GGM试验真菌检测

GGM试验真菌检测第1页/共60页真菌感染会带来怎样的后果呢？第2页/共60页Mortality,lengthofhospitalization,andcostsassociatedwithinvasivefungalinfectionsinhigh-riskpatients.MenzinJ,MeyersJL,FriedmanM,PerfectJR,LangstonAA,DannaRP,PapadopoulosG.AmJHealthSystPharm.2009Oct1;66(19):1711-7.3第3页/共60页4第4页/共60页5第5页/共60页6第6页/共60页7第7页/共60页8第8页/共60页9第9页/共60页G试验和GM试验

----真菌检测马桂伶2011-3-1610第10页/共60页深部真菌白色念珠菌新型隐球菌曲霉菌毛霉菌11第11页/共60页传统的检测方法主要为血培养和组织活检，但血培养历时太长，且阳性率较低。近年来，用于检则真菌的抗原、抗体及代谢产物的血清学检查已用于深部真菌感染的实验室检测。

目前的血清学检查主要针对真菌胞壁或胞内成分——beta-葡聚糖、甘露糖、烯醇化酶和Cand-Tec抗原等。12第12页/共60页G试验-（1，3）-β-D葡聚糖试验G试验检测的是真菌细胞壁成分(1，3)-β-D葡聚糖，由于(1，3)-β-D-葡聚糖仅广泛存在于真菌的细胞壁中，当真菌进入人体血液或深部组织后，经吞噬细胞的吞噬、消化等处理后，(1，3)-β-D-葡聚糖可从胞壁中释放出来，从而使血液及其它体液中(1，3)-β-D-葡聚糖含量增高。

当真菌在体内含量减少时，机体免疫可迅速清除(1，3)-β-D-葡聚糖。

在浅部真菌感染中，(1，3)-β-D-葡聚糖未被释放出来，故其在体液中的量不增高。13第13页/共60页

20世纪90年代初发现,(1-3)-beta-D-葡聚糖可特异性激活自鲎变形细胞溶解产物提取的G因子,从而旁路激活鲎试验,此过程称为G试验。临床上,由于深部真菌感染的严重程度常常与血浆多糖的升高水平一致,故G试验可协助深部真菌感染的诊断(包括念珠菌感染和曲霉菌感染等)。14第14页/共60页GM实验-半乳甘露聚糖试验甘露糖是目前研究最为广泛的一种抗原,广泛存在于真菌胞壁中,是真菌胞壁的重要组成成分.15第15页/共60页Plasma(1-3)-beta-Dglucanmeasurementindiagnosisofinvasivedeepmycosisandfungalfebileepisodes目的：探讨(1-3)-beta-Dglucan在筛查侵袭性真菌感染及

真菌性发热中的价值。方法：检测了202例病员标本，以(1-3)-beta-D-葡聚糖

的血浆浓度20pg/ml为界值,41例

确诊病员(以活

检和培养阳性为标准)，37例为阳性,阳性率为90%;59例其他原因所致发热者全部阴性,阴性率为100%结论：(1-3)-beta-D-葡聚糖可用于早期诊断深部真菌感

染,其缺点是不能定性,且此法不能检测出隐球菌

感染,可能是因为隐球菌具有厚壁胞膜。ObayashiT,YoshidaM,MoriT,etal.Plasma(1，3)-beta-Dglucanmeasurementindiagnosisofinvasivedeepmycosisandfungalfebileepisodes[J].Lancet,1995,345(1):17-20.16第16页/共60页17第17页/共60页Karageorgopoulos

DM,b-D-GlucanAssayfortheDiagnosisofInvasiveFungalInfections:AMeta-analysis,ClinicalInfectiousDiseases.2011;52(6):750–7718第18页/共60页76.8%85.3%19第19页/共60页conclusionBDGhasgooddiagnosticaccuracyfordistinguishingprovenorprobableIFIsfromnoIFIs.Itcanbeusefulinclinicalpractice,ifimplementedinthepropersetting.20第20页/共60页Toupdatethe

case-fatalityrate(CFR)

associatedwithinvasiveaspergillosisaccordingtounderlyingconditions,siteofinfection,andantifungaltherapy,dataweresystematicallyreviewedandpooledfromclinicaltrials,cohortorcase-controlstudies,andcaseseriesof≥10patientswithdefiniteorprobableaspergillosis.Subjectswere1941patientsdescribedinstudiespublishedafter1995thatprovidedsufficientoutcomedata;casesincludedwereidentifiedbyMEDLINEandEMBASEsearches.ThemainoutcomemeasurewastheCFR.Fiftyof222studiesmettheinclusioncriteria.TheoverallCFRwas58%,andtheCFRwashighestforbonemarrowtransplantrecipients(86.7%).

AmphotericinBdeoxycholateandlipidformulationsofamphotericinBfailedtopreventdeathinone-halftotwo-thirdsofpatients.MortalityishighdespiteimprovementsindiagnosisanddespitetheadventofnewerformulationsofamphotericinB.Underlyingpatientconditionsandthesiteofinfectionremainimportantprognosticfactors.LinSJ,SchranzJ,TeutschSM.Aspergillosiscase-fatalityrate:systematicreviewoftheliterature.ClinInfectDis.2001;32:358–366.21第21页/共60页ChristopherD,DiagnosisofInvasiveAspergillosisUsingaGalactomannanAssay:AMeta-Analysis,ClinicalInfectiousDiseases2006;42:1417–2722第22页/共60页23第23页/共60页00.930.0.710.6100.8924第24页/共60页ConclusionsGMtesthasmoderateaccuracyfordiagnosisofinvasiveaspergillosisinimmunocompromisedpatients.Thetestismoreusefulinpatientswhohavehematologicalmalignancyorwhohaveundergonehematopoieticcelltransplantation25第25页/共60页GM试验在非血液病患者真菌检测中的应用26第26页/共60页27第27页/共60页28第28页/共60页29第29页/共60页conclusion1TheprevalenceofinvasiveaspergillosisinthegroupofpatientswithCOPDwas16.13%。2The1ng/mlcut-offshowedahigherpositivepredictivevalue(100%)andcomparablenegativepredictivevaluetothe0.5ng/mlcut-off.ThevalueofthetestinCOPDpatientsyieldedsimilarresults.30第30页/共60页COPDpatientsmayhaveincreasedsusceptibilityto

fungalinvasiveinfectionforseveralreasons(1)structuralchangesinlungarchitecturerelatedtothepulmonarydisease;(2)thecommonuseoflong-termorrepeatedshort-termsteroidtreatmentsasanadditionalimmunosuppressivefactor;(3)frequenthospitalisationandantibiotictreatment,leadingtoexposuretoselectedfungalpathogens;(4)co-morbidityfactorssuchasalcoholism,diabetesmellitusormalnutrition.F.Ader.Invasivepulmonaryaspergillosisinchronicobstructivepulmonarydisease:anemergingfungalpathogen.ClinMicrobiolInfect,2005;11:427–42931第31页/共60页GM试验在COPD合并真菌感染诊断中的应用32第32页/共60页33第33页/共60页34第34页/共60页conclusionInCOPDpatients,invasivepulmonaryaspergillosiscurrentlycarriesaverypoorprognosis.Outcomecouldperhapsbeimprovedbymorerapiddiagnosisandprompttherapywithvoriconazole.35第35页/共60页重度COPD患者合并侵袭性曲霉菌病的结果？36第36页/共60页37第37页/共60页38第38页/共60页E39第39页/共60页GMtestresult40第40页/共60页GMtestandmortalityGMtestAllpatients(%)IPApatients(%)Non-IPApatients(%)Firsttestpositive6081.833.3Atlestonepositive54.683.320Positiveforboth72.787.533.341第41页/共60页GroupMortalityAllpatients

IPAgroup

non-IPAgroupAspergillusisolated33.3%(30/90),73.7%(14/19),22.5%(16/71),

70.0%(14/20).42第42页/共60页conclusion1TheincidenceofIPAintheCOPDpatientsadmittedtotheICUwas11.1%(19/171)2serumGMshouldbetestedatleasttwiceaweektoachieveearlydiagnosisofaspergillosis.3atleastonepositiveresultoftwoconsecutiveGMtestsappearstobeusefulinthediagnosisofIPAincriticallyillCOPDpatientsinanICU.4positiveserumGMresultscombinedwiththeisolationofAspergillusfromrespiratorysamplesmaybeapotentialmarkerofhighmortality.43第43页/共60页GGM试验的联合应用44第44页/共60页45第45页/共60页RepresentativekineticsofBG()andGM()indifferentpatients.(a)ProvenIAinapatientwithacutemyeloidleukemiawhorespondedtotreatmentwithamphotericinBandcaspofungin.46第46页/共60页(b)ProvenIAinapatientwithchroniclymphocyticleukemiawhodidnotrespondtotreatmentwithamphotericinB.47第47页/共60页(c)False-positiveBGresultsinapatientwithmultiplemyelomaandnoIA.48第48页/共60页(d)False-positiveGMresultsinapatientwithnon-Hodgkin’slymphomaandnoIA.49第49页/共60页(e)NegativeBGandGMresultsinapatientwithacutemyeloidleukemiaandnoIAwhowascolonizedbyC.albicansandC.glabrata.50第50页/共60页(f)NegativeBGandGMresultsinapatientwithchroniclymphocyticleukemiaandnoIAwhowascolonizedbyC.albicans51第51页/共60页conclusion1Thesensitivity,specificity,andpositiveandnegativepredictivevaluesforGMandBGwereidentical,87.5,89.6,70,and96.3%

2

False-positivereactionsoccurredatarateof10.3%inbothtests,butthepatientsshowingfalse-positiveresultsweredifferentineachtest.Bothtestsanticipatedtheclinicaldiagnosis,computedtomographyabnormalities,andtheinitiationofantifungaltherapyinmostpatients,butBGtendedtobecomepositiveearlierthanGM.3Acombinationofthetwotestsimprovedthespecificity(to100%)andpositivepredictivevalue(to100%)ofeachindividualtestwithoutaffectingthesensitivityandnegativepredictivevalues.

BGandGMdetectionareusefultestsforthediagnosisofIAinhigh-riskhematologicalpatients,andthecombinationofthetwotestswasveryusefultoidentifyfalse-positivereactionsbyeachtest.52第52页/共60页总之：G、GM试验都可用于侵袭性真菌感染的检测，G试验对念珠菌及曲霉菌都有较好的敏感度，但不能区分出是念珠菌还是曲霉菌感染；GM试验对曲霉菌感染有较好的特异度。联合GGM试验对临床诊断侵袭性曲霉菌病有较好的价值，但这两个试验用于隐球菌检测，缺乏临床证据，GM试验能否用于念珠菌的检测仍不明确。53第53页/共60页感谢聆听不妥之处，望批评指正54第54页/共60页55第55页/共60页DiagnosisProveninvasiveFIProbableinvasiveFIPossibleinvasiveFIHistopathologicorcytopathologicexaminationshowinghyphaefromneedleaspirationorbiopsyspecimenwithevidenceofassociatedtissuedamage;orpositivecultureresultforasampleobtainedbysterileprocedurefromnormallysterileandclinicallyorradiologicallyabnormalsiteconsistentwithinfectionAtleast1hostfactorcriterion;1microbiologicalcriterion;and1major(or2minor)clinicalcriteriafromabnormalsiteconsistentwithinfectionAtleast1hostfactorcriterionand1microbiologicalor1major(or2minor)clinicalcriteriafromabnormalsiteconsistent56第56页/共60页Typeofdiagnosticcriteria

---hostfactors1Neutropenia(<500neutrophils/mm3for110days);2persistentfeverfor>96hrefractorytoappropriatebroad-spectrumantibacterialtreatmentinhigh-riskpatients;3bodytemperatureeither>38Cor<36Candanyofthefollowingpredisposingconditions:①prolongedneutropenia(110days)inprevious60days,②recentorcurrentuseofsignificantimmunosuppressiveagentsinprevious30days,③provenorprobableinvasiveFIduringpreviousepisodeofneutropenia,④coexistenceofsymptomaticAIDS;⑤signsandsymptomsindicatinggraft-versus-hostdisease,particularlysevere(grade2)orchronicextensivedisease;⑥prolonged(13weeks)useofcorticosteroidsinpreviou