课件：真菌疾病的诊断和治疗.ppt

* 酵母菌的鉴定以生物化学检测为基础 * 抗体检测只有推定证据，尤其是IgG，IgM常考虑近期感染。对于念珠菌等正常菌群尤其如此。只有抗体效价非常高，或者两次化验明显升高，才有意义。 用于抗原检测的方法比较可靠。如乳胶凝集试验检测隐球菌、念珠菌、组织胞浆病等。 * * * Recipients of hematopoetic stem cell transplantation for hematological malignancies are among the highest risk patients we see at our hospital. The most common infections are Candida and Aspergillus, followed closely by other moulds such as zygomycetes (Mucor, Rhizopus, Rhizomucor, Cunninghamella). In patients with persistently suppressed lymphocyte counts Cryptococcus can also occur, typically as a focal pneumonia but occasionally as a bloodstream infection or meningitis. PCP pneumonia and severe infections with endemic mycosis can also be encountered in patients with pronounced lymphopenia due to HIV infection. * * * 侵袭性真菌感染的高发病率有所上升的主要原因是医疗技术手段的进步，尤其是针对危重患者13,14 下列情况下，侵袭性真菌感染将会很普遍13,14 当患者免疫功能受抑制时 (例如：中性粒细胞减少患者或者实质器官移植受者) 当胃肠道功能受损时 (例如：手术、外伤或者化疗) 当解剖学屏障不能发挥作用时 (例如： 留置导管或机械通气) 当正常菌群被破坏时 (例如： 应用广谱抗生素) 意识到侵袭性真菌感染的危险因素对于筛选出需要抗真菌治疗的患者是非常主要的13,14 多中心国家霉菌病流行病学调查 (NEMIS)是最大的前瞻性研究，用来确定外科和新生儿重症监护病房患者发生念珠菌血液感染的危险因素13 以前的评价危险因素的研究有局限性，包括：采用单中心的陈旧数据，不是前瞻性研究，另外几乎没有研究关注外科重症监护病房患者13 在NEMIS中，与念珠菌血液感染独立相关的危险因素包括：急性肾功能衰竭，胃肠外营养和之前手术史。中性粒细胞减少并不是独立危险因素13 * * One of the major challenges in the management of invasive candidiasis is establishing an early and accurate diagnosis of infection. While Candida are not difficult to culture from body sites, especially in a patient on broad spectrum antibiotics, frequently this is colonization and does not represent a true invasive infection. However, in some cases colonization of the urine, sputum, or wounds may provide clues of an impending infection. The key question then remains, when do we start therapy. In many high-risk patients, waiting until there is yeast in the blood will be associated with excess deaths, as we know that crude mortality rates for patients once yeast is identified in the bloodstream approach 40%. For this reason, antifungal therapy is often started empirically for Candida- for