真菌性膿毒癥診治進展

TheEpidemiologyofSepsisintheUnitedStatesfrom1979through2000NEnglJMed2003;348:1546-1554現在是1頁\一共有59頁\編輯于星期二Long-termmortalityandmedicalcarechargesinpatientswithseveresepsis.CritCareMed.

2003

Sep;31(9):2316-23.Cumulativemortalityrateamongpatientswithseveresepsis現在是2頁\一共有59頁\編輯于星期二DistributionofvariousmicroorganismsandsitesofinfectioninseveresepsispatientsandtheoutcomeaccordingtothemicroorganismsandsitesofinfectioninseveresepsispatientsCritCareMed2007;35:2538-2546EpidemiologyofseveresepsisincriticallyillsurgicalpatientsintenuniversityhospitalsinChina現在是3頁\一共有59頁\編輯于星期二CharacteristicsofcriticallyillpatientsinICUsinmainlandChina

CritCareMed.

2013

Jan;41(1):84-92PatientOutcomeandRiskFactors

Therewere1,034survivors:986(76.0%)weredischargedhome,and48(3.7%)werestillinthehospitalonNovember30,2009.Therewere263nonsurvivors(20.3%):211diedintheICU,andtheother52diedinthegeneralwards.BinDu,MD;YouzhongAn,MD;YanKang,MDetal;現在是4頁\一共有59頁\編輯于星期二2004年，11個國際醫(yī)學組織的感染和膿毒癥診治方面的專家，出版了第一個改進重癥膿毒癥和膿毒癥休克預后的指南。這個工作組聯合其他工作組在2006年和2007年再次舉行會議，用新的循證方法論系統(tǒng)來評估證據的質量和推薦力度，以更新該指南文件。這些建議的目的是用來指導臨床醫(yī)生治療重癥膿毒癥和膿毒癥性休克的病人。需要指出的是，當醫(yī)生面對具體病人獨特的臨床指標時，這些指南中的建議不能取代臨床醫(yī)生的決策?，F在是5頁\一共有59頁\編輯于星期二2008201211個國際組織15個國際組織29個國際組織44位委員55位委員69位委員135篇參考文獻341篇參考文獻636篇參考文獻現在是6頁\一共有59頁\編輯于星期二Chest.1992Jun;101(6):1644-55不足之處：標準存在的敏感性高但特異性差的問題

ACCP/SCCM1992Definitionsforsepsisandorganfailureandguidelinesfortheuseofinnovativetherapiesinsepsis現在是7頁\一共有59頁\編輯于星期二NewdiagnosticCriteriaforSepsis:2012CritCareMed.2013Feb;41(2):580-637.現在是8頁\一共有59頁\編輯于星期二NewdiagnosticCriteriaforSepsis:2012CritCareMed.2013Feb;41(2):580-637.現在是9頁\一共有59頁\編輯于星期二Onecase:女性，85歲，住院號：2260073主訴：患者系“反復咳嗽、咳痰三年，加重一周”入院入院時間：2013年3月26日轉入時間：2013年4月05日診療過程：入我院干部病房后出現發(fā)熱現象，同時伴有胸悶、氣喘加重，痰培養(yǎng)示細菌（嗜麥芽窄食假單胞菌及熱帶念珠菌）；2012年5月行肺CT檢查示“間質性肺炎”現在是10頁\一共有59頁\編輯于星期二Onecase:女性，85歲，住院號：22600732013年4月5日出現呼吸困難加重，氧飽和度下降至82%，予以積極的對癥處理后，癥狀不能改善，故轉入我科加強治療。現在是11頁\一共有59頁\編輯于星期二轉入后檢查急診生化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

現在是12頁\一共有59頁\編輯于星期二入科診斷：重癥醫(yī)院獲得性肺炎(吸入性)；感染性休克？；呼吸衰竭(Ｉ型)；間質性肺疾病(IPF/IIP)；3級高血壓，極高危；老年性癡呆；慢性腎衰竭。診療計劃：1、一般治療，糾正休克；2、氣管插管、機械通氣（輕度鎮(zhèn)痛鎮(zhèn)靜）；3、抗感染治療（頭孢哌酮舒巴坦2.0靜脈滴注q12h;滅滴靈注射液0.5g靜脈滴注bid;）；4、補液、營養(yǎng)支持及維持水電解質平衡等對癥支持處理；血氣分析+乳酸:

PH7.072,PCO232.6mmHg,PO247.2mmHg,ABE-19.1mmol/LSBE-19.0mmol/L，Lac5.5mmol/L。CURB-65評分:4分同時，進一步完善病原學診斷（血培養(yǎng)，痰培養(yǎng)等）現在是13頁\一共有59頁\編輯于星期二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.現在是14頁\一共有59頁\編輯于星期二ANCA：C-ANCA（-）及P-ANCA（-）尿常規(guī)：陰性現在是15頁\一共有59頁\編輯于星期二4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日升壓藥物去甲腎難以撤除，尿量逐漸減少調整抗生素（替考拉寧）?現在是16頁\一共有59頁\編輯于星期二轉入后檢查復查床邊胸片無明顯進展性改變?，F在是17頁\一共有59頁\編輯于星期二Itisaclinicalsyndromeinwhichfocalinfiltratesbeginwithsomeclinicalassociationofacutepulmonaryinfection(i.e.fever,expectoration,malaise,ordyspnea)anddespiteaminimumof10daysofantibiotictherapypatientseitherdonotimproveorworsenclinicallyorradiographicopacitiesfailtoresolvewithin12weeksoftheonsetofthepneumonia.Nonresolvingpneumonia（無反應性肺炎）CurrOpinPulmMed.

2005May;11(3):247-52.Progressiveand

nonresolving

pneumonia.Nonresolvingpneumoniadefinitions（無反應性肺炎）Failuretorespondtoantimicrobialtreatmentwasclassifiedasnonrespondingorprogressivepneumonia.Nonrespondingpneumoniawasdefinedaspersistingfever＞38℃and/orclinicalsymptoms(malaise,cough,expectoration,dyspnea)afteratleast72hofantimicrobialtreatment.現在是18頁\一共有59頁\編輯于星期二Antimicrobialtreatmentfailuresinpatientswithcommunity-acquiredpneumonia:causesandprognosticimplications.AmJ

Respir

Crit

Care

Med.

2000

Jul;162(1):154-60.444patients,49patients(11%)hadarepeatedinvestigationbecauseofantimicrobialtreatmentfailure.Considerationswhenapatientwithcommunity-acquiredpneumoniaisnotimproving現在是19頁\一共有59頁\編輯于星期二1、女性，85歲；2、“反復咳嗽、咳痰三年，加重一周伴胸悶、氣喘”，長期服用抗生素及激素；3、抗生素治療效果差（無反應）；4、CD4/CD8=1.1總結分析病史特點：診斷：無反應性肺炎現在是20頁\一共有59頁\編輯于星期二Results:Treatmentfailureoccurredin215patients(15.1%):134earlyfailure(62.3%)and81latefailure(37.7%).Thecauseswereinfectiousin86patients(40%),non-infectiousin34(15.8%).Thorax.

2009

Nov;59(11):960-5.Riskfactorsoftreatmentfailureincommunityacquiredpneumonia.Themaincausesofearlyfailurewereprogressivepneumonia(n=54),pleuralempyema(n=18)lackofresponse(n=13),anduncontrolledsepsis(n=9).ArchInternMed.

2010

Mar8;164(5):502-8.CausesandfactorsassociatedwithearlyfailureinhospitalizedpatientswithCAP現在是21頁\一共有59頁\編輯于星期二Results：Thefollowingshowedtheprevalenceratesofthecauses:infection41.7%,unknowncauses50.0%,non-infectiouscauses8.3%．DiagnosisandTreatmentofNonrespondingPneumoniaPatientsPJCCPVDJanuary2012,Vol,20No.1（顧靖華）現在是22頁\一共有59頁\編輯于星期二進一步完善相關檢查現在是23頁\一共有59頁\編輯于星期二重癥醫(yī)學科(ICU)患者是侵襲性真菌感染(IFI)的高發(fā)人群,并日益成為導致ICU患者死亡的重要病因之一。ICU患者最突出的特點：解剖生理屏障完整性的破壞。

《重癥患者侵襲性真菌感染診斷和治療指南》中華醫(yī)學會重癥醫(yī)學分會現在是24頁\一共有59頁\編輯于星期二NEnglJMed2003;348:1546-1554TheEpidemiologyofSepsisintheUnitedStatesfrom1979through2000IntJAntimicrobAgents.2008;32:S87-91Epidemiologyofcandidemiainintensivecareunits現在是25頁\一共有59頁\編輯于星期二外周靜脈CVC血培養(yǎng)檢查結果（微生物室電話提前報，5月9日下午）BDG=102pg/mlThe

University

of

Virginiariskfactorsscoringsystem：36現在是26頁\一共有59頁\編輯于星期二NosocomialBloodstreamInfectionsinUSHospitals:Analysisof24,179CasesfromaProspectiveNationwideSurveillanceStudy.ClinInfectDis.

2004Aug1;39(3):309-17.

現在是27頁\一共有59頁\編輯于星期二107(39.5%)patientswithisolatedcandidemia,77(28.4%)withinvasivecandidiasis.In37%ofthecases,candidemiaoccurredwithinthefirst5daysafterICUadmission.CritCareMed.

2009

May;37(5):1612-8OnehundredeightyICUsinFrance現在是28頁\一共有59頁\編輯于星期二AnnSurg.

2001Apr;233(4):542-8.

PelzRK,

HendrixCW,

SwobodaSM,

現在是29頁\一共有59頁\編輯于星期二IntJAntimicrobAgents.

2009

Sep;34(3):205-9ConsensusstatementonthemanagementofinvasivecandidiasisinICUintheAsia-PacificRegion現在是30頁\一共有59頁\編輯于星期二CHINASCANteamNonalbicans>54.7%C.albicans41.8%mixedinfectionotherCandidaspeciesDiagnosticconfirmationwasbasedsolelyonatleastonepositivebloodculturein290(94.8%)casesDiagnosiswasconfirmedbyhistopathologyinonepatient(0.3%)InvasivecandidiasisinintensivecareunitsinChina:amulticentreprospectiveobservationalstudy.JAntimicrobChemother.2013Mar29.1-9FengmeiGuo1,YiYang1,YanKang,etal.現在是31頁\一共有59頁\編輯于星期二CritCare.2008;12(1):R5Impactofinvasivefungalinfectiononoutcomesofseveresepsis:amul-

ticentermatchedcohortstudyincriticallyillsurgicalpatients現在是32頁\一共有59頁\編輯于星期二OutcomesofcandidemicsepticshockpatientscomparedwithbacteremicsepticshockpatientsCritCareMed.2002Aug;30(8):1808-14.現在是33頁\一共有59頁\編輯于星期二InternationalGuidelinesforManagementofSevereSepsisandSepticShock:2012whatactuallychangedaboutfungus?現在是34頁\一共有59頁\編輯于星期二Useofthe1,3beta-D-glucanassay(grade2B),mannanandanti-mannanantibodyassays(2C).Change1:Diagnosis現在是35頁\一共有59頁\編輯于星期二InternMed.

2011;50(22):2783-91Diagnosisofinvasivefungaldiseaseusingserum(1→3)-β-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現在是36頁\一共有59頁\編輯于星期二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-β-D-GlucanAssaysClinInfectDis.

2012May;54(9):1240-8.現在是37頁\一共有59頁\編輯于星期二Change2:DiagnosisUseoflowprocalcitoninlevelsorsimilarbiomarkerstoassisttheclinicianinthediscontinuationofempiricantibioticsinpatientswhoinitiallyappearedseptic,buthavenosubsequentevidenceofinfection(grade2C).DiagnMicrobiolInfectDis.2012Jul;73(3):221-7現在是38頁\一共有59頁\編輯于星期二AmJRespirCritCareMed.2001Aug1;164(3):396-402AreasundertheROCwere:PCT,0.92;IL-6,0.75;IL-8,0.71clinicalmodelwithPCT,0.94,andclinicalmodelwithoutPCT,0.77BaselinePlasmaLevelsofPCT,IL-6,andIL-8現在是39頁\一共有59頁\編輯于星期二Clinicalexperienceswithanewsemi-quantitativesolidphaseimmunoassayforrapidmeasurementof

procalcitonin.ClinChemLabMed.

2000Oct;38(10):989-95.現在是40頁\一共有59頁\編輯于星期二CritCareMed.

2006Jul;34(7):1996-2003.GlobaldiagnosticaccuracyoddsratiosforprocalcitoninProcalcitoninasadiagnostictestforsepsisincriticallyilladultsandaftersurgeryortrauma:asystematicreviewandmeta-analysisReviewArticle現在是41頁\一共有59頁\編輯于星期二APCTcut-offvalueof2ng/mLseparatedCandidasepsisfrombacterialsepsiswithasensitivityof92%,aspecificityof93%,andpositiveandnegativepredictivevaluesof94%.Thebestcut-offvalueforCRPtoseparatebacterialsepsisfromCandidasepsiswas100mg/L,withasensitivityof82%andaspecificityof53%ThecombinationofCRP(withacut-offvalueof100mg/L)andPCT(withacut-offof2ng/mL)didnotincreasesensitivityorspecificityforadiagnosisofCandidasepsis.Markersofsepsisandorgandysfunctionattimeofbloodculture.Dataareexpressedasmedian.

ProcalcitoninlevelsinsurgicalpatientsatriskofcandidemiaJInfect.2010Jun;60(6):425-30.現在是42頁\一共有59頁\編輯于星期二SerumlevelsofC-reactiveprotein(CRP)andprocalcitonin(PCT)onthestudieddaysaccordingtothepresenceofinvasivefungalinfection(IFI)orbacterialinfection(BI).EurJClinMicrobiolInfectDis.

2005

Apr;24(4):272-5.Valueofmeasuringserumprocalcitonin,C-reactiveprotein,andmannanantigenstodistinguishfungalfrombacterialinfections現在是43頁\一共有59頁\編輯于星期二SerumlevelsofC-reactiveprotein(CRP)andprocalcitonin(PCT)onthestudieddaysaccordingtothepresenceofinvasivefungalinfection(IFI)orbacterialinfection(BI).EurJClinMicrobiolInfectDis.

2005

Apr;24(4):272-5.Valueofmeasuringserumprocalcitonin,C-reactiveprotein,andmannanantigenstodistinguishfungalfrombacterialinfections成也蕭何，敗也蕭何現在是44頁\一共有59頁\編輯于星期二EurJClinInvest.2008Oct;38(10):784-5Acuteinfluenceofaerobicphysicalexerciseonprocalcitonin馬拉松也能升高PCT現在是45頁\一共有59頁\編輯于星期二Change2:DiagnosisUseoflowprocalcitoninlevelsorsimilarbiomarkerstoassisttheclinicianinthediscontinuation

ofempiricantibioticsinpatientswhoinitiallyappearedseptic,buthavenosubsequentevidenceofinfection(grade2C).DiagnMicrobiolInfectDis.2012Jul;73(3):221-7現在是46頁\一共有59頁\編輯于星期二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.

2008

Mar1;177(5):498-505Useofprocalcitonintoshortenantibiotictreatmentdurationinsepticpatients:arandomizedtrial.現在是47頁\一共有59頁\編輯于星期二Lancet.

2010

Feb6;375(9713):463-74

現在是48頁\一共有59頁\編輯于星期二Change3:DiagnosisTimetopositivityofbloodculture(TTP)canpredictdifferentCandidaspeciesinsteadofpathogenconcentrationincandidemia現在是49頁\一共有59頁\編輯于星期二JClinMicrobiol.

2008

Jul;46(7):2222-6Timetobloodculturepositivityasamarkerforcatheter-relatedcandidemia現在是50頁\一共有59頁\編輯于星期二Timetobloodculturepositivityasamarkerforcatheter-relatedcandidemiaAccuracyofaTTPcutoffof30hforthediagnosisofCRCin50patientswithindwellingCVCsJClinMicrobiol.

2008

Jul;46(7):2222-6InpatientswithanindwellingCVC,definiteCRCgroupexhibitedsignificantlyshorterTTPthanculturesfromthenon-CRCgroup(17.32hversus37.75h;P0.009).現在是51頁\一共有59頁\編輯于星期二Timetobloodculturepositivityasamarkerforcatheter-relatedcandidemia

ThetimetodetectionofC.glabratawassignificantlylongerthanforotherCandidaspecies.Inconclusion,ourresultssuggestthattheTTPmaybeausefultoolintheevaluationofpatientswithcandidemiawhohaveanindwellingCVC,andinselectedcases,itmaysupportadecisiontoretainthecatheter.DISCUSSION現在是52頁\一共有59頁\編輯于星期二Timetopositivity

of

bloodcultures

of

differentCandidaspeciescausingfungaemia

ThemeanTTPforallisolatescausingcandidaemiawas25.9±24.9h.TheTTPforC.glabratawassignificantlylongerthantheTTPoftheotherspecies.Incontrast,theTTPofC.tropicaliswassignificantlyshorterthanthatoftheotherthreespecies.JMedMicrobiol.

2012

May;61(Pt5):701-4No.ofvialswithpositiveculturesTTP(hr)means+_SDCandidaalbicans8334.2+25.1Candidatropicalis4116.9+7.7Candidaglabrata3356.5+25.5Candidaparapsilosis1438.9+17.1現在是53頁\一共有59頁\編輯于星期二TimetopositivityofdifferentCandidaspeciesEurJClinMicrobiolInfectDis.

2013Feb1.

DepartmentofClinicalLaboratory,PekingUniversityFirstHospital,Beijing,China現在是54頁\一共有59頁\編輯于星期二1996-2005,Theappropriatenessofinitialantimicrobialtherapy,theclinicalinfectionsite,andrelevantpathogenswereretrospectivelydeterminedfor5,715patientswithsepticshockinthreecountries.Inappropriat