上野久美子 他 354 は 高 齢 者 入 院 患 者 の 発 熱 初 期 に お け る病 態 を把 握 し 適 切 な 治 療 が 行 え る よ う に,発 protein 1 Duration of febrile episodes 熱 の 原 因 疾 患, 発 熱 初 日 の 最 高 体
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1 Key words: elderly, febrile episode, nosocomial infection
2 上野久美子 他 354 は 高 齢 者 入 院 患 者 の 発 熱 初 期 に お け る病 態 を把 握 し 適 切 な 治 療 が 行 え る よ う に,発 protein 1 Duration of febrile episodes 熱 の 原 因 疾 患, 発 熱 初 日 の 最 高 体 温 と 白 血 球(White WBC)数,C-reacting Table Blood (CRP)値 Cell: お よび 発 熱 期 間 な ど に つ い て 検 討 し た. 方 法 発 熱 エ ソ ー ドの 定 義 と し て は す で に 報 告 し た6)が,症 状 の 有 無 に か か わ ら ず,1日 37.5 未 満 の 無 熱 期 間 が7日 以 上 発 熱 し た 場 合 を1発 し た.解 熱 エ ソー ドと して 登 録 析 は 発 熱 エ ソ ー ドの 定 義 を 満 た し た 1,105例 温,お の最高体 温 以 上 続 い た 後37.5 に つ い て,エ ソ ー ド登 録 初 日 の 最 高 体 よ び エ ソ ー ド終 了 ま で の 有 熱 期 間,発 後24時 のLGF群 熱 以 上 のHGF群546エ 間 以 内 か つ 治 療 開 始 前 のWBC数,CRP 値 に つ い て 行 っ た.本 以 上 の 高 齢 者 で あ る た め, (41.0%)で (21.4%),3日 日 発 熱116エ 療 や 処 置 に よ り発 熱 が 修 飾 の エ ソ ー ド終 了 ま で の 期 間 中 の 最 高 38.0 未 満(Low-grade 上(High-grade し た.発 fever: LGF)と38.0 HGF)の2群 路 感 染 症(263エ の 他 の 疾 患(164エ 因 不 明(297エ 275エ 以 ソ ー ド(14.0%),4 ソ ー ド(49.2%)で 全 体 の86.9%は 1). で の 発 熱 期 間 は1 以 上が あ っ た HGF群 で は ソ ー ド(31,0%)で,2日 ソ ー ド(69.0%)で は,発 熱 期 間 が2日 ソ ー ド,23.8 ソ ー ド,14.8%),原 ソ ー ド,26.9%)の4群 が377エ ソ ー ド ソ ー ド(50.8%)で2日 1日 の み が169エ 以上 あ っ た.HGF群 以 上 続 く もの がLGF群 と比 較 し て 有 意 に 高 率(p<0.001)で で のそれ あ っ た(Fig 1). に大別 し て 検 討 し た. 最 高 体 温 と 原 因 疾 患:LGF群 とHGF群 の それ ぞ れ に つ い て 発 熱 の 原 因 疾 患 を 比 較 し た.HGF 結 最 高 体 温:発 日 の み が284エ に わ け て比 較 熱 の 原 因 疾 患6)は 呼 吸 器 感 染 症(381エ ソ ー ド,34.5%),尿 %),そ fever: 以 上 発 熱155エ ソ ー ド(10.5%)と 最 高 体 温 と 発 熱 期 間:LGF群 熱初 日の未治療 の時点で の最高体温 を ソ ー ド の 最 高 体 温 と 定 義 し,37.5 ほぼ同 ソー ド 発 熱236エ 4日 以 内 の 発 熱 期 間 で あ っ た(Table 体 温 を 同 一 条 件 で 比 較 す る こ と は で き な か っ た. 1エ の み の 発 熱 が453エ 最 も 多 く,2日 始 さ れ る 例 が 多 く,治 従 っ て,発 ソ ー ド(49,4%)と 発 熱 期 間:1日 発 熱 し た 場 合 は 重 篤 化 を 防 ぐ為 に 早 期 に 治 療 が 開 さ れ,1つ ソ ー ド(50.6%)で,38.0 じ割 合 で あ っ た. 調査 の対象 は種 々の基礎疾 患 を も つ 入 院 中 の65歳 は559エ 果 群 で は 原 因 疾 患 と し て 呼 吸 器 感 染 症 が242エ 熱 初 日 の 最 高 体 温 が38.0 Fig. 1 Duration 未 満 and frequency ソ ー ド(44.3%)と 多 い の に 対 し て,LGF群 of febrile episodes. 感 染症 学 雑 誌 第74巻 で は尿 第4号
3 高齢入院患者の発熱調査 Fig. 2 Fig. 3 路 感 染 症175エ た(p<0.001)(Fig.2).ま HGF群 242エ た,疾 ソ ー ドの う ち88エ 意 に 高 率(p<0.001)で 感 染 症 は381エ 因 疾 患 と して 最 も多 い 呼 吸 器 発 熱 は114エ 以 上持 続 し た 発 発 熱 が263エ 平成12年4月20日 of febrile episodes. 尿 路 感 染 症 に比 し発 熱 が 長 期 化 す る 傾 向 で あ っ た (p<0.001).ま あ っ た.一 の 他 の 原 因 で 発 熱 した群 で は 占 め て お り,そ の 中 に は,敗 瘡 等 が 含 まれ て い た.逆 血 症 や 蜂 窩 織 炎,褥 に 原 因 不 明 群 は1日 ソ ー ド(52.9%)で の み の 発 熱 が157エ あ っ た(Fig.3).ま た全 エ 以 上 持 続 す る 発 熱652エ ソ ー ドの う ち 呼 吸 器 感 染 症 は267エ ソ ー ド41.0%と 最 も 高 率 で あ っ た. 呼 吸 器 感 染 症 と尿 路 感 染 症 に つ い て 初 日 の 最 高 方,尿 路 ソ ー ド中125エ 以 上は138エ た,そ 3日 以 上 持 続 す る 発 熱 が54.3%を ソ ー ド 中2日 熱 の 原 因 疾 患 別 に発 熱 あ っ た が,2日 ソ ー ド,47.5%で2日 あ っ た.両 比 較 し有 あ っ た. ソ ー ド,70.1%で 感 染 症 で は1日 ソ ー ドの う ち1口 ソ ー ド,29.9%で %で ソ ー ドの う ち 路 感 染 症263エ ソ ー ド(33.5%)に 原 因 疾 患 と 発 熱 期 間:発 期 間 を 比 較 し た.原 多かっ 患 別 に 検 討 す る と, は 呼 吸 器 感 染 症381エ of febrile episodes. and frequency よ び原 因 不 明 ソ ー ド(34.0%)と ソ ー ド(63.5%)で,尿 熱 は267エ Origin, duration ソ ー ド(31.3%)お の 発 熱 の 割 合 が190エ Origin and frequency 355 ソ ー ド,52.5 疾 患 を 比 較 す る と呼 吸 器 感 染 症 は 体 温 別 に 発 熱 期 間 を み る と,両 はLGF群 疾 患 其 にHGF群 に 比 べ て 発 熱 期 間 が2日 が 有 意 に 高 率 で あ っ た(呼 以 上 続 く もの 吸 器 感 染 症p<0.05,尿 路 感 染 症p<0.01)(Fig.4). 原 因 疾 患 と 検 査 値:発 熱 エ ソ ー ド登 録 時 の 検
4 Fig. 4 Comparison of the maximum body temperature, duration and frequency of febrile episodes between respiratory tract infection and urinary tract infection. Table 2 Causes of febrile episodes and WBC and CRP
5 Table 3 Relation between maximum body temperature and WBC and CRP Table 4 Relation between duration of febrile episodes and WBC and CRP
6 1) Kuramoto: Age and disease pattern in the elderly. Asian Med 1987; 30: ) Yoshikawa TT, Norman DC: Approach to fever and infection in the nursing home. J Am Geriatr Soc 1996; 44: ) Esopsito AL: Pneumonia in the elderly in respiratory infection. In: Penningt on JE, ed. Diagno- sis and management (3rd ed). Raren Press. Ltd, New York, 1994; p257. 9) Shapiro MF, Greefield S: The complete blood count and leukocyte differential count. Ann Intern Med 1987; 106: ) Waserman M, Levinstein M, Keller M, Lee S, Yoshikawa TT: Utility of fever, white blood cells, and differential count in prediction bacterial infections in the eldery. J Am Geriatr Soc 1989; 37: ) Adnet F, Borron SW, Vicaut E et al.: Value of C- reactiong Protein in the detection of bacterial contamination at the time of presentation in druginduced aspiration pneumonia. Chest 1997; 112: ) Norman DC, Toledo SD: Infections in elderly persons. An altered clinical presentation. Clin Geriatr Med 1992; 8: ) Rockwood K: Acute confusion in elderly medical patients. J Am Geriatr Soc 1989; 37: ) Harper C, Newton P: Clinical aspects of pneumonia in the elderly veteran. J Am Geriatr Soc 1989; 37:
7 The Clinical Feature of Febrille Episodes Kumiko UENO1), Jun HAYASHI1), Shigeru YAMAGA2), Hideyuki IKEMATSU2), Atsuko NABESHIMA1)2), Hiroshi HARA2) & Seizaburo KASHIWAGI1) of General Medicine, Kyushu University Hospital of Clinical Research, Hara-Doi Hospital Institutionalized elderly patients are at risk of nosocomial infection because of their compromised status by aging. To clarify the relationship between fever and disease in elderly patients, we analyzed 1,105 febrile episodes, the etiology of which were already diagnosed, of 443 patients (136 men, 307 women). All patients who were 65 years of age or older and who had been admitted to the hospital for more than 7 days had fevers above 37.5 Ž recorded. The etiologies of the 1,105 febrille episodes were respiratory tract infection in 381 (34.5%), urinary tract infection in 263 (23.8%), other diseases in 164 (14.8%) and in 297 (26.9%) unknown. The episodes were categorized into two groups by the degree of initial fever: group A, 559 episodes (50.6%) of 37.5 `38.0 Ž and group B, 546 episodes (49.4%) of above 38.0 Ž. Of the episodes, 41.0% were one-day fevers, 21.4% two-day fevers, and 14.0 % three-day fevers. The frequency of two-or-more-day fevers was significantly higher in group B (69.0%) than in group A (49.2%) (p<0.001). In group B, respiratory tract infection (44.3%) was more frequent than urinary tract infection (16.1%) (p<0.001). Of the respiratory tract infections, 63.5% were in group B and, in contrast, 66.5% of the urinary tract infections were in group A. The white blood cell count and C- reacting protein levels were significantly higher in group B than in group A (p <0.001). The degree of initial fever is an important predictive marker of severity of disease in elderly patients.
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