儿童肺炎支原体合并甲型流感病毒感染肺炎的临床特征及重症肺炎危险因素分析

Clinical features and risk factors for severe pneumonia in children with Mycoplasma pneumoniae and influenza A virus co-infection

摘要:

目的 分析儿童肺炎支原体（MP）合并甲型流感病毒（IAV）感染性肺炎的临床特征和进展为重症肺炎的危险因素。方法 回顾性分析2022年12月—2024年1月首都医科大学附属北京友谊医院收治的217例MP感染性肺炎患儿的临床资料。根据病原学结果分为单纯肺炎支原体肺炎（MPP）组（单纯组，139例）和MP-IAV感染性肺炎组（合并组，78例）。比较两组患儿的临床特征。分析合并组患儿的临床特征，影响因素的分析采用多因素逐步Logistic回归模型。采用受试者工作特征（ROC）曲线评价相关指标对MP-IAV感染重症肺炎的预测价值。结果 单纯组夏季和秋季病例占比、白细胞计数、中性粒细胞及MP抗体滴度水平均高于合并组（P <0.05），喘息发生率、重症肺炎发生率、血小板、血小板/淋巴细胞比值、D-二聚体（D-D）水平、肺外并发症率及支气管灌洗实施率均低于合并组（P <0.05）。重症组呼吸频率>30次/min占比、C反应蛋白、D-D、乳酸脱氢酶（LDH）水平、初始大环内酯类抗生素（MA）转换四环素类治疗率均高于非重症组（P <0.05），发热天数、抗病毒治疗启动时间均长于非重症组（P <0.05），MA单药治疗率低于非重症组（P <0.05）。多因素逐步Logistic回归分析结果显示：抗流感病毒治疗启动时间延迟［O^R =1.563（95% CI：1.070，2.284）］、呼吸频率>30次/min［O^R =11.705（95% CI：2.796，48.994）］和LDH水平升高［O^R =1.011（95% CI：1.001，1.022）］均为MP-IAV感染进展为重症肺炎的危险因素（P <0.05），初始MA单药治疗［O^R =0.170（95% CI：0.036，0.792）］为MP-IAV感染性肺炎患儿进展为重症肺炎的保护因素（P <0.05）。LDH、抗病毒启动时间、呼吸频率预测MP-IAV感染重症肺炎的曲线下面积（AUC）为0.698、0.811、0.781，敏感性分别为62.9%（95% CI：0.463，0.770）、74.3%（95% CI：0.583，0.861）、88.6%（95% CI：0.745，0.958），特异性分别为70.0%（95% CI：0.549，0.817）、88.4%（95% CI：0.756，0.951）、65.1%（95% CI：0.498，0.780）。抗病毒治疗启动时间与呼吸频率的AUC比较，差异无统计学意义（P >0.05），抗病毒治疗启动时间、呼吸频率与LDH的AUC比较，差异均有统计学意义（P <0.05）。结论 MP-IAV感染的肺炎儿童临床症状更重，喘息和肺外并发症多见。对于此类患儿，应警惕呼吸急促、LDH升高等重症预警信号，并尽早启动抗流感病毒治疗。初始MA单药治疗为MP-IAV感染性肺炎患儿进展为重症肺炎的保护因素，这一结果反映了病情轻重对治疗方案选择的影响。因此，对初始MA治疗反应不佳者，应密切监测初期治疗反应并及时调整方案。

Abstract:

Objective To analyze the clinical features of pneumonia in children with Mycoplasma pneumoniae (MP) and influenza A virus (IAV) co-infection and the risk factors for progression to severe pneumonia.Methods The clinical data of 217 children with MP pneumonia admitted to Beijing Friendship Hospital, Capital Medical University, from December 2022 to January 2024 were retrospectively analyzed. According to etiological findings, the children were divided into an MP pneumonia (MPP) alone group (n = 139) and an MP-IAV co-infection pneumonia group (n = 78). Clinical features were compared between the two groups. The clinical features of children in the co-infection group were analyzed, and multivariate logistic regression was used to identify influencing factors. Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value of relevant indicators for severe pneumonia in children with MP-IAV co-infection.Results he proportions of cases occurring in summer and autumn, white blood cell count, neutrophil count, and MP antibody titer were higher in the MPP alone group than in the co-infection group (P < 0.05), whereas the incidences of wheezing and severe pneumonia, platelet count, platelet-to-lymphocyte ratio, D-dimer (D-D) level, incidence of extrapulmonary complications, and rate of bronchial lavage were lower (P < 0.05). In the co-infection group, the proportion of children with a respiratory rate > 30 breaths/min, C-reactive protein, D-D, and lactate dehydrogenase (LDH) levels, and the rate of switching from initial macrolide antibiotic (MA) therapy to tetracycline therapy were higher in the severe group than in the non-severe group (P < 0.05). Fever duration and time to initiation of antiviral therapy were longer, whereas the rate of initial MA monotherapy was lower, in the severe group (P < 0.05). Multivariate logistic regression analysis showed that delayed initiation of anti-influenza therapy [O^R = 1.563 (95% CI: 1.070, 2.284) ], respiratory rate > 30 breaths/min [O^R = 11.705 (95% CI: 2.796, 48.994) ], and elevated LDH levels [O^R = 1.011 (95% CI: 1.001, 1.022) ] were risk factors for progression to severe pneumonia in children with MP-IAV co-infection (P < 0.05), whereas initial MA monotherapy [O^R = 0.170 (95% CI: 0.036, 0.792) ] was a protective factor (P < 0.05). The areas under the ROC curve (AUCs) for LDH, time to initiation of antiviral therapy, and respiratory rate were 0.698, 0.811, and 0.781, respectively. The corresponding sensitivities were 62.9% (95% CI: 0.463, 0.770), 74.3% (95% CI: 0.583, 0.861), and 88.6% (95% CI: 0.745, 0.958), and the specificities were 70.0% (95% CI: 0.549, 0.817), 88.4% (95% CI: 0.756, 0.951), and 65.1% (95% CI: 0.498, 0.780), respectively. The AUCs for time to initiation of antiviral therapy and respiratory rate did not differ significantly (P > 0.05), whereas both differed significantly from the AUC for LDH (P < 0.05).Conclusion Children with MP-IAV co-infection pneumonia have more severe clinical manifestations, with wheezing and extrapulmonary complications occurring more frequently. Tachypnea, elevated LDH, and other warning signs of severe disease should be closely monitored, and anti-influenza therapy should be initiated as early as possible. Initial MA monotherapy is a protective factor against progression to severe pneumonia in children with MP-IAV co-infection; this finding reflects the influence of disease severity on treatment selection. Therefore, the early response to treatment should be closely monitored in patients with a poor response to initial MA therapy, and the regimen should be adjusted promptly.