临床医生如何看待真菌感染与定植精品文档PPT文件格式下载.ppt
《临床医生如何看待真菌感染与定植精品文档PPT文件格式下载.ppt》由会员分享,可在线阅读,更多相关《临床医生如何看待真菌感染与定植精品文档PPT文件格式下载.ppt(59页珍藏版)》请在冰豆网上搜索。
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。
662022/10/252022/10/25DoctorXiongDoctorXiong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):
81-95772022/10/252022/10/25DoctorXiongDoctorXiong念珠菌属于类酵母样菌,有酵母相和菌丝相p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p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882022/10/252022/10/25DoctorXiongDoctorXiongColonizationwithCandidahasbeenidentifiedasanimportantriskfactorwithhighpredictivevaluefordevelopmentofinvasivedisease(particularlywithincreasingnumbersofcolonizedsites).念珠菌定植侵袭性念珠菌感染定植菌争议的焦点Invasivecandidiasisintheintensivecareunit.CritCareMed2006.34(3):
857-863EggimannP,GarbinoJ,PittetDEpidemiologyofCandidaspeciesinfectionsincriticallyillnon-immunosuppressedpatientsLancetInfectDis,2003,3(11):
685-702PK992022/10/252022/10/25DoctorXiongDoctorXiongp多部位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独立危险因素。
p念珠菌定植后导致侵袭性感染的途径途径可能有:
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LipsettPASurgicalcriticalcare=fungalinfectionsinsurgicalpatientsCritCareMed,2006,34(9Suppl):
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。
10102022/10/252022/10/25DoctorXiongDoctorXiongAlthoughcolonizationdoesnotdefineinfection,thesedatasupportthewell-knownroleofCandidacolonizationasakeyfactorinthedecisiontostartearlyantifungaltreatmentforICUpatients.Abedsidescoringsystem(“Candidascore”)forearlyantifungaltreatmentinnonneutropeniccriticallyillpatientswithCandidaColonization.CritCareMed2006.34(3):
730-737.定植与感染的死亡率11112022/10/252022/10/25DoctorXiongDoctorXiongS.S.Magilletal.DiagnosticMicrobiologyandInfectiousDisease55(2006)293301进展为IC的百分比uTheanatomicsiteofCandidacolonizationin182surgicalintensivecareunit(SICU)patientswhoparticipatedinarandomizedtrialoffluconazoletopreventcandidiasis.uAtotalof2851surveillancefungalculturescollectedfrom5anatomicsiteswereanalyzed.uSurveillancefungalculturesofparticularanatomicsitesmayhelpdifferentiatepatientsathigherriskofdevelopingICfromthoseatlowrisk.进展为进展为ICIC的百分比的百分比0.0%2.0%4.0%6.0%8.0%10.0%12.0%14.0%尿道肺部肠道非念珠菌定植非念珠菌定植念珠菌定植念珠菌定植P=0.02P=0.04P=0.0113.2%2.8%8.0%1.2%8.4%0.0%定植可进展为侵袭性念珠菌病12122022/10/252022/10/25DoctorXiongDoctorXiongu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。
u口咽和直肠拭子念珠菌只要1cfu,胃液、尿105cfu/L,痰107cfu/L就认为念珠菌定植阳性。
念珠菌定植指数(CI)PittetD,MonodM,SuterPM,eta1CandidacolonizationandsubsequentinfectionsincriticallyillsurgicalpatientsAnnSurg,1994,220(6):
75175813132022/10/252022/10/25DoctorXiongDoctorXiongu口咽和直肠拭予念珠菌102cfu,胃液、尿、痰108cfu/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)PiarrouxR,GrenouilletF,BalvayP,eta1Assessmentofpre-emptivetreatmenttopreventseverecandidiasisincriticallyillsurgicalpatientsCritCareMed,2004,32(12)12443244914142022/10/252022/10/25DoctorXiongDoctorXiong念珠菌指数(CS)u将患者的危险系数相加,就得到该患者的CS。
u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+1.112CCI+2.038严重脓毒症。
LeanC,RuizSuntansS,SaavedraP,eta1Abedsidescoringsystem(”Candidascore”)forearlyantifungaltreatmentinnonneutropeniccriticallyi11patientswithCandidacolonizationCritCareMed,2006,34(3):
73073715152022/10/252022/10/25DoctorXiongDoctorXiongpInadditiontomultifocalCandidaspeciescolonization,threeotherriskfactorswerefoundtobesignificantpredictorsofprovencandidalinfectioninthelogisticregressionmodel:
Useoftotalparenteralnutrition;
SurgeryonICUadmission;
Clinicalmanifestationsofseveresepsis.ScoreScore11112211Abedsidescoringsystem(“Candidascore”)forearlyantifungaltreatmentinnonneutropeniccriticallyillpatientswithCandidaColonization.CritCareMed2006.34(3):
730-737.16162022/10/252022/10/25DoctorXiongDoctorXiongWeshallonlyneedthepresenceofsepsisandanyoneofthethreeotherremainingriskfactorsorthepresenceofallofthemtogetherexceptsepsisinordertoconsiderstartingantifungaltreatmentforoneparticularpatient.LogisticregressionmodelAbedsidescoringsystem(“Candidascore”)forearlyantifungaltreatmentinnonneutropeniccriticallyillpatientswithCandidaColonization.CritCareMed2006.34(3):
730-737.17172022/10/252022/10/25DoctorXiongDoctorXiong2008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、CSHsuehPR,GraybillJR,PlayfordEG,eta1ConsensusstatementonthemanagementofinvasivecandidiasiainintensivecareunitsintheAsiaPacificregionIntJAntimicrobAgents,2009,34(3):
205209u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。
u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