重症患者合并侵入性真菌感染的转归分析

Treatment outcomes of critically ill patients complicated with invasive fungal infections

目的探讨重症患者并发侵入性真菌感染的转归及影响因素,提高ICU侵入性真菌感染的防治水平。方法回顾性调查2005-2012年医院135例ICU侵入性真菌感染病例,分析治疗转归的影响因素,运用logistic回归模型进行多因素分析。结果从临床标本中共分离出151株病原菌,94.0%为假丝酵母菌属,5.3%为曲霉菌属;分离株对氟康唑耐药率高达8.3%,伊曲康唑耐药率为4.6%,对两性霉素B全部敏感;重症患者合并侵入性真菌感染的治愈率为58.5%,多因素分析以治愈/好转作为阳性事件,结果发现中性粒细胞缺乏(OR=0.6,P=0.03)、抗真菌治疗延迟>13d(OR=0.5,P=0.02)以及APACHEⅡ评分>20分(OR=0.8,P=0.04)是治疗失败的危险因素。结论假丝酵母菌属是ICU侵入性真菌感染的主要病原菌,其对氟康唑的耐药性日趋明显。重症患者合并IFI治愈率较低,因此在临床实践中应对治疗转归的危险因素提高警惕,尤其要注意粒细胞缺乏和APACHEⅡ评分>20的患者,同时应充分重视侵入性真菌的早期治疗。

OBJECTIVE To investigate the prognostic factors for treatment outcomes of critically ill patients with in- vasive fungal infections （IFI） so as to improve the level of prevention of invasive fungal infections in ICU. METHODS Totally 135 cases of patients with invasive fungal infections, who were enrolled the ICU from 2005 to 2012, were retrospectively investigated, then the influencing factors for the treatment outcomes were analyzed, and the multivariate logistic regression analysis was performed. RESULTS A total of 151 strains of pathogens were isolated from the clinical specimens, 94.0% of which were Candida, Aspergillus 5. 3%. The drug resistance rates of the isolated strains to fluconazole were 8.3 %, itraconazole 4.6 %, while all the strains were susceptible to amphotericin B. The cure rate of the critically ill patients with invasive fungal infections was 58.5%. The multivariate analysis of the cure/improvement as positive event showed that agranulocytosis （OR=0.6, P= 0.03）, delay of antifungal therapy for more than 13 days （OR= 0. 5, P= 0. 02）, and APACHE II score more than 20 points （OR=0. 8, P=0.04） were risk factors for the failure of treatment. CONCLUSION Candida are the predominant pathogens causing IFI in the ICU and increasingly resistant to fluconazole. The cure rate of IFI in the critically ill patients is relatively low. Great attention should be paid to the risk factors for the treatment outcomes during the cIinical practice, especially the patients with agranulocytosis or APACHE II score more than 20 points, meanwhile, the early treatment of IFI should be attached great importance.