重症患者侵袭性真菌感染诊断和治疗指南汇.ppt

内容提要 Pat at risk of developing IFD The main players 1. SEC 1996-1998 Yeast fungi (candida): 91.4% C albicans 40% C tropicalis 60% Mould fungi: 5.9% 2. PUMCH 1950-1990 Biopsy: Yeast fungi :15% Mould fungi: 85% Pathogenesisinvasive Candida infections Most systemic infections with Candida albicans are caused by endogenous organisms via translocation from the gastrointestinal tract or by sequential spread from other body sites Apparent outbreaks of infection have been reported, raising the possibility of horizontal transmission Average of 39% of surgical ICU staff were found to carry Candida species Infection control measures may be valuable ICU患者念珠菌血症的高危因素 念珠菌感染的预后--高死亡率 Epidemiology of Invasive Aspergillosis Prospective Survey in France (1994-1999) Invasive Aspergillosis in Critically Ill Pats without Malignancy 1,850 pats in a medical ICU 127例确诊/临床诊断曲霉菌病 Microbiological or histopathologic evidence of infection with Aspergillus: 6.9% Aspergillus fumigatus: 96% Aspergillus niger: 3 isolate Aspergillus flavus: 1 isolate Crude Mortality for Invasive Aspergillosis 内容提要 Defining invasive fungal disease 临床表现不典型，为基础疾病或药物治疗掩盖或混淆 合格标本获取不易，危重病人难承受侵入性检查 继发性感染常呈双重感染或复合菌感染，难以定主次 实验室检查手段有限，并有时效性？ 结果的评判困难，难以确定病原性 危险因素＋临床表现＋影像学＋实验室检查 重症患者IFI的诊治流程 内容提要 预防性抗真菌治疗 一般不主张预防性抗真菌治疗 预防性抗真菌治疗盲目性大、费用高，增加耐药性 但具有IFI危险因素的ICU重患可应考虑 具有高危因素的器官移植的危重患者 接受免疫抑制治疗的高危肿瘤患者 具有高危因素的粒细胞缺乏患者 高危的HIV患者 预防性抗真菌治疗 Crit Care Med 2006; 34:1216–1224 经验性治疗 Cordonnier C et al. Blood 2006; 108: abstr 2019 治疗小结　 意义: 尽可能降低不恰当的经验性治疗所导致的抗真菌药物的不必要使用，降低真菌耐药及医疗花费增加 前提: 临床医生的警觉性及实验室诊断技术进步 GM 、G试验 以及真菌特异DNA的PCR + 临床征象(CT扫描) + 微生物培养 抢先治疗 开始抢先治疗、监测病程和评价治疗反应 提供更多的参考价值 9% 3% €2337 €2218 66% 46% 95% 98% 150 143 293 neutropenic patients IFI were diagnosed survivors antifungals mean costs 现有的关于抢先治疗与经验性治疗比较的研究显示，患者存活率无差异，经验性治疗的花费和应用的抗真菌药物相对更多。 EMPIRIC 3 days persisting fever PRE-EMPTIVE imaging clinics laboratory Empirical OR Preemptive? 实验室设备有限 经验有