重症患者真菌感染聚焦念珠菌及氟康唑的地位广西北海MPPT课件下载推荐.ppt
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呼吸、腹腔、泌尿、血流ICU获得感染:
呼吸、泌尿、血流、(手术部位-SICU),感染相关问题是ICU永恒主题ICU工作要点之一是感染(51%感染病人),提要,ICU与感染危重病人侵袭性真菌感染真菌感染诊断相关问题抗真菌药物抗真菌药物选择,ICU感染的病原学,细菌(G+;
G-;
厌氧菌)不典型细菌真菌病毒etc,Mycoses.2012,55:
435443,日本Toho1955-2006年间的10297例尸检进行分析,Mycoses.2012,55:
435443,Among2,984ICUadmissions,therewere489deaths222autopsieswereconductedPostmortemexaminationrevealedunexpectedfindingsin50patients,IntensiveCareMed.2004,30:
20802085,Criticalandurgentcare:
61-73,Positiveisolates(4947/7087=70%),VincentJL,etal.JAMA.2009,302(21):
2323-2329.,TortoranoAMetal.Mycoses.2011,55:
7379.,May2006-April200838ICUsof27Italianhospitals384fungalinfections(318invasiveCandidainfections,63mouldinfectionsand3cryptococcosis)werenotified.,Aspergillus57Mucormycosis4Fusariumverticillioides1Trichodermasp1,CandidaAspergillusCryptococcosisMucormycosis,18ICUs18-monthstudy105episodesIFIsoccurredin5,561PatientsCandida:
16.5cases/1,000admissionsFilamentousfungi:
2.3cases/1,000admissions,Filamentousfungi:
mainlyinvasivepulmonaryaspergillosis(IPA),GuoF,etal.JAntimicrobChemother.2013,68(7):
1660-8.,中国16家大型教学医院HAP临床调查(599例分离到694株菌),MicrobiologyofPeritonitis,1.LarocheM,HardingG.EurJClinMicrobiolInfectDis.1998;
17:
542-550.2.BariePS.JChemother.1999;
11:
464-477.,B.fragilisgroupClostridiumspp.EnterococciS.EpidermidisMRSAPseudomonas+A.baumanniiCandida,B.fragilisgroupClostridiumspp.E.coliKlebsiellaspp.StreptococcusEnterococcusspp.Candida,E.coliKlebsiellaspp.Streptococcusspp.,Tertiary(Polymicrobial)2,Secondary(Polymicrobial)1,2,Primary(Monomicrobial)1,最初1-4周病原特征,KoreanJUrol.2013;
54:
59-65,ESBL53.1%,ESBL37.5%,WisplinghoffH,etal.ClinicalInfectiousDiseases.2004;
39:
30917,1995-2002,Nosocomialbloodstreamisolates(SCOPEStudy),49UShospitals7-year24,179cases,SurveillanceandControlofPathogensofEpidemiological,NosocomialBloodstreamIsolates(SCOPEStudy),9.8%,23.2%,67.0%,WisplinghoffH,etal.ClinicalInfectiousDiseases.2004;
30917,TortoranoAMetal.Mycoses.2011,55,7379.,危重病人侵袭性真菌感染,Candida、Aspergillus、Cryptococcosis、MucormycosisICU:
60%(-);
40%(+);
20%(Fungal,mostlycandida)呼吸(Candida5)腹腔(继发性、第三类型腹膜炎)泌尿(Candida2-4)血流(Candida3),其它部位,消化系统、骨关节、心血管系统等念珠菌最为常见,腹腔感染,以念珠菌最为常见(除外近平滑),真菌血流感染,呼吸系统,泌尿系统,中枢神经系统,以隐球菌多见念珠菌,曲霉菌少见,常见病原体为曲霉菌和念珠菌、隐球菌(烟曲霉),以念珠菌最为常见(近平滑),以念珠菌尿最为多见(除外近平滑),侵袭性真菌感染,危重病人侵袭性真菌感染,提要,ICU与感染危重病人侵袭性真菌感染念珠菌来源抗真菌药物及选择关于氟康唑,C.Albicans(白色念)C.Glabrata(光滑念)C.parapsilosis(近平滑念)C.Tropicalis(热带念)C.Krusei(克柔念)C.Guilliermondii(季也蒙念)C.Lusitaniae(葡萄牙念),C.inconspicuaC.norvegensisC.dubliniensisC.lipolyticaC.zeylanoidesC.pelliculosaCandidaspp.,C.kefyrC.rugosaC.famata,CandidaSPP.(165species),C.Albican白念NonC.Albicans非白念,CandidaColonization,Pulmonarytree,Bowel,Vagina,Esophageal/GI,Candida:
Infectionsites,C.parapsilosis,C.tropicalis,C.albicans,C.krusei,C.glabrata,TheSourceofCandidemia,ClinicalInfectiousDiseases.2001,33:
1959-67,ModelforInvasiveCandidiasisBlijlevens,Donnelly,DePauw.BritJHaematol2002;
117:
259-64,injury,antibiotics,GItract,LancetInfectDis.2003.3:
685-702,NatRevMicrobiol.2013.10
(2):
112-122,NatRevMicrobiol.2013.10
(2):
112-122,念珠菌来源,外源性:
导管位置、导管护理内源性:
胃肠粘膜保护、肠内营养定植&
高负荷定植&
感染,提要,ICU与感染危重病人侵袭性真菌感染念珠菌来源抗真菌药物及选择关于氟康唑,系统性抗真菌药:
全球,isavuconazole,ravuconazole,fluconazole,itraconazole,posaconazole,L-AMB,ABCD,ABLC,voriconazole,caspofungin,micafungin,anidulafungin,AmphotericinB,Azoles,Candins,AMB,Phospholipidbilayerofthefungalcellmembrane,Fungalcellwall,b-(1,3)-glucan,b-(1,6)-glucan,b-(1,3)-glucansynthaseGlucanSynthesisInhibitorEchinocadinCaspofunginMicafungin(FK463)Anidulafungin(LY303,306),ErgosterolPolyenes(AmB,LFAB)AzolesFluconazole,ItraconazoleVoriconazolePosaconazoleRavuconazole(BMS-207,147),AntifungalMechanismsofAction:
“Newer”AntifungalAgents,nucleus,NucleosideAnalogsFlucytosine,MayoClinProc.2011;
86(8):
805-817,GeneralpatternsofsusceptibilityofCandidaSpp.,IDSAGuidelines.CID2009,48:
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