15例真菌败血症的回顾性研究

Retrospective analysis of 15 patients with fungal septicaemia

目的 探讨真菌败血症的治疗及早期诊断 ,以改善预后。方法 结合文献复习 ,回顾性研究 1992年 8月～ 2 0 0 0年 9月间的 15例真菌败血症患者的临床特征、治疗效果及预后。结果 15例中 ,除 1例为社区获得性感染外 ,14例为医院获得性感染 ;后者首次阳性血培养前的住院时间 7d～12个月 ,中位数为 1 5个月。易感危险因素中 ,以严重基础疾病 (10例 / 15例 )、使用广谱抗生素 (14例/ 15例 )、应用糖皮质激素或化疗药物 (11例 / 15例 )的因素最为突出 ,少数 (4例 / 15例 )有中性粒细胞减少。而具有上述两种以上易感危险因素者达 11例。主要致病菌为念珠菌属包括白色念珠菌和非白色念珠菌属 (如热带念珠菌、近平滑念珠菌等 )。病死率为 5 3 3% (8/ 15 )。对抗真菌治疗有效的 7例中 ,合并心内膜炎的 2例成功地施行了瓣膜赘生物 (直径均 >1cm)清除术。结论 本组败血症多发生在机体防御功能明显降低的患者中 ,主要致病菌为白色念珠菌和非白色念珠菌属 ,尽可能及早明确诊断和治疗有助于降低病死率。

Objective Study on the early diagnosis, antifungal therapy, and prophylaxis for fungemia. Method Retrospective study of the clinical features, treatment and outcome of 15 patients with fungemia from August 1992 to September 2000 at Peking Union Medical College Hospital. Results The patients′ ages ranged from 25 days (1 newborn) to 72 years (mean: 54.5 years in 14 patients); 11 were male. The length of hospitalization before fungemia varied from 7 days to 12 months (median: 1.5 months) in 14 patients who fulfilled criteria for nosocomial fungemia, another one with fungemia occured outside of hospital. The main underlying conditions were: malignant disease (cancer, leukemia and acute aplastic anemia ) in 10 patients (66.7%), infections following abdominal surgery in 2 patients (13.3%), trauma in 1 patient, rheumatic heart disease in 1 patient and 1 newborn. In this group the risk factors for fungemia included: prior antimicrobial therapy (14 of 15, 93.3%), steroids/cytotoxic chemotherapy (11 of 15, 73.3%), neutropenia ( 4/15, 26.7%), central venous catheterization and hyperalimentation (2 of 15, 13.3%). There were two or more risk factors in each of 11 patients. Fungal species isolated from 15 patients were: C. albicans (in 4 ), C. tropicalis (in 3 ), C. parapsilosis (in 3 ), C. sake (in 1 ), Trichosporon beigelii (in 1 ) and Yeast like fungus (in 3). Before or during of fungemia, there were abnormal pulmonary signs or chest roentgenogram in 11 (73.3%), thrush in 2 (13.3%), enteritis in 2 ( 13.3%), urinary tract infection in 2 (13.3%) and endocarditis in 2 (13.3%). The overall mortality was 53.3% (8 of 15) and was 26.7%(4 of 15) duo to fungemia. Out of 7 survived patients, 4 were cured , 3 with fluconazole ( length of therapy: 3～5 weeks) and 1 with a combination therapy of amphotericin B plus fluconazole (length of therapy: 3 months), other 3 were improved with fluconazole or amphotericin B ( length of therapy: >2 weeks ). During the antifungal therapy, 2 patients with the complication of fungal endocarditis underwent surgical removal of vegetation on the infected valves. Conclusion In this study, the most frequent infectious agents were Candida albicans and non albicans Candida species. Early diagnosis is of importance to guide appropriate antifungal therapy and reduce mortality.