真菌性脓毒症诊治进展

TheEpidemiologyofSepsisintheUnitedStatesfrom1979through2000NEnglJMed2003;348:1546-1554现在是1页\一共有59页\编辑于星期二Long-termmortalityandmedicalcarechargesinpatientswithseveresepsis.CritCareMed.

2003

Sep;31(9):2316-23.Cumulativemortalityrateamongpatientswithseveresepsis现在是2页\一共有59页\编辑于星期二DistributionofvariousmicroorganismsandsitesofinfectioninseveresepsispatientsandtheoutcomeaccordingtothemicroorganismsandsitesofinfectioninseveresepsispatientsCritCareMed2007;35:2538-2546EpidemiologyofseveresepsisincriticallyillsurgicalpatientsintenuniversityhospitalsinChina现在是3页\一共有59页\编辑于星期二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;现在是4页\一共有59页\编辑于星期二2004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。现在是5页\一共有59页\编辑于星期二2008201211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篇参考文献现在是6页\一共有59页\编辑于星期二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/SCCM1992Definitionsforsepsisandorganfailureandguidelinesfortheuseofinnovativetherapiesinsepsis现在是7页\一共有59页\编辑于星期二NewdiagnosticCriteriaforSepsis:2012CritCareMed.2013Feb;41(2):580-637.现在是8页\一共有59页\编辑于星期二NewdiagnosticCriteriaforSepsis:2012CritCareMed.2013Feb;41(2):580-637.现在是9页\一共有59页\编辑于星期二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”现在是10页\一共有59页\编辑于星期二Onecase:女性，85岁，住院号：22600732013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。现在是11页\一共有59页\编辑于星期二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

现在是12页\一共有59页\编辑于星期二入科诊断：重症医院获得性肺炎(吸入性)；感染性休克？；呼吸衰竭(Ｉ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）现在是13页\一共有59页\编辑于星期二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.现在是14页\一共有59页\编辑于星期二ANCA：C-ANCA（-）及P-ANCA（-）尿常规：阴性现在是15页\一共有59页\编辑于星期二4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）?现在是16页\一共有59页\编辑于星期二转入后检查复查床边胸片无明显进展性改变。现在是17页\一共有59页\编辑于星期二Itisaclinicalsyndromeinwhichfocalinfiltratesbeginwithsomeclinicalassociationofacutepulmonaryinfection(i.e.fever,expectoration,malaise,ordyspnea)anddespiteaminimumof10daysofantibiotictherapypatientseitherdonotimproveorworsenclinicallyorradiographicopacitiesfailtoresolvewithin12weeksoftheonsetofthepneumonia.Nonresolvingpneumonia（无反应性肺炎）CurrOpinPulmMed.

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

nonresolving

pneumonia.Nonresolvingpneumoniadefinitions（无反应性肺炎）Failuretorespondtoantimicrobialtreatmentwasclassifiedasnonrespondingorprogressivepneumonia.Nonrespondingpneumoniawasdefinedaspersistingfever＞38℃and/orclinicalsymptoms(malaise,cough,expectoration,dyspnea)afteratleast72hofantimicrobialtreatment.现在是18页\一共有59页\编辑于星期二Antimicrobialtreatmentfailuresinpatientswithcommunity-acquiredpneumonia:causesandprognosticimplications.AmJ

Respir

Crit

Care

Med.

2000

Jul;162(1):154-60.444patients,49patients(11%)hadarepeatedinvestigationbecauseofantimicrobialtreatmentfailure.Considerationswhenapatientwithcommunity-acquiredpneumoniaisnotimproving现在是19页\一共有59页\编辑于星期二1、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：无反应性肺炎现在是20页\一共有59页\编辑于星期二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现在是21页\一共有59页\编辑于星期二Results：Thefollowingshowedtheprevalenceratesofthecauses:infection41.7%,unknowncauses50.0%,non-infectiouscauses8.3%．DiagnosisandTreatmentofNonrespondingPneumoniaPatientsPJCCPVDJanuary2012,Vol,20No.1（顾靖华）现在是22页\一共有59页\编辑于星期二进一步完善相关检查现在是23页\一共有59页\编辑于星期二重症医学科(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现在是24页\一共有59页\编辑于星期二NEnglJMed2003;348:1546-1554TheEpidemiologyofSepsisintheUnitedStatesfrom1979through2000IntJAntimicrobAgents.2008;32:S87-91Epidemiologyofcandidemiainintensivecareunits现在是25页\一共有59页\编辑于星期二外周静脉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/mlThe

University

of

Virginiariskfactorsscoringsystem：36现在是26页\一共有59页\编辑于星期二NosocomialBloodstreamInfectionsinUSHospitals:Analysisof24,179CasesfromaProspectiveNationwideSurveillanceStudy.ClinInfectDis.

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

现在是27页\一共有59页\编辑于星期二107(39.5%)patientswithisolatedcandidemia,77(28.4%)withinvasivecandidiasis.In37%ofthecases,candidemiaoccurredwithinthefirst5daysafterICUadmission.CritCareMed.

2009

May;37(5):1612-8OnehundredeightyICUsinFrance现在是28页\一共有59页\编辑于星期二AnnSurg.

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

PelzRK,

HendrixCW,

SwobodaSM,

现在是29页\一共有59页\编辑于星期二IntJAntimicrobAgents.

2009

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

ticentermatchedcohortstudyincriticallyillsurgicalpatients现在是32页\一共有59页\编辑于星期二OutcomesofcandidemicsepticshockpatientscomparedwithbacteremicsepticshockpatientsCritCareMed.2002Aug;30(8):1808-14.现在是33页\一共有59页\编辑于星期二InternationalGuidelinesforManagementofSevereSepsisandSepticShock:2012whatactuallychangedaboutfungus?现在是34页\一共有59页\编辑于星期二Useofthe1,3beta-D-glucanassay(grade2B),mannanandanti-mannanantibodyassays(2C).Change1:Diagnosis现在是35页\一共有59页\编辑于星期二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现在是36页\一共有59页\编辑于星期二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.现在是37页\一共有59页\编辑于星期二Change2:DiagnosisUseoflowprocalcitoninlevelsorsimilarbiomarkerstoassisttheclinicianinthediscontinuationofempiricantibioticsinpatientswhoinitiallyappearedseptic,buthavenosubsequentevidenceofinfection(grade2C).DiagnMicrobiolInfectDis.2012Jul;73(3):221-7现在是38页\一共有59页\编辑于星期二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现在是39页\一共有59页\编辑于星期二Clinicalexperienceswithanewsemi-quantitativesolidphaseimmunoassayforrapidmeasurementof

procalcitonin.ClinChemLabMed.

2000Oct;38(10):989-95.现在是40页\一共有59页\编辑于星期二CritCareMed.

2006Jul;34(7):1996-2003.GlobaldiagnosticaccuracyoddsratiosforprocalcitoninProcalcitoninasadiagnostictestforsepsisincriticallyilladultsandaftersurgeryortrauma:asystematicreviewandmeta-analysisReviewArticle现在是41页\一共有59页\编辑于星期二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.现在是42页\一共有59页\编辑于星期二SerumlevelsofC-reactiveprotein(CRP)andprocalcitonin(PCT)onthestudieddaysaccordingtothepresenceofinvasivefungalinfection(IFI)orbacterialinfection(BI).EurJClinMicrobiolInfectDis.

2005

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

2005

Apr;24(4):272-5.Valueofmeasuringserumprocalcitonin,C-reactiveprotein,andmannanantigenstodistinguishfungalfrombacterialinfections成也萧何，败也萧何现在是44页\一共有59页\编辑于星期二EurJClinInvest.2008Oct;38(10):784-5Acuteinfluenceofaerobicphysicalexerciseonprocalcitonin马拉松也能升高PCT现在是45页\一共有59页\编辑于星期二Change2:DiagnosisUseoflowprocalcitoninlevelsorsimilarbiomarkerstoassisttheclinicianinthediscontinuation

ofempiricantibioticsinpatientswhoinitiallyappearedseptic,buthavenosubsequentevidenceofinfection(grade2C).DiagnMicrobiolInfectDis.2012Jul;73(3):221-7现在是46页\一共有59页\编辑于星期二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.现在是47页\一共有59页\编辑于星期二Lancet.

2010

Feb6;375(9713):463-74

现在是48页\一共有59页\编辑于星期二Change3:DiagnosisTimetopositivityofbloodculture(TTP)canpredictdifferentCandidaspeciesinsteadofpathogenconcentrationincandidemia现在是49页\一共有59页\编辑于星期二JClinMicrobiol.

2008

Jul;46(7):2222-6Timetobloodculturepositivityasamarkerforcatheter-relatedcandidemia现在是50页\一共有59页\编辑于星期二Timetobloodculturepositivityasamarkerforcatheter-relatedcandidemiaAccuracyofaTTPcutoffof30hforthediagnosisofCRCin50patientswithindwellingCVCsJClinMicrobiol.

2008

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

ThetimetodetectionofC.glabratawassignificantlylongerthanforotherCandidaspecies.Inconclusion,ourresultssuggestthattheTTPmaybeausefultoolintheevaluationofpatientswithcandidemiawhohaveanindwellingCVC,andinselectedcases,itmaysupportadecisiontoretainthecatheter.DISCUSSION现在是52页\一共有59页\编辑于星期二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现在是53页\一共有59页\编辑于星期二TimetopositivityofdifferentCandidaspeciesEurJClinMicrobiolInfectDis.

2013Feb1.

DepartmentofClinicalLaboratory,PekingUniversityFirstHospital,Beijing,China现在是54页\一共有59页\编辑于星期二1996-2005,Theappropriatenessofinitialantimicrobialtherapy,theclinicalinfectionsite,andrelevantpathogenswereretrospectivelydeterminedfor5,715patientswithsepticshockinthreecountries.Inappropriat