呼吸科重症患者肺部真菌感染的临床特征与影响因素分析

Clinical characteristics and factors influencing development of a pulmonary fungal infection in patients with severe respiratory diseases

目的探究呼吸科重症患者肺部真菌感染的临床特征、常用药物的耐药情况及影响因素分析,为临床治疗提供参考依据。方法选取呼吸科重症患者肺部感染患者120例,采集患者晨痰进行感染菌种鉴定,采用MIC法检测真菌对常用抗生素药物的耐药率,采用KB纸片法测定联合用药对耐药性的影响。结果真菌感染组中低蛋白症患者39例,无低蛋白症者21例;对照组中低蛋白症患者16例,无低蛋白症患者44例;差异有统计学意义。真菌感染组中住院时间≤15 d患者22例,对照组中住院时间≤15 d患者34例,两组差异有统计学意义。真菌感染组中中心静脉置管患者19例,对照组中心静脉置管患者10例,两组差异有统计学意义。本次研究中共计检出真菌60株,白色假丝酵母菌22株、光滑假丝酵母菌11株、近平假丝酵母菌9株、热带假丝酵母菌8株、克柔假丝酵母菌6株、其他未分型4株,构成比为36.67%、18.33%、15.00%、13.33%、10.00%和6.67%。检出真菌对氟康唑、伊曲康唑、伏立康唑、两性霉素B、益康唑、咪康唑、酮康唑、5-氟胞嘧啶和制霉菌素耐药株数为23、11、9、5、16、12、11、19和20株,耐药率为38.33%、18.33%、15.00%、8.33%、26.67%、20.00%、18.33%、31.67%和33.33%。白色假丝酵母菌对上述9种临床常用抗真菌药物耐药株数为8、4、4、2、6、4、3、5和7株,耐药率为36.36%、18.18%、18.18%、9.09%、27.27%、18.18%、13.64%、22.73%和31.82%。高浓度左氧氟沙星与氟康唑联合使用抑菌圈变大,说明左氧氟沙星仅在浓度较大时增强氟康唑作用效果,具有协同作用。利福平和阿奇霉素在低浓度和高浓度与氟康唑联合使用时抑菌圈均变大,表明联合用药时菌株透过药物增多,增强了氟康唑作用效果,具有协同作用。讨论医院呼吸科重症患者肺部真菌感染常见且呈增多趋势;早期真菌培养及药敏试验可以减少盲目用药产生的耐药菌株产生。联合用药可以减少耐药发生,提高肺部真菌感染的治疗效果。

Objectives To examine the clinical characteristics,drug resistance,and factors influencing development of a pulmonary fungal infection in patients with severe respiratory diseases in order to provide a reference for clinical treatment.Methods Subjects were 120 patients with a severe pulmonary infection who were seen by Respiratory Medicine.Morning sputum was collected for microbe identification.The MIC method was used to detect the resistance of fungi to commonly used antibiotics,and the K-B disc diffusion method was used to detect the effect of drug combinations on fungal resistance.Results Of patients with a fungal infection,39 had hypoproteinemia and 21 did not.In the control group,16 patients had hypoproteinemia and 44 did not.The difference in the rate at which hypoproteinemia was detected was significant.In the fungal infection group,22 patients were hospitalized for 15 days for less;in the control group,34 patients were hospitalized for 15 days or less.In the fungal infection group,19 patients underwent central venous catheterization;in the control group,10 patients underwent central venous catheterization.Sixty strains of fungi were detected.Of those,22(36.67%)were strains of Candida albicans,11(18.33%)were strains of C.glabrata,9(15.00%)were strains of C.parapsilosis,8(13.33%)were strains of C.tropicalis,6(10.00%)were strains of C.krusei,and 4(6.67%)were unidentified strains.Twenty-three strains of fungi were resistant to fluconazole,11 were resistant to itraconazole,9 were resistant to voriconazole,5 were resistant to amphotericin B,16 were resistant to Econazole,12 were resistant to miconazole,11 were resistant to ketoconazole,19 were resistant to 5-fluorocytosine,and 20 were resistant to nystatin.The resistance of fungi to fluconazole was 38.33%,their resistance to itraconazole was 18.33%,their resistance to voriconazole was 15.00%,their resistance to amphotericin B was 8.33%,their resistance to econazole was 26.67%,their resistance to miconazole was 20.00%,their resistance to ketoconazole was 18.33%,their resistance to 5-fluorocytosine was 31.67%,and their resistance to nystatin was 33.33%.Eight strains(36.36%)of C.albicans were resistant to fluconazole,4(18.18%)were resistant to itraconazole,4(18.18%)were resistant to voriconazole,2(9.09%)were resistant to amphotericin B,6(27.27%)were resistant to econazole,4(18.18%)were resistant to miconazole,3(13.64%)were resistant to ketoconazole,5(22.73%)were resistant to 5-fluorocytosine,and 7(31.82%)were resistant to nystatin.The bacteriostatic circle produced by a high concentration of levofloxacin combined with fluconazole increased in size,indicating that levofloxacin and fluconazole had a synergistic effect,with levofloxacin merely enhancing the effect of fluconazole at a high concentration.When rifampicin and azithromycin were used in combination with fluconazole at low and high concentrations,the bacteriostatic circle increased in size,indicating that the number of fungal cells passing through the drug increased.Rifampicin,azithromycin,and fluconazole had a synergistic effect,with rifampicin and azithromycin enhancing the effect of fluconazole.Conclusion Pulmonary fungal infections are common and increasing in patients with severe respiratory disease seen by Respiratory Medicine at this Hospital.A fungal culture early on and a drug sensitivity test can inhibit the growth of drug-resistant strains.A combination of drugs can reduce drug resistance and improve their efficacy against a pulmonary fungal infection.