重症急性胰腺炎合并深部真菌感染的诊断和防治

Diagnosis and prevention of fungal infection in severe acute pancreatitis

目的探讨重症急性胰腺炎 (SAP)合并深部真菌感染的早期诊断和防治措施。方法将 1998年 7月至 2 0 0 2年 6月收治的SAP患者随机分为大蒜素组、氟康唑组、对照组 ,观察其真菌感染发生率、真菌清除率和病死率。用Logistic多因素回归比较SAP合并真菌感染和单纯细菌感染患者的临床资料 ,分析其特点和真菌易感因素。结果大蒜素组真菌感染发生率 (16 % )和氟康唑组(9 % )低于对照组 (30 % ) ,二性霉素B、治疗量氟康唑对大蒜素组 (3/ 4 )和对照组 (4 / 7)的真菌清除率优于氟康唑组 (0 / 2 ) ,3组发生真菌感染患者的病死率分别是 3/ 7、1/ 4和 2 / 2。本组共有 13例真菌感染 ,2 5例单纯细菌感染 ,糖尿病、SAPⅡ级、多次手术、肠胆瘘是SAP发生真菌感染的危险因子。发生真菌感染患者的住院时间比单纯细菌感染者更长 (5 8d比 4 3d ,P =0 0 4 ) ,病死率更高 (4 6 %比 16 % ,P =0 0 5 )。结论真菌感染是SAP死亡的独立危险因素。预防性应用大蒜素、小剂量氟康唑可降低SAP的真菌感染发生率 ;用二性霉素B和治疗量氟康唑可有效清除多数SAP合并真菌感染患者的真菌株 ,改善预后。

ObjectiveTo study the early diagnosis and prevention of fungal infection in severe acute pancreatitis(SAP). Method 1.SAP patients from July 1998 to June 2002 were prospectively randomized into 3 groups: garlicin prevention group, fluconazole (low dosage) prevention group and control group, the incidence of fungal infection in SAP was compared between the groups. For fungal infection patients, the fungal clearance and mortality rate were observed. 2.Clinical data of SAP patients with fungal infection and with simple bacterial infection was compared by multivariate logistic regression, and clinical characters and risk factors of fungal infection were evaluated. Results 1.There were lower incidences of fungal infection in garlicin group (16% vs. 30%,P<0.05) and fluconazole group(9% vs. 30%,P<0.01) than that in control group; After treatment with amphotericin B or therapy-dose fluconazole, the fungal clearance rate in garlicin group (3/4) and control group (4/7) was higher than that in fluconazole group (0/2); Mortality in the 3 groups were 3/7,1/4 and 2/2.2.There were 13 cases with fungal infection(FI) and 25 cases with bacterial infection(BI); Hospital stay (58 d vs. 43 d, P=0.04) and mortality(46% vs. 16%,P=0.05) of FI were significantly higher than that of BI; Risk factors of FI included diabetes, grade Ⅱ severity, multi-operation, intestinal and/or biliary fistulas. ConclusionsFungal infection is an independent risk factor of death in SAP. Prophylactic antifungal agents could reduce the incidence of fungal infection in SAP. Therapy-dose fluconazole could clear the fungus strain of most fungal infection cases.