儿童血液病合并侵袭性真菌病164例临床分析

Clinical Analysis of 164 Children of Blood Disease Complicated with Invasive Fungal Disease

目的:探讨儿童侵袭性真菌病(invasive fungal disease,IFD)的临床特点和防治方法。方法:回顾性分析本中心2012年1月至2015年1月符合IFD诊断标准的164例临床资料,了解其发病率、临床特征、相关因素,治疗方法和预后。结果:在本院收治的1 289例血液病患儿中164例发生IFD,发病率为12.7%;感染部位主要为单纯肺部、血液和胃肠道,发生率分别为84.2%、5.5%和3%;共检出真菌35例,其中白色假丝酵母菌、曲霉菌和光滑假丝酵母菌检出率较高,分别为51.5%、20%和14.3%;164例患儿完全缓解36例,部分缓解97例,疾病稳定10例,进展11例,死亡10例,总有效率达81.1%。单因素分析表明,粒细胞缺乏、粒细胞恢复、长期使用糖皮质激素和免疫抑制剂及不同的诊断级别是影响患儿抗真菌疗效的显著因素;多因素分析结果则进一步表明,粒细胞恢复和诊断级别为影响IFD患儿疗效的独立预后因素。164例患儿抗真菌治疗,在开始的12周内的总体活存率为81.7%,其中伊曲康唑、伏立康唑、两性霉素B和卡泊芬净治疗的患儿12周生存率分别为81.4%、80%、69.4%和97.1%,Log-rank检验显示差异具有显著性意义。除卡泊芬净外,其余3种药物均出现不同程度的毒副作用,经对症治疗后患儿均可耐受。结论:本院血液病患儿IFD的发生率为12.7%,肺部为最常见感染部位,且以念珠菌居多。促进粒细胞恢复和尽早的分层诊断有助于IFD的治疗。对于经济条件较好的患儿,卡泊芬净是一种高效、低毒和预后好的抗真菌药物,值得临床推荐使用。

Objective:To investigate the clinical characteristics,prevention and treatment of invasive fungal disease(IFD).Methods:The clinical data of 164 patients who met the diagnostic criteria of IFD in our center from January 2012 to January 2015 were retrospectively analyzed.The incidence,clinical characteristics,related factors,treatment methods and prognosis were analyzed.Results:Among 1289 cases of blood diseases,164 cases suffered from IFD with inciduce of 12.7%.The main infection sites were as followed:lung,blood and gastrointestinal tract,with incidence of 84.2%,5.5%and 3%respectively.The funge was found in 35 cases by detection;among fungi,the detected rate of candida albicans.aspergillus and candida glabrata was more high with 51.5%,20%and 14.3%respectively.Among 164 childen with blood deseases complicated by IFD,36 cases gained complete remission,97 cases gained partial remission,10 cases were stable,11 cases were progressive and 10 cases died,the overall effective rate reached 81.1%.The univariate analysis showed that the gramulopenia,granulocyte recovery,long-term use of corticosteroid and immuno-suppressive agents,as well as different grades of diagnosis were significant factors affecting the efficacy of antifungal therapy for blood disease children with IFD,the multivariate analysis further showed that the granulocyte recovery and diagnosis grades were independent prognostic factors affecting the therapeutic efficacy for IFD children.The overall survival rate of IFD children with 12 weeks of antifungal treatnment was 81.7%,out of which the survival rate of IFD children at 12 weeks of treatment with itraconazole,voriconazole,amphotericin B and caspofungin was 81.4%,80%,69.4%and 97.1%respectively,there were significant differences in survival rate between each other by long rank test.In addition of caspofungin,the other 3 kinds of drugs had toxic side effects of different degrees,but IFD children could tolerated these effects after symptomatic treatment.Conclusion:The incidence of IFD in children with blood deseases in our hospital is 12.7%,the lung is most common infective site,moreover patogens of IFD mainly is candida.The promotion of granulocyte recovery and early stratified diagnosis can contribule to the treatment of IFD.For the IFD children with better economic condition,the caspofungin is a potent antifungal agent with high efficacy,low toxicity and better prognosis.