ICU患儿肺部真菌感染的危险因素分析及对策

目的 分析重症监护病房患儿肺部真菌感染的危险因素,探讨控制对策及治疗措施.方法 采用回顾性调查方法对2003年1月--2007年2月PICU收治的1 057例危重症患儿进行调查,对肺部真菌感染率、感染相关危险因素、病原学特点及预防控制、治疗效果进行分析.结果 发生肺部真菌感染48例,PICU肺部真菌感染发生率为4.54%,肺部真菌感染的相关危险因素主要有住院时间长、短期内反复住院、使用广谱抗生素、肾上腺皮质激素及免疫抑制剂的应用、机械通气及溺粪.病原菌主要有白色念珠菌、光滑念珠菌、热带念珠菌、克柔念珠菌、曲霉菌、毛霉菌等.经抗真菌治疗治愈28例(58.3%),显效9例(18.8%),无效10例(20.8%),放弃治疗1例(2.1%).结论 PICU患儿肺部真菌感染的发生与多种易感因素有关;合理使用抗生素、慎用.肾上腺皮质激素、加强消毒隔离措施等是降低PICU患儿发生肺部真菌感染的关键;认识患儿发生真菌感染的易感因素、早期诊断、合理使用抗真菌药,是治愈儿童肺部真菌感染的关键.     

儿科重症监护病房鲍曼不动杆菌感染的危险因素与耐药性分析

目的了解儿童重症监护病房(PICU)鲍曼不动杆菌感染的危险因素及耐药情况。方法总结2006年1月至2011年9月PICU中99例鲍曼不动杆菌感染患儿的资料,对鲍曼不动杆菌感染的发生率、发生时间及感染部位进行分析,了解PICU鲍曼不动杆菌感染的危险因素及耐药情况。结果 PICU共收治危重患儿4 762例,鲍曼不动杆菌感染患儿99例,发生率为2.08%(99/4762),死亡14例,病死率14.14%(14/99)。发生鲍曼不动杆菌的时间为入PICU后(12.4±9.3)d。主要为肺部感染93例(93.94%);伤口感染4例(4.04%);尿路感染2例(2.02%)。发生鲍曼不动杆菌感染的危险因素为长期使用广谱抗生素、儿童危重病例评分低、机械通气及留置导尿管。近三年(2009—2011年)耐药水平比前三年(2006—2008年)有明显上升趋势。结论鲍曼不动杆菌易引起院内感染,主要为肺部感染,且耐药性明显上升。应加强抗生素的合理应用、加强病区的管理和侵入性操作时的无菌管理。     

儿童支气管哮喘合并肺部真菌感染的临床特征及危险因素分析

目的 探讨儿童支气管哮喘合并肺部真菌感染的临床特征，并分析支气管哮喘患儿继发肺部真菌感染的危险因素。方法 回顾性分析2015年1月至2018年6月收治的发生肺部真菌感染（真菌感染组）和未伴肺部真菌感染（对照组）的支气管哮喘患儿各75例的临床资料。记录真菌感染组病原菌分布、临床症状及体征、治疗结局等情况，并采用多因素logistic回归分析肺部真菌感染的危险因素。结果 75例真菌感染组患儿中，共检出69株病原体，其中白色假丝酵母菌检出率最高（61%）。患儿临床症状以咳嗽（93%）、持续高热（56%）、喘息（49%）、呼吸困难（48%）为主；体征则以干湿啰音（43%）、湿啰音（29%）居多，部分患儿伴肝脾肿大。经抗真菌治疗后显效39例，好转26例，无效7例，恶化并死亡3例。多因素logistic回归分析显示，年龄 < 3岁、合并鼻窦炎和/或过敏性鼻炎、住院期间哮喘发作 > 3次、静脉应用糖皮质激素、不规范使用抗生素、机械通气及住院时间长均为哮喘患儿发生肺部真菌感染的独立危险因素（分别OR=4.865、3.241、2.255、3.725、3.568、1.549、3.808，P < 0.05）。结论 对于支气管哮喘患儿，若表现为咳嗽、持续高热，有明显干湿啰音，并合并有肝脾肿大，需高度警惕是否继发肺部真菌感染。年龄 < 3岁、有鼻窦炎和/或过敏性鼻炎、住院期间哮喘发作 > 3次、静脉应用糖皮质激素、不规范使用抗生素、机械通气或住院时间长的支气管哮喘患儿继发真菌感染的风险较高。     

儿科重症监护病房院内侵袭性真菌血流感染21例临床分析

目的 提高对侵袭性真菌感染（invasive fungal infection,IFI）的认识,帮助早期诊断、早期治疗,积极改善预后。方法　选取2012年1月至2018年1月于中国医科大学附属盛京医院儿科重症监护病房（PICU）住院,临床诊断IFI血流感染的21例患儿为研究对象,回顾性分析其临床特点、高危因素及预后。结果　临床诊断IFI血流感染的21例患儿中,真菌感染的发生与年龄性别无明显相关性,致病菌以白色念珠菌及近平滑假丝酵母菌为主,近平滑假丝酵母菌病死率较高（80%）;21例真菌血流感染的患儿,28 d随访存活8例,死亡13例,病死率高达61.90%;原发病以呼吸系统（14.29%）、消化系统疾病（23.81%）居多,其中重症肺炎4例,消化道穿孔4例;高危因素主要以广谱抗生素联合应用、侵入性操作（气管插管、中心静脉置管、导尿及留置胃管等）、长期ICU住院等为著,均在85%以上。真菌感染多表现为不典型发热（80.95%）,白细胞异常升高或降低（47.62%）,C反应蛋白多升高（80.95%）,G试验的阳性率可达到42.86%;存活组的8例患儿诊断真菌感染前75%预防性应用抗真菌治疗,死亡组预防用药率为53.85%。结论　长期ICU住院、大量广谱抗生素的长期及联合应用、侵入性操作、自身免疫缺陷等因素的存在增加了真菌感染的风险,对于临床原发病基础上出现不典型难治感染,要警惕真菌感染,应积极完善相关微生物学检查。     

儿童重症监护病房侵袭性真菌感染的临床特点

目的探讨儿童重症监护病房(PICU)侵袭性真菌感染(IFI)的临床特点及危险因素。方法回顾性分析2009年5月-2011年5月本院PICU收治的41例IFI患儿的临床资料,总结其易感因素、临床表现、辅助检查、治疗及预后。结果 PICU共收治患儿2 013例,其中41例发生IFI,发生率为2.04%;死亡8例,病死率为19.51%。其中84.6%为念珠菌属。感染部位:呼吸系统29例,消化系统4例,泌尿系统3例,中枢神经系统3例,血液系统2例。危险因素有危重症评分、机械通气、中心静脉置管、尿管留置。易感因素有广谱抗生素应用、激素、低蛋白血症、化疗等。结论念珠菌属是PICU发生IFI的主要病原,合理使用抗生素、限制激素应用、减少或缩短不必要的侵入性操作及合理使用抗真菌药物,是降低IFI发病率、提高抢救成功率的有效策略。     

儿童肺部侵袭性真菌感染危险因素分析

目的 分析儿童肺部侵袭性真菌感染发生的危险因素.方法 收集2009年1月至2012年12月在我院PICU住院的51例肺部侵袭性真菌感染患儿的病历资料,对肺部真菌感染的危险因素包括危重症评分、机械通气天数、使用抗生素及激素情况等进行分析.结果 肺部侵袭性真菌感染的发生率随着危重症评分的降低逐渐升高（P＜0.05）.肺部侵袭性真菌感染在未予机械通气治疗、机械通气治疗时间在7d以内、机械通气时间在7d以上的患儿中发生率分别为0.002％、6.944％、18.579％ （P ＜0.05）,真菌感染的发生率与机械通气的时间相关.肺部侵袭性真菌感染在未使用抗生素、抗生素使用时间在14 d以内、抗生素使用时间在14 d以上的患儿中发生率分别为0、2.884％、8.904％ （P ＜0.05）;肺部侵袭性真菌感染在未使用激素、激素使用时间在7d以内,激素使用时间在7d以上的患儿中发生率分别为0.007％、5.782％、14.573％ （P ＜0.05）.结论 真菌感染的发生率随着抗生素及激素使用天数的增加而呈上升趋势.合理使用抗生素、激素,缩短机械通气时间可减少肺部侵袭性真菌感染的发生.     

儿童铜绿假单胞菌医院获得性肺炎临床特点及危险因素分析

目的 探讨儿童铜绿假单胞菌医院获得性肺炎(HAP)临床特点及危险因素.方法 回顾性分析重庆医科大学附属儿童医院15例铜绿假单胞菌HAP患儿临床资料.结果 铜绿假单胞菌HAP发病时间距入院 6 ～ 38 d,平均(15.07 ± 9.63)d;临床均以发热起病,热程长短不一,平均(15.13 ± 11.51)d,病程中易出现呼吸衰竭,常累及其他系统(以消化系统为首位,其次为循环系统).先天性心脏病根治术为铜绿假单胞菌HAP首位原发疾病(46.67%).铜绿假单胞菌HAP危险因素有侵入性操作(100%),ICU停留时间＞ 4 d(80%),广谱抗生素使用＞ 1周(53.33%),手术创伤(66.67%)等;侵入操作以气管插管及安置胃管常见,分别占86.67%、80%.15例患儿中痊愈7例(46.67%),好转出院5例(33.33%),死亡2例(13.33%).结论 儿童铜绿假单胞菌HAP易发展为重症,先天性心脏病根治术为其首位原发疾病,侵入操作、ICU停留时间＞ 4 d、广谱抗菌素的使用＞ 1周、手术创伤等为其常见危险因素.     

儿童念珠菌感染138例临床特征分析

目的 了解儿童念珠菌感染的临床特征.方法 回顾性分析2003-2005年138例念珠菌培养阳性的住院儿童的临床资料.按1:1比例选择年龄和性别相似、同期住院的念珠菌培养阴性患儿作为对照.危险因素分析应用SAS6.12统计软件计算.结果 3年念珠菌培养阳性率分别为0.43%、0.50%和0.79%.气管内吸出物和支气管肺泡灌洗液(BALF)培养阳性34例(24.6%),深部鼻咽吸出物培养阳性94例(68.1%),血培养阳性10例(7.2%).气管插管机械通气25例(18.1%);静脉插管13例(9.4%);全静脉营养11例(8.0%).抗生素使用率为100%,平均使用种类为(3.03±1.89)种;第三代头孢菌素使用率56.7%.抗生素平均使用时间15.5 d.使用全身糖皮质激素33例(23.9%).结论 儿童念珠菌感染的发病率有所增加.秋冬季阳性率较高可能与儿童呼吸道疾病发病率增高和环境真菌数量增多有关.粒细胞减少症、营养不良等基础疾病,广谱抗生素、糖皮质激素和侵入性诊疗措施等均为念珠菌感染的危险因素.     

儿童重症监护病房侵袭性真菌感染38例临床分析

目的：探讨儿童重症监护病房（PICU）侵袭性真菌感染（IFI）的临床特征,为其有效防治提供依据。方法：回顾性分析38例IFI患儿的临床特征及治疗转归情况。结果：38例患儿中,以呼吸道感染最多见（89%）;感染前均有较严重的基础疾病,且使用过多种抗生素,其中碳青霉烯类抗生素使用率高达95%;47%患儿曾全身激素治疗;所有患儿均有侵入性操作史,其中47%患儿接受过气管插管及机械通气治疗;所有患儿临床症状及体征不典型,影像学检查无特异性。真菌培养共检出致病真菌56株,以白色念珠菌为主（41%）,其次为曲霉菌（25%）和毛霉菌（20%）;所有患儿及时予以高效抗真菌药物治疗,治愈15例,好转16例,有效率为82%,不良反应发生率为16%。结论：呼吸道为最常见IFI感染部位;白色念珠菌为主要病原;多数患儿有严重基础疾病、广谱抗生素及糖皮质激素的使用史和侵入性操作史;早期诊断、及时使用高效抗真菌药物可改善预后。     

儿童侵袭性肺部真菌感染危险因素分析

目的 分析发生侵袭性肺部真菌感染（IPFI）的危险因素,为早期防治IPFI 提供理论依据。方法 采用回顾性病例对照研究方法,对2012 年1 月至2013 年3 月儿科重症监护病房住院的48 例符合IPFI临床诊断的患儿和同期住院的不符合IPFI 临床诊断的106 例肺炎患儿的临床资料进行对照分析,应用非条件多因素logistic 回归分析明确IPFI 发生的主要危险因素。结果 真菌感染组的平均年龄、血清白蛋白水平低于非真菌感染组（PPP结论 临床怀疑婴幼儿IPFI 而相关病原学检查困难,如果存在有创机械通气、腹泻、长时间使用广谱抗生素和糖皮质激素、低血清白蛋白血症等高危因素时,应及时考虑IPFI 的可能,尽早开展经验性抗真菌治疗。     

Invasive candidiasis in pediatric intensive care units

Candidemia and disseminated candidiasis are major causes of morbidity and mortality in hospitalized patients especially in the intensive care units (ICU). The incidence of invasive candidasis is on a steady rise because of increasing use of multiple antibiotics and invasive procedures carried out in the ICUs. Worldwide there is a shifting trend from C. albicans towards non albicans species, with an associated increase in mortality and antifungal resistance. In the ICU a predisposed host in one who is on broad spectrum antibiotics, parenteral nutrition, and central venous catheters. There are no pathognomonic signs or symptoms. The clinical clues are: unexplained fever or signs of severe sepsis or septic shock while on antibiotics, multiple, non-tender, nodular erythematous cutaneous lesions. The spectrum of infection with candida species range from superficial candidiasis of the skin and mucosa to more serious life threatening infections. Treatment of candidiasis involves removal of the most likely source of infection and drug therapy to speed up the clearance of infection. Amphotericin B remains the initial drug of first choice in hemodynamically unstable critically ill children in the wake of increasing resistance to azoles. Evaluation of newer antifungal agents and precise role of prophylactic therapy in ICU patients is needed.     

儿童重症监护病房侵袭性真菌感染危险因素分析

目的 分析儿童重症监护病房(PICU)侵袭性真菌感染的特点及危险因素.方法 总结2007年至2009年我院PICU收治的35例发生侵袭性真菌感染患儿的临床资料,对真菌感染危险因素进行分析,包括危重病例评分、机械通气、导尿管和胃管置入、床旁血液净化治疗等.结果 (1)3年间PICU共收治危重患儿2 116例,其中35例发生真菌感染,发生率为1.65%(35/2 116),其中死亡7例,病死率为20.00%(7/35).(2)发生真菌感染的平均时间为人院后(10.4±8.3)d,主要表现为肺炎21例(60.0%),腹膜炎5例(14.3%),尿路感染4例(11.4%),肠道感染3例(8.6%),败血症1例(2.9%),脑膜炎1例(2.9%).(3)儿童危重病例评分低、机械通气、留置胃管及导尿管、连续性静脉血液透析滤过是引起真菌感染的危险因素.(4)致病菌以白色念珠菌为主.结论 侵袭性真菌感染已成为PICU主要的院内感染,白色念珠菌是主要致病菌.合理利用抗生素、减少不必要的侵入性操作、及时使用抗真菌药,可能是应对侵袭性真菌感染的有效策略.

Abstract：

Objective To analyze the incidence,clinical feature and the risk factors of invasive fungal infection in pediatric intensive care unit (PICU). Methods We retrospectively summaried the invasive fungal infection in our PICU from Jan 2007 to Dec 2009 in order to analyze the incidence, clinical feature and the risk factors of invasive fungal infection in PICU. Multiple clinical data were collected such as pediatric critical illness score, mechanical ventilation, urinary drainage tube, indwelling gastric canal and continuous blood purification. Results ( 1 ) The incidence rate of invasive fungal infection was 1.65 % ( 35/2 116 ). The morbidity was 20. 00% ( 7/35 ). ( 2 ) Mean infected day was ( 10. 4 ±- 8. 3 ) d after admission. The clinical manifestations included fungal pneumonia( 60. 0% ), peritonitis ( 14. 3% ), urinary tract infection ( 11.4% ),intestinal tract infection(8. 6% ) ,sepsis(2. 9% ) and meningitis(2. 9% ). All of the patients had used broad spectrum antibiotic. (3) The risk factors of invasive fungal infection included lower pediatric critical illness score, mechanical ventilation, indwelling gastric tube, urinary drainage tube and continuous blood purification.(4) Candia albicans was the predominant pathogen in invasive fungal infection. Conclusion Invasive fungal infection has become one of the main nosocomial infection in PICU. Lung is most commonly involved and candida albicans is the major pathogen. Using antibiotics appropriately, decreasing unnecessary invasive performance,and rationally using antifungal agent mi.ght be effective strategy for invasive fungal infection in PICU.     

New therapeutic options for invasive fungal diseases

Invasive fungal infections are increasing in prevalence because of modern support for immunocompromised patients allowing longer survivial times. The risk of fungal infection has also increased because of the use of broad spectrum of antibiotics in this patient population, and the intensity and duration of immunosuppression. The list of antifungal options has expanded with renewed interest in these infections with high morbidity and mortality. Amphotericin B deoxycholate has been and continues to be the mainstay of antifungal agents. Lipid formulations of amphotericin that improve the serum and the tissue level of amphotericin B while decreasing toxicity are being increasingly used. Imidazoles, including fluconazole and itraconazole, have reduced toxicities in comparison with amphotericin B deoxycholate, but their spectrum activity is limited. Echinocandins, including caspofungin and new investigational agents with unique mechanisms of action, offer great promise as antifungal agents either alone or in a combination agent with amphotericin B. Antifungal strategies and antifungal resistance in relationship to clinical outcomes are also discussed. Copyright © 2001 by W.B. Saunders Company     

Invasive fungal infection in children undergoing chemotherapy for cancer

BACKGROUND: In children with cancer, invasive fungal infection is a serious complication of anticancer therapy. Successful treatment is a major challenge for clinical oncologists. METHODS: The records of all episodes of invasive fungal infection occurring in children with cancer undergoing chemotherapy at Mackay Memorial Hospital, Taipei between January 1987 and October 2005 were reviewed. The following were documented: general characteristics, clinical presentation, predisposing factors, pathogens, antifungal treatment, association with anticancer therapy and outcome. We endeavoured to preserve renal function by administration of new antifungal agents. Anticancer therapy was given as soon as possible after diagnosis and the dose of chemotherapeutic agents was adjusted as required to prevent unduly prolonged interruption of chemotherapy and minimise the risk of leukaemia relapse. RESULTS: Twenty-six patients with 29 episodes of invasive fungal infection were reviewed. Candida species were the leading pathogens (14/29) followed by Aspergillus species (11/29). In six episodes there was both visceral dissemination and fungaemia. In 23/29 patients, antibiotic therapy preceded fungal infection with a median of 11 days. Three children died from extensive fungal infection and four from progression of malignancy; the remainder survived with a median follow-up of 40 months (range 12-233). The actuarial 12-month survival rate was 87%; in patients with invasive candidiasis and aspergillosis the rates were 75% and 100%, respectively. CONCLUSIONS: In children with cancer, most invasive fungal infections can be treated successfully. Current antifungal prophylaxis should protect patients from fungal infection.     

Prevention and treatment of invasive fungal infection in very low birthweight infants

Invasive fungal infection is an important cause of mortality and morbidity in very low birthweight (VLBW) infants. Extremely preterm and extremely low birthweight infants are at highest risk because of the intensive and invasive nature of the care that these infants receive. Additional specific risk factors include prolonged use of parenteral nutrition and exposure to broad-spectrum antibiotics and histamine type 2 receptor blockers. Diagnosis is difficult and often delayed, and this may contribute to the high levels of deep-organ dissemination and associated mortality and morbidity. The most commonly used antifungal agents are amphotericin B and fluconazole. Recent research has assessed the value of early empirical and prophylactic treatment. However, although systemic antifungal prophylaxis reduces the incidence of invasive fungal infection, there is no evidence of effect on mortality. Concern exists about the impact that widespread use of prophylaxis may have on the emergence of antifungal resistance.     

儿科抗真菌药物的合理使用

近20年来，随着广谱抗菌药物、免疫抑制剂、激素、抗肿瘤药物和靶向生物制剂的广泛应用以及真菌检测方法的不断改进，儿童侵袭性真菌病的发病率呈逐年上升趋势，侵袭性真菌病成为免疫低下儿童的主要死亡原因之一。除了原发性免疫缺陷、肿瘤、造血干细胞移植、实体器官移植及获得性免疫缺陷综合征病毒（HIV）感染等，婴幼儿本身也是真菌感染的高危因素。因此早期诊断、及时应用有效抗真菌药是挽救患儿生命的重要措施。儿童作为特殊人群，抗真菌药物的选择和剂量与成人不同，该文主要探讨如何选择合适的抗真菌药物来预防和治疗儿童真菌病。