吉林大学第二医院10年来侵袭性肺真菌感染回顾性分析
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摘要
背景:随着近年来经济及医疗水平的日益提高,由于广谱抗生素的长期应用、各种侵入性检测设备、导管的体内介入、留置、高强度免疫抑制剂和大剂量化疗药物的临床应用以及新兴的治疗技术如造血干细胞移植、实体器官(肝、肾、心等脏器)移植的广泛开展等,临床上侵袭性肺部真菌感染(invasive pulmonary fungal infections,IPFI)的发病率明显上升。也日益成为导致器官移植受者、恶性血液病和恶性肿瘤患者以及其他危重病患者的死亡原因之一。
目的:为了积累国内近年来侵袭性肺部真菌感染的流行病学及临床资料,探讨IPFI的临床特点及诊疗,为临床医生提高对IPFI的认识、及早诊治提供理论依据,同时为完善我国侵袭性肺部真菌感染的诊断标准和治疗原则,我们对吉林大学第二附属医院侵袭性肺部真菌感染情况进行了分析。
方法:分析吉林大学第二附属医院住院病人侵袭性肺部真菌感染的发病情况和相关疾病,进一步探讨侵袭性肺部真菌感染的易感因素。回顾性分析自1998年l月至2007年12月间在吉林大学第二附属医院住院病人中经微生物学检验或病理学检查证实的19例真菌感染病例,对所有病例与年龄、基础疾病、危险因素、治疗经过、用药情况间的关系进行分析。
结果:1、IPFI的真菌来源:念珠菌12例,曲霉菌4例,隐球菌1例,未能明确感染真菌类型2例。其中,念珠菌属又以白色念珠菌最多见,占念珠菌属的66.67%,占所有病例的42.11%,其余为克柔氏念珠菌及光滑念珠菌,占念珠菌属16.67%。除念珠菌属外,以曲霉菌最多见,占总的病例(21.05%)。2、合并基础疾病:IPFI确诊患者以呼吸系统疾病最多见,共有10例(52.62%),其中慢性阻塞性肺疾病(COPD)5例(26.32%),弥漫性间质性肺疾病(ILD)1例(5.26%),肺癌2例(10.53%),支气管哮喘2例(10.53%),支气管扩张症1例(5.26%),肺结核1例(5.26%),此外尚有循环系统疾病4例(21.05%),系统性疾病2例(10.53%),脑血管病3例(15.79%),糖尿病3例(15.79%),其他部位恶性实体肿瘤2例(10.53%)。7例患者(36.84%)合并有2种以上基础疾病。3、真菌感染前抗生素使用情况:所有确诊患者均在发病前有抗生素的使用史,有14例患者在发病之前30天内应用过抗生素14天以上且联合用药(≥2联),其中使用青霉素类药8例(42.11%),二、三、四代头孢类抗生素12例(63.16%),大环内酯类抗生素5例(26.32%),喹诺酮类抗生素4例(21.05%),碳氢霉烯8例(42.11%)。4、其他:年龄≥65的患者有14例,低蛋白血症11例。
结论:
1、IPFI患者病情复杂、真菌诊断技术滞后、临床思维模式僵化以及医患配合等多种原因导致了目前IPFI的诊断困难。
2、念珠菌属是我院侵袭性肺部真菌感染的主要真菌,尤以白色念珠菌最常见,但曲霉菌亦占有一定的比例。
3、通过研究认为IPFI主要发生在呼吸系统疾病特别是COPD、肺部恶性肿瘤等疾病。
4、老年、长期使用多种广谱抗生素、低蛋白血症等是引起IPFI常见的危险因素,与国内外其他研究类似。
Background: With the economy in recent years and increasing the level of medical care, due to the long-term application of broad-spectrum antibiotics, all kinds of intrusion detection equipment, the in vivo catheter intervention, high-intensity immunosuppressive medicament and high-dose chemotherapy and the extensive application of rising technologies such as hematopoietic stem cell transplantation, substantiality organ (liver, kidney, heart and other organ) transplantation in clinical, the incidence of invasive pulmonary fungal infection (invasive pulmonary fungal infections, IPFI) had became a marked increase in evidence. Also became to be one of causes to death increasingly , especially to organ transplant recipients, patients with hematologic malignancies and malignant tumors, as well as other critically ill patients.
Objective: To accumulate epidemiological and clinical data of domestic invasive pulmonary fungal infection in recent years, explore the clinical characteristics and treatment of IPFI to increase the knowledge about IPFI for clinicians, which help to make early diagnosis and treatment and provide a theoretical basis, as well as perfecting the invasive pulmonary fungal infection in the diagnostic criteria and treatment principles,.We have analyzed the case about invasive pulmonary fungal infection from the second Affiliated Hospital of Jilin University.
Methods: Analysis the information of patients diagnosed as invasive pulmonary fungal infection in Second Affiliated Hospital of Jilin University, to explore invasive pulmonary fungal infection risk factors. Retrospective analysis from Jan 1998 to on in Dec 2007 in the Second Affiliated Hospital of Jilin University, we get 19 cases of fungal infections confirmed by the microbiology or pathology tests, discuss the correlations between inefctions and age of all cases, the basic disease, the risk of factor, treatment,.
Results: 1, IPFI fungal origin:12cases of Candida,4 cases of aspergillosis, cryptococcosis 1 cases, 2 cases of infection caused by unknown fungal. Candida albicans is the most common in Candida, accounting for 66.67% of Candida, accounting for 42.11% of all cases of IPFI, the rest's Candida krusei and Candida glabrata, accounting for 16.67% Candida. In addition to Candida, the most common Aspergillus in total cases (21.05%). 2, The combined basis disease respiratory diseases in IPFI was most common, above to a total of 10 cases (52.62%), in which chronic obstructive pulmonary disease (COPD) 5 cases (26.32%), diffuse interstitial lung disease (ILD) 1 cases ( 5.26%), 2 cases lung cancer (10.53%), 2 cases bronchial asthma (10.53%), bronchiectasis in 1 case (5.26%), tuberculosis in 1 case (5.26%), There are 4 cases of diseases about the circulatory system (21.05% ), 2 cases of systemic diseases (10.53%), 3 cases of cerebrovascular disease (15.79%), 3 cases of diabetes (15.79%), 2 cases of malignant tumors (10.53%). 7 patients (36.84%) have combined for more than two kinds of diseases. 3, Antibiotic treatment before fungal infections : ll patients diagnosed IPFI have been used antibiotics in last 30 days, 14 patients have combined applicated antibiotics more than 14 days before diagnosed, including penicillin used in 8 cases (42.11%), third and fourth generation cephalosporins in 9 cases (47.37%), 5 cases of macrolide antibiotics (26.32%).4、other: 14 patients were the elderly(≥65),11 patients with Hypoproteinemia
Conclusion: Candida is found in invasive pulmonary fungal infection fungi, particularly the most common Candida albicans, Aspergillus but also occupy a certain proportion. Through the analysis of fungal infection-related factors that occurred mainly in IPFI respiratory diseases, especially COPD, lung diseases such as malignant tumors, while long-term use of a variety of broad-spectrum antibiotics, hypoproteinemia, is caused by the use of hormones and other risk factors IPFI , similar to other studies at home and abroad.
1, It’s hard to diagnostics IPFI due to badly state of patient, lag of diagnostic techniques about fungal, ossification of clinical viewpoint.
2, Candida is the most common epiphyte in our hospital invasive pulmonary fungal infection, particularly the most common Candida albicans, Aspergillus also occupy a certain proportion.
3, Respiratory diseases are most common combine disease in IPFI patients, especially COPD as well as malignant tumors.
4, We can find some common risk factors of IPFI such as the elderly, long-term using a variety of broad-spectrum antibiotics, hypoproteinemia, similar to other studies at home and abroad.
目的:为了积累国内近年来侵袭性肺部真菌感染的流行病学及临床资料,探讨IPFI的临床特点及诊疗,为临床医生提高对IPFI的认识、及早诊治提供理论依据,同时为完善我国侵袭性肺部真菌感染的诊断标准和治疗原则,我们对吉林大学第二附属医院侵袭性肺部真菌感染情况进行了分析。
方法:分析吉林大学第二附属医院住院病人侵袭性肺部真菌感染的发病情况和相关疾病,进一步探讨侵袭性肺部真菌感染的易感因素。回顾性分析自1998年l月至2007年12月间在吉林大学第二附属医院住院病人中经微生物学检验或病理学检查证实的19例真菌感染病例,对所有病例与年龄、基础疾病、危险因素、治疗经过、用药情况间的关系进行分析。
结果:1、IPFI的真菌来源:念珠菌12例,曲霉菌4例,隐球菌1例,未能明确感染真菌类型2例。其中,念珠菌属又以白色念珠菌最多见,占念珠菌属的66.67%,占所有病例的42.11%,其余为克柔氏念珠菌及光滑念珠菌,占念珠菌属16.67%。除念珠菌属外,以曲霉菌最多见,占总的病例(21.05%)。2、合并基础疾病:IPFI确诊患者以呼吸系统疾病最多见,共有10例(52.62%),其中慢性阻塞性肺疾病(COPD)5例(26.32%),弥漫性间质性肺疾病(ILD)1例(5.26%),肺癌2例(10.53%),支气管哮喘2例(10.53%),支气管扩张症1例(5.26%),肺结核1例(5.26%),此外尚有循环系统疾病4例(21.05%),系统性疾病2例(10.53%),脑血管病3例(15.79%),糖尿病3例(15.79%),其他部位恶性实体肿瘤2例(10.53%)。7例患者(36.84%)合并有2种以上基础疾病。3、真菌感染前抗生素使用情况:所有确诊患者均在发病前有抗生素的使用史,有14例患者在发病之前30天内应用过抗生素14天以上且联合用药(≥2联),其中使用青霉素类药8例(42.11%),二、三、四代头孢类抗生素12例(63.16%),大环内酯类抗生素5例(26.32%),喹诺酮类抗生素4例(21.05%),碳氢霉烯8例(42.11%)。4、其他:年龄≥65的患者有14例,低蛋白血症11例。
结论:
1、IPFI患者病情复杂、真菌诊断技术滞后、临床思维模式僵化以及医患配合等多种原因导致了目前IPFI的诊断困难。
2、念珠菌属是我院侵袭性肺部真菌感染的主要真菌,尤以白色念珠菌最常见,但曲霉菌亦占有一定的比例。
3、通过研究认为IPFI主要发生在呼吸系统疾病特别是COPD、肺部恶性肿瘤等疾病。
4、老年、长期使用多种广谱抗生素、低蛋白血症等是引起IPFI常见的危险因素,与国内外其他研究类似。
Background: With the economy in recent years and increasing the level of medical care, due to the long-term application of broad-spectrum antibiotics, all kinds of intrusion detection equipment, the in vivo catheter intervention, high-intensity immunosuppressive medicament and high-dose chemotherapy and the extensive application of rising technologies such as hematopoietic stem cell transplantation, substantiality organ (liver, kidney, heart and other organ) transplantation in clinical, the incidence of invasive pulmonary fungal infection (invasive pulmonary fungal infections, IPFI) had became a marked increase in evidence. Also became to be one of causes to death increasingly , especially to organ transplant recipients, patients with hematologic malignancies and malignant tumors, as well as other critically ill patients.
Objective: To accumulate epidemiological and clinical data of domestic invasive pulmonary fungal infection in recent years, explore the clinical characteristics and treatment of IPFI to increase the knowledge about IPFI for clinicians, which help to make early diagnosis and treatment and provide a theoretical basis, as well as perfecting the invasive pulmonary fungal infection in the diagnostic criteria and treatment principles,.We have analyzed the case about invasive pulmonary fungal infection from the second Affiliated Hospital of Jilin University.
Methods: Analysis the information of patients diagnosed as invasive pulmonary fungal infection in Second Affiliated Hospital of Jilin University, to explore invasive pulmonary fungal infection risk factors. Retrospective analysis from Jan 1998 to on in Dec 2007 in the Second Affiliated Hospital of Jilin University, we get 19 cases of fungal infections confirmed by the microbiology or pathology tests, discuss the correlations between inefctions and age of all cases, the basic disease, the risk of factor, treatment,.
Results: 1, IPFI fungal origin:12cases of Candida,4 cases of aspergillosis, cryptococcosis 1 cases, 2 cases of infection caused by unknown fungal. Candida albicans is the most common in Candida, accounting for 66.67% of Candida, accounting for 42.11% of all cases of IPFI, the rest's Candida krusei and Candida glabrata, accounting for 16.67% Candida. In addition to Candida, the most common Aspergillus in total cases (21.05%). 2, The combined basis disease respiratory diseases in IPFI was most common, above to a total of 10 cases (52.62%), in which chronic obstructive pulmonary disease (COPD) 5 cases (26.32%), diffuse interstitial lung disease (ILD) 1 cases ( 5.26%), 2 cases lung cancer (10.53%), 2 cases bronchial asthma (10.53%), bronchiectasis in 1 case (5.26%), tuberculosis in 1 case (5.26%), There are 4 cases of diseases about the circulatory system (21.05% ), 2 cases of systemic diseases (10.53%), 3 cases of cerebrovascular disease (15.79%), 3 cases of diabetes (15.79%), 2 cases of malignant tumors (10.53%). 7 patients (36.84%) have combined for more than two kinds of diseases. 3, Antibiotic treatment before fungal infections : ll patients diagnosed IPFI have been used antibiotics in last 30 days, 14 patients have combined applicated antibiotics more than 14 days before diagnosed, including penicillin used in 8 cases (42.11%), third and fourth generation cephalosporins in 9 cases (47.37%), 5 cases of macrolide antibiotics (26.32%).4、other: 14 patients were the elderly(≥65),11 patients with Hypoproteinemia
Conclusion: Candida is found in invasive pulmonary fungal infection fungi, particularly the most common Candida albicans, Aspergillus but also occupy a certain proportion. Through the analysis of fungal infection-related factors that occurred mainly in IPFI respiratory diseases, especially COPD, lung diseases such as malignant tumors, while long-term use of a variety of broad-spectrum antibiotics, hypoproteinemia, is caused by the use of hormones and other risk factors IPFI , similar to other studies at home and abroad.
1, It’s hard to diagnostics IPFI due to badly state of patient, lag of diagnostic techniques about fungal, ossification of clinical viewpoint.
2, Candida is the most common epiphyte in our hospital invasive pulmonary fungal infection, particularly the most common Candida albicans, Aspergillus also occupy a certain proportion.
3, Respiratory diseases are most common combine disease in IPFI patients, especially COPD as well as malignant tumors.
4, We can find some common risk factors of IPFI such as the elderly, long-term using a variety of broad-spectrum antibiotics, hypoproteinemia, similar to other studies at home and abroad.
引文
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[1]韦莉萍,桂希恩,杨自成,等.医院内真菌深部感染调查及其危险因素分析[J ]中华医院感染学杂志。1998,8(1):28-30.
[2]曹彬,对肺部真菌感染病原流行病学研究的两点体会,中华结核和呼吸杂志,2007 ,11(30) :859～861.
[3]Defining opportunistic invasive fungal infections in immunoeom -promised patients with cancer and hematopoitic stemcell transplants:an international consensus.Clin Infect Dis.2002,34:7-14
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[1]韦莉萍,桂希恩,杨自成,等.医院内真菌深部感染调查及其危险因素分析[J ]中华医院感染学杂志。1998,8(1):28-30.
[2]曹彬,对肺部真菌感染病原流行病学研究的两点体会,中华结核和呼吸杂志,2007 ,11(30) :859～861.
[3]Defining opportunistic invasive fungal infections in immunoeom -promised patients with cancer and hematopoitic stemcell transplants:an international consensus.Clin Infect Dis.2002,34:7-14
[4]钱小顺,朱元珏,许文兵,等. 127例肺部真菌感染的临床分析[J].中华结核和呼吸杂志,2000 ,23(7) :417～419
[5]施毅,肺部真菌感染的诊治进展,中国实用内科学杂志[J],2007,27(1):8-11.
[6]方国美,何谨玢,王如伟,等.抗菌药物临床应用前瞻性调查[J].中华医院感染学杂志,2000;10(2):1431.
[7]AounM.CrokavtF.Paesmans M.et al.Imipenem versutargeted therapy in cancer patients[J].lnt J Antimicrob Agents.1998:10(4)2:263
[8]Gunnarsson,N,Eliasson A,Nielsen J.Control of fluxes towards antibiotics and the role of primary me tabolism in production of antibiotics [J].Adv Biochem Eng Biotechnol,2004,88:137-78.
[9]刘巍,高小培,朴商等.呼吸道继发真菌感染。实用内科杂志,1991,4:179
[10]滕维亚,狄惠芝.深部真菌感染研究进展[J].中华医院感染学杂志,1999,9(1):62.
[11]殷少军,瞿介明.呼吸机相关肺炎抗生素治疗策略.中华结核和呼吸杂志,2001:24(6):329
[12]Caras l,GrigorescuA,StavaruC,et al.Evidence for immune defect in brest and lung Caneer Patients〔J〕.Cancer immunol Immunother,2004,53(12):1146 -1152
[13]Gao Y,Tang W,Dai X,et al.Effects of water-soluble Ganoderma lucidum Polysaccarides on the immune functions of Patients with advanced lung caneer [J].Medfood,2005,8(2):159-168