真菌性脓毒症诊治进展课件.ppt

真菌性脓毒症诊治进展 1 医药交流课件 TheEpidemiologyofSepsisintheUnitedStatesfrom1979through2000 NEnglJMed2003 348 1546 1554 医药交流课件 Long termmortalityandmedicalcarechargesinpatientswithseveresepsis CritCareMed 2003Sep 31 9 2316 23 Cumulativemortalityrateamongpatientswithseveresepsis 医药交流课件 Distributionofvariousmicroorganismsandsitesofinfectioninseveresepsispatientsandtheoutcomeaccordingtothemicroorganismsandsitesofinfectioninseveresepsispatients CritCareMed2007 35 2538 2546 EpidemiologyofseveresepsisincriticallyillsurgicalpatientsintenuniversityhospitalsinChina 医药交流课件 CharacteristicsofcriticallyillpatientsinICUsinmainlandChina CritCareMed 2013Jan 41 1 84 92 PatientOutcomeandRiskFactorsTherewere1 034survivors 986 76 0 weredischargedhome and48 3 7 werestillinthehospitalonNovember30 2009 Therewere263nonsurvivors 20 3 211diedintheICU andtheother52diedinthegeneralwards BinDu MD YouzhongAn MD YanKang MDetal 医药交流课件 2004年 11个国际医学组织的感染和脓毒症诊治方面的专家 出版了第一个改进重症脓毒症和脓毒症休克预后的指南 这个工作组联合其他工作组在2006年和2007年再次举行会议 用新的循证方法论系统来评估证据的质量和推荐力度 以更新该指南文件 这些建议的目的是用来指导临床医生治疗重症脓毒症和脓毒症性休克的病人 需要指出的是 当医生面对具体病人独特的临床指标时 这些指南中的建议不能取代临床医生的决策 医药交流课件 2008201211个国际组织15个国际组织29个国际组织44位委员55位委员69位委员135篇参考文献341篇参考文献636篇参考文献 医药交流课件 Chest 1992Jun 101 6 1644 55 不足之处 标准存在的敏感性高但特异性差的问题 ACCP SCCM1992 Definitionsforsepsisandorganfailureandguidelinesfortheuseofinnovativetherapiesinsepsis 医药交流课件 NewdiagnosticCriteriaforSepsis 2012 CritCareMed 2013Feb 41 2 580 637 医药交流课件 NewdiagnosticCriteriaforSepsis 2012 CritCareMed 2013Feb 41 2 580 637 医药交流课件 Onecase 女性 85岁 住院号 2260073 主诉 患者系 反复咳嗽 咳痰三年 加重一周 入院入院时间 2013年3月26日转入时间 2013年4月05日诊疗过程 入我院干部病房后出现发热现象 同时伴有胸闷 气喘加重 痰培养示细菌 嗜麦芽窄食假单胞菌及热带念珠菌 2012年5月行肺CT检查示 间质性肺炎 医药交流课件 Onecase 女性 85岁 住院号 2260073 2013年4月5日出现呼吸困难加重 氧饱和度下降至82 予以积极的对症处理后 症状不能改善 故转入我科加强治疗 医药交流课件 转入后检查 急诊生化K5 05mmol L Na141 1mmol L CL113 0mmol L Ca1 46mmol L CREA248 4umol LCO215 8mmol L AG17 30 GLU3 01mmol L ALB16 3g L 医药交流课件 入科诊断 重症医院获得性肺炎 吸入性 感染性休克 呼吸衰竭 型 间质性肺疾病 IPF IIP 3级高血压 极高危 老年性痴呆 慢性肾衰竭 诊疗计划 1 一般治疗 纠正休克 2 气管插管 机械通气 轻度镇痛镇静 3 抗感染治疗 头孢哌酮舒巴坦2 0静脉滴注q12h 灭滴灵注射液0 5g静脉滴注bid 4 补液 营养支持及维持水电解质平衡等对症支持处理 血气分析 乳酸 PH7 072 PCO232 6mmHg PO247 2mmHg ABE 19 1mmol LSBE 19 0mmol L Lac5 5mmol L CURB 65评分 4分 同时 进一步完善病原学诊断 血培养 痰培养等 医药交流课件 BecauseinvasionofthelungparenchymabyCandidaspecieswithresultingCandidapneumoniaisarareevent controversysurroundsthisentity Infact theisolationofcandidalspeciesfromrespiratorysecretionsismostoftennotclinicallysignificant AmJRespirCritCareMed 2011Jan1 183 1 96 128 AnofficialAmericanThoracicSocietystatement Treatmentoffungalinfectionsinadultpulmonaryandcriticalcarepatients AtMemorialHospitalandNewYorkHospital 30patients TheCandidapulmonarydiseaseappearedtobesignificantclinicalfactorinonlythreecases PulmonarydiseasecausedbyCandidaspecies AmJMed 1977Dec 63 6 914 25 Todate fewdataareavailableontheCandidaspeciesthatcausePC Itisofnotethatinourseries thevariousnon albicansspeciesofCandidadidnotappeartobemorelikelytocausePCthanisCandidaalbicans Pulmonarycandidiasisinpatientswithcancer anautopsystudy ClinInfectDis 2002Feb1 34 3 400 3 Epub2001Dec17 医药交流课件 ANCA C ANCA 及P ANCA 尿常规 阴性 医药交流课件 4月07日 4月08日 4月09日 4月10日 4月11日 4月12日 4月13日 升压药物去甲肾难以撤除 尿量逐渐减少 调整抗生素 替考拉宁 医药交流课件 转入后检查 复查床边胸片无明显进展性改变 医药交流课件 Itisaclinicalsyndromeinwhichfocalinfiltratesbeginwithsomeclinicalassociationofacutepulmonaryinfection i e fever expectoration malaise ordyspnea anddespiteaminimumof10daysofantibiotictherapypatientseitherdonotimproveorworsenclinicallyorradiographicopacitiesfailtoresolvewithin12weeksoftheonsetofthepneumonia Nonresolvingpneumonia 无反应性肺炎 CurrOpinPulmMed 2005May 11 3 247 52 Progressiveandnonresolvingpneumonia Nonresolvingpneumoniadefinitions 无反应性肺炎 Failuretorespondtoantimicrobialtreatmentwasclassifiedasnonrespondingorprogressivepneumonia Nonrespondingpneumoniawasdefinedaspersistingfever 38 and orclinicalsymptoms malaise cough expectoration dyspnea afteratleast72hofantimicrobialtreatment 医药交流课件 Antimicrobialtreatmentfailuresinpatientswithcommunity acquiredpneumonia causesandprognosticimplications AmJRespirCritCareMed 2000Jul 162 1 154 60 444patients 49patients 11 hadarepeatedinvestigationbecauseofantimicrobialtreatmentfailure Considerationswhenapatientwithcommunity acquiredpneumoniaisnotimproving 医药交流课件 1 女性 85岁 2 反复咳嗽 咳痰三年 加重一周伴胸闷 气喘 长期服用抗生素及激素 3 抗生素治疗效果差 无反应 4 CD4 CD8 1 1 总结分析病史特点 诊断 无反应性肺炎 医药交流课件 Results Treatmentfailureoccurredin215patients 15 1 134earlyfailure 62 3 and81latefailure 37 7 Thecauseswereinfectiousin86patients 40 non infectiousin34 15 8 Thorax 2009Nov 59 11 960 5 Riskfactorsoftreatmentfailureincommunityacquiredpneumonia Themaincausesofearlyfailurewereprogressivepneumonia n 54 pleuralempyema n 18 lackofresponse n 13 anduncontrolledsepsis n 9 ArchInternMed 2010Mar8 164 5 502 8 CausesandfactorsassociatedwithearlyfailureinhospitalizedpatientswithCAP 医药交流课件 Results Thefollowingshowedtheprevalenceratesofthecauses infection41 7 unknowncauses50 0 non infectiouscauses8 3 DiagnosisandTreatmentofNonrespondingPneumoniaPatientsPJCCPVDJanuary2012 Vol 20No 1 顾靖华 医药交流课件 进一步完善相关检查 医药交流课件 重症医学科 ICU 患者是侵袭性真菌感染 IFI 的高发人群 并日益成为导致ICU患者死亡的重要病因之一 ICU患者最突出的特点 解剖生理屏障完整性的破坏 重症患者侵袭性真菌感染诊断和治疗指南 中华医学会重症医学分会 医药交流课件 NEnglJMed2003 348 1546 1554 TheEpidemiologyofSepsisintheUnitedStatesfrom1979through2000 IntJAntimicrobAgents 2008 32 S87 91 Epidemiologyofcandidemiainintensivecareunits 医药交流课件 外周静脉 CVC 血培养检查结果 微生物室电话提前报 5月9日下午 BDG 102pg ml TheUniversityofVirginiariskfactorsscoringsystem 36 医药交流课件 NosocomialBloodstreamInfectionsinUSHospitals Analysisof24 179CasesfromaProspectiveNationwideSurveillanceStudy ClinInfectDis 2004Aug1 39 3 309 17 医药交流课件 107 39 5 patientswithisolatedcandidemia 77 28 4 withinvasivecandidiasis In37 ofthecases candidemiaoccurredwithinthefirst5daysafterICUadmission CritCareMed 2009May 37 5 1612 8 OnehundredeightyICUsinFrance 医药交流课件 AnnSurg 2001Apr 233 4 542 8 PelzRK HendrixCW SwobodaSM 医药交流课件 IntJAntimicrobAgents 2009Sep 34 3 205 9 ConsensusstatementonthemanagementofinvasivecandidiasisinICUintheAsia PacificRegion 医药交流课件 CHINASCANteam Nonalbicans 54 7 C albicans41 8 mixedinfection otherCandidaspecies Diagnosticconfirmationwasbasedsolelyonatleastonepositivebloodculturein290 94 8 casesDiagnosiswasconfirmedbyhistopathologyinonepatient 0 3 InvasivecandidiasisinintensivecareunitsinChina amulticentreprospectiveobservationalstudy JAntimicrobChemother 2013Mar29 1 9FengmeiGuo1 YiYang1 YanKang etal 医药交流课件 CritCare 2008 12 1 R5 Impactofinvasivefungalinfectiononoutcomesofseveresepsis amul ticentermatchedcohortstudyincriticallyillsurgicalpatients 医药交流课件 Outcomesofcandidemicsepticshockpatientscomparedwithbacteremicsepticshockpatients CritCareMed 2002Aug 30 8 1808 14 医药交流课件 InternationalGuidelinesforManagementofSevereSepsisandSepticShock 2012whatactuallychangedaboutfungus 医药交流课件 Useofthe1 3beta D glucanassay grade2B mannanandanti mannanantibodyassays 2C Change1 Diagnosis 医药交流课件 InternMed 2011 50 22 2783 91 Diagnosisofinvasivefungaldiseaseusingserum 1 3 D glucan abivariatemeta analysis NOTE AUC theareaunderthesummaryreceiveroperatingcharacteristiccurve CI confidenceinterval galactomannan GM IA invasiveaspergillosis IFD invasivefungaldisease NLR negativelikelihoodratio PLR positivelikelihoodratio SEN sensitivity SPE specificity PooledTestPerformanceoftheIncludedStudiesintheMeta Analysis 医药交流课件 InternalcontroldetectionwaspositiveforallsamplesthatwerenegativebyPCR ThemediantimefromdiagnosticculturesforCandidatocollectionofsamplesforPCRandBDGwas4days interquartilerange 1 6days Abbreviations BDG 1 3 b D glucan PCR polymerasechainreaction aCandidemiaanddeep seatedcandidiasisgroupsincluded5patientswhohadbothconditions bDeep seatedcandidiasisincludedpatientswithintra abdominalinfectionsandinfectionsofothersites boneanddevitalizedsurroundingtissue n 2 lumbarspinedevice n 1 cranialabscess n 1 cPCRwaspositiveifpositiveresultwasobtainedonplasmaand orsera dPvaluesareforsensitivitiesoftherespectiveassays asdeterminedbyMcNemartest PerformanceofPolymeraseChainReactionand1 3 D GlucanAssays ClinInfectDis 2012May 54 9 1240 8 医药交流课件 Change2 DiagnosisUseoflowprocalcitoninlevelsorsimilarbiomarkerstoassisttheclinicianinthediscontinuationofempiricantibioticsinpatientswhoinitiallyappearedseptic buthavenosubsequentevidenceofinfection grade2C DiagnMicrobiolInfectDis 2012Jul 73 3 221 7 医药交流课件 AmJRespirCritCareMed 2001Aug1 164 3 396 402 AreasundertheROCwere PCT 0 92 IL 6 0 75 IL 8 0 71 clinicalmodelwithPCT 0 94 andclinicalmodelwithoutPCT 0 77 BaselinePlasmaLevelsofPCT IL 6 andIL 8 医药交流课件 Clinicalexperienceswithanewsemi quantitativesolidphaseimmunoassayforrapidmeasurementofprocalcitonin ClinChemLabMed 2000Oct 38 10 989 95 医药交流课件 CritCareMed 2006Jul 34 7 1996 2003 Globaldiagnosticaccuracyoddsratiosforprocalcitonin Procalcitoninasadiagnostictestforsepsisincriticallyilladultsandaftersurgeryortrauma asystematicreviewandmeta analysis ReviewArticle 医药交流课件 APCTcut offvalueof2ng mLseparatedCandidasepsisfrombacterialsepsiswithasensitivityof92 aspecificityof93 andpositiveandnegativepredictivevaluesof94 Thebestcut offvalueforCRPtoseparatebacterialsepsisfromCandidasepsiswas100mg L withasensitivityof82 andaspecificityof53 ThecombinationofCRP withacut offvalueof100mg L andPCT withacut offof2ng mL didnotincreasesensitivityorspecificityforadiagnosisofCandidasepsis Markersofsepsisandorgandysfunctionattimeofbloodculture Dataareexpressedasmedian Procalcitoninlevelsinsurgicalpatientsatriskofcandidemia JInfect 2010Jun 60 6 425 30 医药交流课件 SerumlevelsofC reactiveprotein CRP andprocalcitonin PCT onthestudieddaysaccordingtothepresenceofinvasivefungalinfection IFI orbacterialinfection BI EurJClinMicrobiolInfectDis 2005Apr 24 4 272 5 Valueofmeasuringserumprocalcitonin C reactiveprotein andmannanantigenstodistinguishfungalfrombacterialinfections 医药交流课件 SerumlevelsofC reactiveprotein CRP andprocalcitonin PCT onthestudieddaysaccordingtothepresenceofinvasivefungalinfection IFI orbacterialinfection BI EurJClinMicrobiolInfectDis 2005Apr 24 4 272 5 Valueofmeasuringserumprocalcitonin C reactiveprotein andmannanantigenstodistinguishfungalfrombacterialinfections 成也萧何 败也萧何 医药交流课件 EurJClinInvest 2008Oct 38 10 784 5 Acuteinfluenceofaerobicphysicalexerciseonprocalcitonin 马拉松也能升高PCT 医药交流课件 Change2 DiagnosisUseoflowprocalcitoninlevelsorsimilarbiomarkerstoassisttheclinicianinthediscontinuationofempiricantibioticsinpatientswhoinitiallyappearedseptic buthavenosubsequentevidenceofinfection grade2C DiagnMicrobiolInfectDis 2012Jul 73 3 221 7 医药交流课件 PatientsrandomizedtothePCTgrouphadasignificantlyshortermedianICUlengthofstaythancontrolsubjects 3d range 1 18d vs 5d range 1 30d respectively P 0 03 andatendencytostayforashorterperiodinthehospital 14d range 5 64d vs 21d range 5 89d P 0 16 AmJRespirCritCareMed 2008Mar1 177 5 498 505 Useofprocalcitonintoshortenantibiotictreatmentdurationinsepticpatients arandomizedtrial 医药交流课件 Lancet 2010Feb6 375 9713 463 74 医药交流课件 Change3 Diagnosis Timetopositivityofbloodculture TTP canpredictdifferentCandidaspeciesinsteadofpathogenconcentrationincandidemia 医药交流课件 JClinMicrobiol 2008Jul 46 7 2222 6 Timetobloodculturepositivityasamarkerforcatheter relatedcandidemia 医药交流课件 Timetobloodculturepositivityasamarkerforcatheter relatedcandidemia AccuracyofaTTPcutoffof30hforthediagnosisofCRCin50patientswithindwellingCVCs JClinMicrobiol 2008Jul 46 7 2222 6 InpatientswithanindwellingCVC definiteCRCgroupexhibitedsignificantlyshorterTTPthanculturesfromthenon CRCgroup 17 32hversus37 75h P0 009 医药交流课件 Timetobloodculturepositivityasamarkerforcatheter relatedcandidemia ThetimetodetectionofC glabratawassignificantlylongerthanforotherCandidaspecies Inconclusion ourresultssuggestthattheTTPmaybeausefultoolintheevaluationofpatientswithcandidemiawhohaveanindwellingCVC andinselectedcases itmaysupportadecisiontoretainthecatheter DISCUSSION 医药交流课件 TimetopositivityofbloodculturesofdifferentCandidaspeciescausingfungaemia ThemeanTTPforallisolatescausingcandidaemiawas25 9 24 9h TheTTPforC glabratawassignificantlylongerthantheTTPoftheotherspecies Incontrast theTTPofC tropicaliswassignificantlyshorterthanthatoftheotherthreespecies JMedMicrobiol 2012May 61 Pt5 701 4 医药交流课件 TimetopositivityofdifferentCandidaspecies EurJClinMicrobiolInfectDis 2013Feb1 DepartmentofClinicalLaboratory PekingUniversityFirstHospital Beijing China 医药交流课件 1996 2005 Theappropriatenessofinitialantimicrobialtherapy theclinicalinfectionsite andrelevantpathogenswereretrospectivelydeterminedfor5 715patientswithsepticshockinthreecountries Inappropriateinitialantimicrobialtherapyforsepticshockoccursinabout20 ofpatientsandisassociatedwithafivefoldreductioninsurvival Chest 2009Nov 136 5 1237 48 医药交流课件 ESCMID guidelineforthediagnosisandmanagementofCandidadiseases2012 non neutropenicadul