] score of 5.8 [2.9] on day1). All patients were administered with neuraminidase inhibitors (NAIs), 13.4%(39/238) of patients received mechanical ventilation, the median duration of ventilation was 7 days(IQR,4-11 days) and ICU stay was 8 days (IQR,3-11 days). Overall mortality among confirmed patients at 14 days was 5.9%(95% confidence interval,2.9%-8.9%,n=14);14-28 days was 2.5%(95% confidence interval,0.5%-4.5%,n=6); 28-56 days was 1.3%(95% confidence interval, 0.3%-3.7%,n=3). Although this overall population was young, older patients were more likely to die. The study of oseltamivir confirmed earlier administration (in 48 hours) can reduce duration of clinical symptom and reduce mortality.CONCLUSION Infection due to 2009 influenza A (H1N1) in Shandong mostly occurred in young adults, female more than male. Hemoptysis was a typical syndrome but had no correlation with critical degree. The clinical symptoms were slight and 90% of patients were discharge from hospital. The mortality of 2009 H1N1 infection had no difference with the season influenza virus. The third pregnancy, obesity and patients with comorbidities can induce death. When patients appeared suspected symptoms, oseltamivir should be used as soon as possible, especially in these critically ill patients with serious comorbidities. 【关键词】甲型H1N1病毒 奥司他韦 死亡率 高危因素 【英文关键词】Influenza A(H1N1)      Oseltamivir      Mortality Rate      Comorbidities 【目录】山东省甲型H1N1感染病例临床资料分析及奥司他韦疗效研究中文摘要6-8ABSTRACT8-9符号说明10-11前言11-13设计与方法13-15结果15-43入院病例临床特征15-21病情发展及预后21-22治疗方面22-37生存病例与死亡病例比较37-38所有病例比较38-43讨论43-46结论46-47附图47-50参考文献50-56致谢56-57学位论文评阅及答辩情况表57