经验性抗真菌治疗对支气管肺泡灌洗液半乳甘露聚糖在慢性阻塞性肺疾病合并侵袭性肺曲霉病中诊断敏感度的影响

The effect of empirical antifungal treatment on the diagnostic sensitivity of galactomannan in bronchoalveolar lavage fluid in chronic obstructive pulmonary disease patients combined with invasive pulmonary aspergillosis

目的分析经验性抗真菌治疗对支气管肺泡灌洗液(BALF)半乳甘露聚糖(GM)在慢性阻塞性肺疾病(COPD)合并侵袭性肺曲霉病(IPA)中诊断敏感度的影响。方法选取福建医科大学附属泉州第一医院2015年1月至2019年1月收治的COPD合并IPA为研究对象,气管镜前给予抗真菌药者为经验性治疗组,余为诊断驱动治疗组,回顾性分析两组BALFGM结果。结果共66例COPD合并IPA者纳入分析,其中经验性治疗组17例、诊断驱动治疗组49例,5例确诊、61例临床诊断。血GM与微生物检验敏感度在经验治疗组与诊断驱动治疗组间的差异均无统计学意义(χ^(2)=0.248、0.379,P=0.619、0.538)。以BALF GM 0.5为折点,经验治疗组敏感度88.2%(95%CI:62.3%~97.9%),略低于诊断驱动治疗组93.9%(95%CI:82.1%~98.4%),但差异无统计学意义(χ^(2)=0.051,P=0.821);而以BALF GM 1.0为折点,经验治疗组敏感度52.9%(95%CI:28.5%~76.1%),低于诊断驱动治疗组81.6%(95%CI:67.4%~90.8%)(χ^(2)=4.036,P=0.045)。Logistic回归分析结果显示,校正机械通气(OR=0.807、95%CI:0.215~3.026、P=0.750)及使用半合成青霉素(OR=0.498.95%CI:0.140~1.776、P=0.283)的影响,BALFGM假阴性与治疗分组采用经验治疗有关(OR=0.243、95%CI:0.068~0.949、P=0.030)。结论气管镜前经验性抗真菌药可降低BLAF GM诊断IPA的敏感度。

Objective To investigate the effect of empirical antifungal treatment on the diagnostic sensitivity of galactomannan(GM)in bronchoalveolar lavage(BALF)in chronic obstructive pulmonary disease(COPD)patients combined with invasive pulmonary aspergillos1s(IPA).Methods COPD patients with IPA were enrolled between January 2015 and January 2019 as research objects.Patients who were treated with antifungal drugs prior to bronchoscopy were considered as the empirical group,and other patients were considered as the diagnosis-driven group.The results of BALF GM were compared between the two groups.Results A total of 66 COPD patients with IPA were enrolled m this study,with 5 cases confirmed and 61 cases clinically diagnosed.Of them,17 cases were in the empirical group and 49 in the diagnosis-driven group.There was no significant difference in the sensitivity of blood GM and microbiological examination between the two groups (χ^(2)=0.248 and 0.379,P=0.619 and 0.538).With BALF GM0.5 as a cutoff value,the sensitivity of BALF GM was slightly lower in the empirical group than in the diagnosis-driven group but with no significant difference(88.2%,95%CI:62.3%-97.9%vs.93.9%,95%CI:82.1%-98.4%,χ^(2)=0.051,P=0.821).However,with BALF GM 1.0 as a cutoff value,the sensitivity decreased greatly in the empirical group compared with the diagnosis-driven group(52.9%,95%CI:28.5%-76.1%vs.80.6%,95%CI:67.4%-90.8%,χ^(2)=4.036,P=0.045).Logistic regression analysis showed that after adjustmg for mechanical ventilation(OR=0.807,95%CI:0.215-3.026,P=0.750)and use of semisynthetic penicillins(OR=0.498,95%CI:0.140-1.776,P=0.283),the false negative rate of BALF GM was associated with empirical antifungal therapy(OR=0.243,95%CI:0.068-0.949,P=0.030).Conclusions Empirical antifungal therapy prior to bronchoscopy can decrease the diagnostic sensitivity of BALF GM in COPD patients with IPA.