校正念珠菌定植指数在重症侵袭性念珠菌感染抢先治疗中的应用——多中心前瞻性随机对照临床研究

The preemptive treatment of invasive critically ill patients： a multicenter, Candida infection with reference of prospective, randomized controlled corrected colonization index in clinical study

目的评价运用校正念珠菌定植指数（CCI）对发生侵袭性念珠菌感染（ICI）高危重症患者进行抗念珠菌抢先治疗的有效性，并获取念珠菌流行病学资料。方法选择2008年10月1日-2009年4月30日天津市5家三级甲等医院重症监护病房（ICU）内急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分10分以上住院患者110例，随机分为CCI组（55例）和对照组（55例）对CCI进行监测。对照组依据临床医师经验对患者制定治疗方案。CCI组临床出现脓毒症且CCI≥0．4者立即给予抗念珠菌治疗，CCI〈0．4者则不予抗念珠菌治疗；如临床症状加重甚至生命体征不稳定，则进行补救性抗念珠菌治疗。结果两组患者一般资料、治疗方法、APACHEⅡ评分及脓毒症发生率、ICU停留时间等指标比较差异均无统计学意义（P均〉0．05）。CCI组和对照组分别有48例和50例发生脓毒症，自发生脓毒症起至临床应用抗念珠菌药物所需时间分别为（0．94±0．67）d，（3．75±3．62）d（P〈0．05）；CCI≥0．4（57例）与CCI〈0．4（53例）两者间ICU内停留时间[分别为（15．34±6．63）d，（7．24土3．75）d]、不能建立肠内营养支持率（分别为64．9％，43．4％）也存在显著差异（P均〈0．05），而APACHEⅡ评分、需要机械通气和血液净化等脏器支持治疗者的比例差异均无统计学意义（P均〉0．05）。分析110例患者575株念珠菌多部位定植菌种分布显示，白色念珠菌仍占较大比例（59．3％），热带念珠菌占10．8％，其他依次为光滑念珠菌、罗伦特隐球菌、克柔念珠菌。结论运用CCI可增加对ICU内ICI实施抢先治疗的准确性和时效性，同时可获得患者ICI菌种流行病学资料。

Objective To evaluate preemptive treatment for invasive Candida infection （ICI） with reference of corrected colonization index （CCI） in critically ill patients with high risk factors of Candida infection, and to collect the epidemiology data of Candida infection. Methods One hundred and ten critically ill patients with acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） seore〉10 were selected from intensive care units （ICUs） of 5 grade I class A hospitals in Tianjin from October 1st 2008 to April 30th 2009, and they were randomly divided into two groups; CCI group and control group （55 cases in each group）. CCI was monitored in all patients. In control group the responsible intensivists ordered the treatment according to their own experience, and in CCI group, when the patientls CCI≥0.4 and with evidence of sepsis, the patients were given anti-Candida immediately. When CCI 〈 0.4, anti-Candida treatment was not given. But when the patients＇ condition became worse or unstable, complementary anti-Candida treatment was given. Results There were no significant differences in general data, treatment of diseases of the patients, APACHE Ⅱ scores, incidence of sepsis and length of ICU stay （LOS） between two groups （all P〉0. 05）. There were 50 patients and 48 patients developing sepsis in control group and CCI group, respectively. In CCI group, the time between the onset of sepsis to beginning of anti-Candida treatment was significantly shorter than the control group [（0. 94±0. 67） days vs. （3.75±3.62） days, P〈0.05]. In the group of CCI≥0.4 （57 patients） the LOS （（15. 34±6. 63） days） and the incidence of failure in establishing enteral nutrition （64.9%） were significantly higher than that of the group of CCI〈 0.4 [53 patients, （7.24±3.75）days, 43.4%, both P 〈 0.051. There was no significant difference in APACHE Ⅱ scores, incidence of mechanical ventilation and blood purification between two groups （all P〉0.05）. Analysis of 575 strains of Candida colonized in 110 patients, revealed that C. albicans ranked first （59.3%）, C. tropiealis ranked second （10.8%）, followed by C. glabrata, Cryptococcus and C. krusei. Conclusion Application of CCI may enhance the accuracy of timely preemptive treatment for ICI, and facilitate the collection of epidemiological data of Candida in critically ill patients.