系统性红斑狼疮合并医院内真菌感染的病原学分析与治疗

The pathogenic features and treatment of systemic lupus erythematosus complicated with nosocomial fungal infections

目的探讨系统性红斑狼疮(SLE)合并医院内真菌感染的病原学特征、临床表现、易感因素、治疗和预后。方法回顾性分析1998年1月至2008年1月经微生物学检查证实的82例SLE合并医院内真菌感染患者资料。结果1525例SLE患者中,82例发生医院内真菌感染,发生率5.4%。占SLE医院感染总例数的17.9%(82/458)。感染部位常见为口腔(34%),下呼吸道(32%)和胃肠道(21%)。82例中共分离出真菌103株,最常见为念珠菌属(74.7%),其次为隐球菌(9.8%)和曲霉菌(5.8%)。易感因素为低蛋白血症、血白细胞减少、低补体血症,长期使用肾上腺皮质激素、免疫抑制剂和广谱抗生素以及侵入性操作等。抗真菌治疗单用氟康唑47例,制霉菌素7例,伏立康唑6例,伊曲康唑5例,两性霉素B5例,卡泊芬净1例,其余均为联合用药。本组治愈39例,好转23例,恶化3例,死亡17例,病死率达21%。结论念珠菌为常见致病菌。SLE合并医院内真菌感染病死率高。临床医生应高度警惕真菌感染,早期诊断及合理治疗有助于改善SLE患者预后。

Objective To explore the pathogenic features, clinical spectrum, risk factors, antifungal therapy and prognosis in systemic lupus erythematosus （fiLE） patients complicated with nosocomial fungal infections. Methods A review was performed of 82 SLE patients with nosocomial fungal infections in our hospital between Jan 1998 and Jan 2008. Results Of 1525 SLE patients, 82 （5.4 %） suffered nosocomial fungal infections. The infections most frequently involved oral cavity （34%）, lower respiratory tract （32%） and gastrointestinal tract （21%）. 113 fungal strains were isolated from the 82 cases. The most common pathogen was Candida （74.7%）, followed by Cryptococcus （9.8%） and Aspergillus （5.8%）. Hypoproteinemia, leukopenia, low serum complement level, invasive operation, long-term use of corticosteroids, immunosuppressants and broad-spectrum antibiotics were found to be risk factors. Antifungal therapy included single use of fluconazole （n=47）, nystatin （n=7）, voriconazole （n=6）, itraconazole （n=5）, amphotericin S （n=5）, caspofungin （n=1） or certain combination of these agents in the remaining cases. Of all cases, 39 were cured, 23 improved, 3 worsened and 17 （21%） died. Conclusion Clinicians should be alerted against SLE with nosocomial fungal infections, which is most frequently caused by Candida and usually highly fatal. Early diagnosis and rational treatment could improve the prognosis.