icu侵袭性真菌感染诊治.pptx

ICU病人侵袭性肺部真菌感染的

诊断与治疗

2015年10月

内容

一、ICU-IPA的诊断问题与治疗

■EORTC/MSG诊断标准是否适应ICU病人?

■胸部CT对ICU病人IPA的诊断价值

■ICU病人真菌学检查结果的评估

■ICU病人IPA的诊断路径?

■IPA的抗真菌药物选择

二、ICU念珠菌感染的诊断与治疗

ICU-IPA特点

●ICU病人病种、病情复杂多样，IPA表现不典型，病情危重难以获得组织学标本，诊断困难

-IPA发病率难以估计，约0.017%～6.9%,病死率46%～95%一无免疫受损的IPA病人平均住院时间和住ICU时间分别为27d和

16d

●ICU病人发生IPA的危险因素(非经典危险因素)

-COPD

一糖皮质激素治疗

一急性呼吸衰竭、ARDS

一败血症/脓毒性休克，脓毒症后免疫麻痹，H1N1感染一急性肾衰、肝衰竭、糖尿病、严重营养不良

BaddleyJW,etal.AspergillosisinICUpatients:epidemiologyandeconomicoutcomes.BMCInfectDis,2013;13:29KoulentiD,etal.ApproachtoIPAincriticallyillpatients.CurrOpinInfectDis,2014;27(2):174-183

Proveninvasivepulmonaryaspergillosis

Microscopicanalysisonsterilemateriathistopathologic,oytopathologic,ordirectmicrosbiopsyinwhichhyphaeareseenaccompaniedbyevidenceofassociatedtissuedamaaspedimenobtainedbylungbiopsy

Probabloinvasivepulmonaryaspergillosis(allthreecriteriamustbemet

T.Hostfactors(oneofthefollowing)

●Recenthistoryofneutropenia(500neutrophis/mm³)for10d

EORTC/MSG:欧洲癌症研究和治疗组织/真菌病研究组

DePauwB,etal.ReviseddefinitionsofIFDfromtheEORTC/MSGConsensusGroup.ClinInfectDis2008;46:1813-1821.

TsitsikasDA,etal.Impactoftherevised(2008)EORTC/MSGdefinitionsforIFDontheratesofdiagnosisIA.MedMycol2012,50,538-42

Indirecttests(detectionofantigenorcellwallconstituent):galactomannanantigendetectedinplasma,serum,orBALfluidPossibleinvasivepulmonaryaspergillosis

Presenceofhostfactorsandclinicalfeatures(bableinvasiveaspergillsis)butintheabsenceofornegativemycologicalfindings.

·Inheritedsevereimmunodeficiency

20Cinicalfeatures(oneofthefollowingthreesignsonCD

●Dense,well-dircumscribedlesion(s)withorwithoutahalosign

Air-crescentsign

●Cavity

3.Mycologicalciteria(oneofthefollowing)

BaddleyJW,etal.BMCInfectDi