[2013.6.28]侵袭性真菌感染与先秦法家思想.ppt

ICU系列幻灯系列幻灯 安徽省立医院安徽省立医院 重症医学科重症医学科 周树生周树生 N Engl J Med 2003;348:1546-1554 Int J Antimicrob Agents.2008;32:S87-91 Nosocomial Bloodstream Infections in US Hospitals:Analysis of 24,179 Cases from a Prospective Nationwide Surveillance Study.Clin Infect Dis.2004 Aug 1;39(3):309-17.CNS Staphylococcus aureus Enterococc Candida species(%)0 15 30 45 Clin Infect Dis.2003 May 1;36(9):1103-10 A total of 2340 patients with underlying malignancy were identified among 22,631 episodes of nosocomial BSIs in a prospectively collected database for 49 hospitals in the US.44.744.7 33.433.4 25.925.9 17.617.6 30.2 11.6 11.5 8.5 107(39.5%)patients with isolated candidemia,77(28.4%)with invasive candidiasis.In 37%of the cases,candidemia occurred within the first 5 days after ICU admission.Crit Care Med.2009 May;37(5):1612-8 One hundred eighty ICUs in France Ann Surg.2001 Apr;233(4):542-8.Pelz RK,Hendrix CW,Swoboda SM,Int J Antimicrob Agents.2009Sep;34(3):205-9 Consensus statement on the management of invasive candidiasis in ICU in the Asia-Pacific Region CHINA SCAN team Non albicans 54.7%C.albicans 41.8%mixed infection other Candida species Diagnostic confirmation was based solely on at least one positive blood culture in 290(94.8%)cases Diagnosis was confirmed by histopathology in one patient(0.3%)Invasive candidiasis in ICU in China:a multicentre prospective observational study J Antimicrob Chemother.2013 Mar 29.1-9 Fengmei Guo1,Yi Yang1,Yan Kang,et al.Anidulafungin for the treatment of candidaemia/invasive candidiasis in selected critically ill patients Clin Microbiol Infect.2012 July;18(7):680687.C.kefyr=乳酒念珠菌;C.dubliniensis=都伯林念珠菌;C.pelliculosa=菌膜念珠菌 J Clin Microbiol.2012;50(6):21562158.First Case Report of Bloodstream Infection Due to a Candida Species Closely Related to the Novel Species Candida pseudorugosa The patient was a 49-year-old woman from Buenos Aires;One limitation was that most laboratories employed commercial identification methods to identify the isolates,and these methods may misidentify some species The C.pseudorugosa isolates described seems to be resistant to amphotericin B caspofungin,itraconazole,and nystatin Invasive Scedosporium apiospermum infection：one case report 刘宝刘宝,周树生等周树生等,中国感染与化疗杂志中国感染与化疗杂志.2009;9(6);466.2009;9(6);466-469469 尖端赛多孢子菌尖端赛多孢子菌 Invasive Scedosporium apiospermum infection：one case report 刘宝刘宝,周树生等周树生等,中国感染与化疗杂志中国感染与化疗杂志.2009;9(6);466.2009;9(6);466-469469 Invasive Scedosporium apiospermum infection：one case report 刘宝刘宝,周树生等周树生等,中国感染与化疗杂志中国感染与化疗杂志.2009;9(6);466.2009;9(6);466-469469 Crit Care.2008;12(1):R5 Impact of invasive fungal infection on outcomes of severe sepsis:a mul-ticenter matched cohort study in critically ill surgical patients Outcomes of candidemic septic shock patients compared with bacteremic septic shock patients Crit Care Med.2002 Aug;30(8):1808-14.In patients with suspected VAP,Candida spp.airway colonization is frequent and associated with increased risk for MDR(P.aeruginosa)bacteria isolation.Similarly,a casecontrol study shown that antifungal therapy was likely to prevent such event in one ICU.Conclusions:Candida spp.airway colonization could promote antibiotic-resistant bacteria selection in patients with suspected VAP.Intensive Care Med.2012;38(8):1272-9.Candida spp.airway colonization could promote antibiotic-resistant bacteria selection in patients with suspected VAP.主观因素主观因素 作案特征作案特征 作案人作案人 直接证据直接证据 罪犯罪犯 +疑罪人疑罪人 +-犯罪嫌疑人犯罪嫌疑人 +-Clin Infect Dis.2002 Jan 1;34(1):7-14.J Clin Microbiol.2007 Jun;45(6):1843-50.侵袭性真菌病主要高危因素侵袭性真菌病主要高危因素 多发结节影多发结节影 肺炎型肺炎型 肿块型肿块型 支气管肺炎型支气管肺炎型 曲菌球曲菌球 间质型间质型 粟粒型粟粒型 胸膜炎型胸膜炎型 空洞型空洞型 雾凇状雾凇状 肺真菌病胸部影像学表现肺真菌病胸部影像学表现（符合临床诊断和确诊病例）（符合临床诊断和确诊病例）CT示右上肺节段性实变，伴支气管充气诊征。尸检标本示节段性实变，高倍镜病理示组织坏死，散在曲霉菌.薄层CT示空洞结节，伴空气新月征。病理标本 示厚壁空洞伴空气新月形成.CHINA SCAN team Non albicans 54.7%C.albicans 41.8%mixed infection other Candida species Diagnostic confirmation was based solely on at least one positive blood culture in 290(94.8%)cases Diagnosis was confirmed by histopathology in one patient(0.3%)J Antimicrob Chemother.2013 Mar 29.1-9 Fengmei Guo1,Yi Yang1,Yan Kang,et al.Invasive candidiasis in ICU in China:a multicentre prospective observational study 一个狡猾的不轻易留下证据的对手 造成的危害巨大 他总是连累无辜，然后作案后从人群中悄然离开 他让我们不停的质疑自己的经验 面对真菌感染我们真的有把握吗面对真菌感染我们真的有把握吗 我们收集的证据够吗?足以让我们下决心定性吗?什么时候宣判?定下多重的刑罚?最大的困扰：最大的困扰：准确和时间准确和时间 2004 2008 2012 11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 International Guidelines for Management of Severe Sepsis and Septic Shock:2012 what actually changed about fungus?Use of the 1,3 beta-D-glucan assay(grade 2B),mannan and anti-mannan antibody assays(2C).Diagnosis 1:Intern Med.2011;50(22):2783-91 Diagnosis of invasive fungal disease using serum(13)-D-glucan:a bivariate meta-analysis.NOTE.AUC,the area under the summary receiver operating characteristic curve;CI,confidence interval;galactomannan,GM;IA,invasive aspergillosis;IFD,invasive fungal disease;NLR,negative likelihood ratio;PLR,positive likelihood ratio;SEN,sensitivity;SPE,specificity.Pooled T