0临床医生如何看待真菌感染与定植.ppt

临床医生如何看待真菌感染与定植,2019/4/20,内容提要,侵袭性曲霉感染误诊分析,念珠菌定植问题,腹腔念珠菌感染诊治问题,1,2,3,真菌概述,酵母菌属,曲霉菌属,深部真菌感染,念珠菌属,隐球菌属,常见的侵袭性念珠菌感染部位,定植不是感染 定植不是与感染没有一点关系,定植感染,污染：外来物质或能量的作用，导致生物体或环境产生不良效应的现象。 定植：各种微生物经常从不同环境落到人体，并能在一定部位定居和不断生长、繁殖后代，这种现象通常称为“定植”。 感染：是指细菌、病毒、真菌、寄生虫等病原体侵入人体所引起的局部组织和全身性炎症反应。,侵袭性真菌病确诊(proven)诊断标准,正常无菌部位并不包括所有与外界相通的器官，即呼吸道、泌尿生殖道、消化道等，因为上述器官是念珠菌属常见的定植部位。 念珠菌病诊断与治疗：专家共识. 中国感染与化疗杂志.2011；11（2）：81-95,念珠菌属于类酵母样菌，有酵母相和菌丝相 酵母相为芽生孢子，在无症状寄居及传播中起作用，不引起症状 菌丝相为芽生孢子伸长呈假菌丝，大量繁殖，侵袭组织能力加强，出现临床症状 需要注意的是，念珠菌中的光滑念珠菌不能产生假菌丝/菌丝，所以，临床不能因为“镜检念珠菌处于酵母相”就排除感染,酵母相,菌丝相,念珠菌多为假菌丝,念珠菌镜检假菌丝或菌丝,Colonization with Candida has been identified as an important risk factor with high predictive value for development of invasive disease (particularly with increasing numbers of colonized sites).,念珠菌定植 侵袭性念珠菌感染,定植菌争议的焦点,Invasive candidiasis in the intensive care unit. Crit Care Med 2006. 34(3):857-863 Eggimann P，Garbino J，Pittet DEpidemiology of Candida species infections in critically ill non-immunosuppressed patientsLancet Infect Dis，2003，3(11)：685-702,PK,多部位念珠菌定植是发生侵袭性念珠菌感染的独立危险因素。 念珠菌定植后导致侵袭性感染的途径可能有： 破坏胃肠道黏膜屏障入血； 从中心静脉导管入血， 从局部感染蔓延至全身。,定植与感染的关系,Lipsett PASurgical critical care=fungal infections in surgical patientsCrit Care Med，2006，34(9 Suppl)：S215-224,约有5086的重症患者发生念珠菌定植，但临床有530发展成严重侵袭性念珠菌感染。,Although colonization does not define infection, these data support the well-known role of Candida colonization as a key factor in the decision to start early antifungal treatment for ICU patients.,A bedside scoring system (“Candida score”) for early antifungal treatment in nonneutropenic critically ill patients with Candida Colonization. Crit Care Med 2006. 34(3):730-737.,定植与感染的死亡率,S.S. Magill et al. Diagnostic Microbiology and Infectious Disease 55 (2006) 293 301,进展为IC的百分比,The anatomic site of Candida colonization in 182 surgical intensive care unit (SICU) patients who participated in a randomized trial of fluconazole to prevent candidiasis. A total of 2851 surveillance fungal cultures collected from 5 anatomic sites were analyzed. Surveillance fungal cultures of particular anatomic sites may help differentiate patients at higher risk of developing IC from those at low risk.,P=0.02,P=0.04,P=0.01,13.2%,2.8%,8.0%,1.2%,8.4%,0.0%,定植可进展为侵袭性念珠菌病,对于怀疑系统性念珠菌感染的患者，应同时进行痰(或其他气道分泌物)、尿、胃液、粪(或直肠拭子)、口咽拭子5个部位的念珠菌定量培养。 口咽和直肠拭子念珠菌只要1 cfu，胃液、尿105 cfu /L，痰107 cfu/L就认为念珠菌定植阳性。,念珠菌定植指数(CI),Pittet D，Monod M，Suter PM，et a1Candida colonization and subsequent infections in critically ill surgical patientsAnn Surg，1994，220(6)：751758,口咽和直肠拭予念珠菌102 cfu，胃液、尿、痰108 cfu/L才能判定念珠菌定植阳性，如CI0.5或CCI0.4就认为有侵袭性念珠菌感染的可能。,校正念珠菌定植指数(CCI),Piarroux R，Grenouillet F，Balvay P，et a1Assessment of pre-emptive treatment to prevent severe candidiasis in critically ill surgical patientsCrit CareMed，2004，32(12)124432449,念珠菌指数(CS),将患者的危险系数相加，就得到该患者的CS。 研究结果显示，CS2.5时诊断侵袭性念珠菌感染的敏感性为81，特异性为74。,CS= 0.908×肠外营养支持+0.997×手术+1.112×CCI+2.038×严重脓毒症。,Lean C， RuizSuntans S， Saavedra P，et a1A bedside scoring system (”Candida score”)for early antifungal treatment in nonneutropenic critically i11 patients with Candida colonizationCrit Care Med，2006，34(3)：730737,In addition to multifocal Candida species colonization, three other risk factors were found to be significant predictors of proven candidal infection in the logistic regression model: Use of total parenteral nutrition； Surgery on ICU admission； Clinical manifestations of severe sepsis.,Score,1,1,2,1,A bedside scoring system (“Candida score”) for early antifungal treatment in nonneutropenic critically ill patients with Candida Colonization. Crit Care Med 2006. 34(3):730-737.,We shall only need the presence of sepsis and any one of the three other remaining risk factors or the presence of all of them together except sepsis in order to consider starting antifungal treatment for one particular patient.,Logistic regression model,A bedside scoring system (“Candida score”) for early antifungal treatment in nonneutropenic critically ill patients with Candida Colonization. Crit Care Med 2006. 34(3):730-737.,2008年亚太危重病论坛也指出，重症高危患者如同时具有高度念珠菌 定植应予以抗念珠菌治疗，同时亦应考虑局部区域的真菌流行病学资料。,要正确看待CI、CCI、CS,Hsueh PR，Graybill JR，Playford EG，et a1Consensus statement on the management of invasive candidiasia in intensive care units in the AsiaPacific regionInt J Antimicrob Agents，2009，34(3)：205209,使用定植指数推测侵袭性念珠菌感染诊断只是一种“可能性”诊断。 对于可能发生侵袭性念珠菌感染的高危患者实施动态监测，一旦病情 变化应及时给予抢先治疗，既要防止发生进一步的侵袭性念珠菌感 染，降低病死率，又要避免不必要的抗真菌药物临床应用，以降低患 者医疗费用和抗生素附加损害。,Eggimann等更明确地为抢先治疗下定义，即对具有多个侵袭性念珠 菌感染高危因素且CCl0.4的脓毒症患者早期给予抗念珠菌治疗。,定植菌抢先治疗的定义,同时他认为实施抢先治疗可降低外科重症患者侵袭性念珠菌感染确诊 病例的发生和降低病死率。,Eggimann P，Garbino J，Pittet DEpidemiology of Candida species infection in critically ill non-immunosuppressed patientsLancet Infect Dis，2003，3(11)：685702,痰培养阳性的临床意义？,如果患者存在明显的高危因素，有肺部感染的临床表现又不能用其他 病原菌感染解释，血清真菌感染标志物（如G试验）阳性，此时痰培 养念珠菌为唯一病原体且为反复培养阳性或为纯培养，可以作为针对 念珠菌诊断性或经验性治疗的依据，至少提醒临床医生应提高警惕， 特别是除肺外还有其他部位也分离到念珠菌时。,怀疑念珠菌肺炎的患者在呼吸道标本检测的同时应做血液真菌培