异基因造血干细胞移植后侵袭性真菌感染及其危险因素分析

本研究分析异基因造血干细胞移植（allo—HSCT）后患者侵袭性真菌感染（IFI）的发生及其高危因素。选择自2000年1月至2007年3月在我院行allo—HSCT患者180例，随访至2007年10月31日，用Kaplan—Meier和Cox回归模型方法，分析了IFI的发生率及其相关的危险因素。结果表明，35例（19、5％）患者在HSCT后发生了IFI，确诊1例，临床诊断34例；其中曲霉菌感染18例（51、4％），念珠菌感染17例（48．6％）。IFI组1年的存活率为34．3％．无IFI组1年的存活率为53．8％，存在显著性差异。在单因素分析中，与IFI的发生率增加有关的因素包括移植前真菌定植或感染、非血缘供者allo—PBHSC或allo—BMHSC移植、急性GVHD发生、广泛性慢性GVHD、应用甲基泼尼松龙。在多因素分析时，非血缘供者异基因外周血或骨髓干细胞移植、急性GVHD发生及移植前真菌感染或定植使IFI发生危险增加（RR分别为：1．589、2、399、1．410）。结论：IFI是allo—HSCT的常见并发症，也是主要致死原因之一，对移植前真菌感染或定植、非血缘供者allo-PBHSC或allo—BMHSC移植及发生急性GVHD的高危患者有必要早期采取干预性治疗。     

重症监护病房患者真菌感染的观察

目的：观察研究重症监护室(ICU)的院内真菌感染的易感因素和防治措施。方法：对复旦大学附属华山医院ICU2003年1月～2003年8月179例患者共612份临床标本进行分离培养。分析真菌感染易感因素及防治对策。结果：179例患者中发生医院真菌感染35例，为19．5％。病情危重，长期应用抗生素、激素及侵袭性操作均是真菌感染的因素。结论：真菌感染的防治应积极消除诱发因素，早期诊断和治疗。     

高血糖在危重症患儿病情发展及预后中的意义

目的 研究高血糖在危重症患儿病情发展及预后中的意义.方法 以145例危重症患儿为研究对象,以入院24h内血糖监测的最高值为分组标准,Glu≤6.1 mmol·L-1为血糖正常组38例,6.1 mmol· L-1＜Glu≤10.0 mmol· L-1为血糖轻度升高组67例,Glu＞10.0 mmol·L-1为重度升高组40例,比较3组入院时的小儿危重病例评分(PCIS)和全身性感染相关性器官功能衰竭评分(SOFA)、实验室指标、ICU住院时间及死亡率.结果 对比PCIS及SOFA评分,重度升高组(81.68±8.16)分、(7.14±2.84)分与轻度升高组(86.57±6.92)分、(5.95±2.68)分及正常组(86.24±6.57)分、(5.52±2.61)分比较差异均有统计学意义(均P＜0.05),轻度升高组与正常组比较差异均无统计学意义(均P＞0.05).比较3组实验室指标(感染性指标、肝肾功能及心肌酶),重度升高组与轻度升高组及正常组各值比较差异均有统计学意义(均P＜0.05),轻度升高组与正常组各值比较差异均无统计学意义(均P＞0.05).对比3组ICU住院时间,重度升高组(11.7±4.9)d与轻度升高组及正常组比较差异均有统计学意义(均P＜0.05),轻度升高组与正常组比较差异无统计学意义(P＞0.05).对比3组死亡率,重度升高组(35％)与轻度升高组及正常组比较差异均有统计学意义(均P＜0.05),轻度升高组与正常组比较差异无统计学意义(P＞0.05).结论 危重患儿血糖升高与病情严重程度及预后密切相关,对其行血糖监测具有重要临床意义.     

Population Pharmacokinetics of Doripenem in Critically Ill Patients with Sepsis in a Malaysian Intensive Care Unit

Doripenem has been recently introduced in Malaysia and is used for severe infections in the intensive care unit. However, limited data currently exist to guide optimal dosing in this scenario. We aimed to describe the population pharmacokinetics of doripenem in Malaysian critically ill patients with sepsis and use Monte Carlo dosing simulations to develop clinically relevant dosing guidelines for these patients. In this pharmacokinetic study, 12 critically ill adult patients with sepsis receiving 500 mg of doripenem every 8 h as a 1-hour infusion were enrolled. Serial blood samples were collected on 2 different days, and population pharmacokinetic analysis was performed using a nonlinear mixed-effects modeling approach. A two-compartment linear model with between-subject and between-occasion variability on clearance was adequate in describing the data. The typical volume of distribution and clearance of doripenem in this cohort were 0.47 liters/kg and 0.14 liters/kg/h, respectively. Doripenem clearance was significantly influenced by patients'' creatinine clearance (CL_CR), such that a 30-ml/min increase in the estimated CL_CR would increase doripenem CL by 52%. Monte Carlo dosing simulations suggested that, for pathogens with a MIC of 8 mg/liter, a dose of 1,000 mg every 8 h as a 4-h infusion is optimal for patients with a CL_CR of 30 to 100 ml/min, while a dose of 2,000 mg every 8 h as a 4-h infusion is best for patients manifesting a CL_CR of >100 ml/min. Findings from this study suggest that, for doripenem usage in Malaysian critically ill patients, an alternative dosing approach may be meritorious, particularly when multidrug resistance pathogens are involved.     

热带地区急性白血病患者侵袭性真菌感染的临床特点和危险因素

目的:分析热带地区急性白血病(AL)患者治疗期间发生侵袭性真菌感染(IFI)的临床特点和危险因素。方法:回顾分析中国人民解放军总医院海南医院2012年4月至2019年4月收治的68例AL患者的临床资料,采用Logistic回归分析影响AL患者IFI发生的因素。结果:68例患者中急性髓系白血病44例,急性淋巴细胞白血病24例;男性39例,女性29例,中位年龄41(13-75)岁。68例患者共接受242例次化疗或造血干细胞移植(HSCT),其中初治或复发后诱导化疗73例次,HSCT 14例次,巩固化疗155例次,患者共接受抗真菌预防治疗152例次,包括初级预防77例次,再次预防75例次。最终发生IFI 31例次,包括临床诊断IFI 24例次,确诊IFI 7例次,IFI总发生率为12.8%(31/242),诱导化疗IFI发生率为24.66%(18/73),HSCT IFI发生率为28.57%(4/14),巩固化疗IFI发生率为5.80%(9/155)。多因素分析显示,诱导化疗或HSCT、粒缺时间≥7 d、危险度分层高危是热带地区AL患者治疗期间IFI发生的独立危险因素。结论:热带地区AL患者...     

Effect of a Clinical Nursing Practice Guideline of Enteral Nutrition Care on the Duration of Mechanical Ventilator for Critically Ill Patients

PurposeEarly enteral nutrition (EN) can improve clinical outcomes in critically ill patients. This study aimed to evaluate the effects of this clinical nursing practice guideline (CNPG) of EN care on the duration of mechanical ventilator in critically ill patients to investigate whether it was able to improve clinical outcomes.MethodsThis study compares a pretest-posttest design for the two groups, which was done before and after to determine the effects of a CNPG of EN care on the duration of a mechanical ventilator in critically ill patients. This study was performed on 44 critically ill patients admitted to the intensive care unit (ICU). The patients were divided into two groups according to EN. For the intervention group, CNPG started within the first 48 hours of admission to the ICU, and for the control group, they received standard nursing care.ResultsAfter the implementation, it showed significant associations between the duration of mechanical ventilator in ICU. The intervention group who received the CNPG had significantly shorter starting time of EN and a reduced duration of mechanical ventilator than those in the control group (p < .001).ConclusionA CNPG for EN care reduced the duration of mechanical ventilator. This could possibly improve the delivery of target calories when compared with current standard practice and improve the outcome of critically ill patients.     

Analysis of the Risk Factors for the Onset of Postoperative Hypothermia in the Postanesthesia Care Unit

PurposeRecent studies on hypothermia typically focused on a single anesthesia method or a particular surgical procedure. Although there are multiple risk factors leading to hypothermia, such as the use of cold solutions or nonhumidified and nonheated anesthetic gases, few studies have reported the incidence of postoperative hypothermia among patients in the postanesthesia care unit (PACU).DesignThis is a retrospective analysis of patients who underwent surgery and were admitted to the PACU immediately after surgery at the Fourth Affiliated Hospital, College of Medicine, Zhejiang University, from September 2018 to March 2019.MethodsPatient data were collected and analyzed in two groups to understand the factors affecting the occurrence of hypothermia. Hypothermia was defined as a core temperature of less than 36°C. On the basis of body temperature, patients in the PACU were divided into hypothermic and nonhypothermic groups. Factors influencing hypothermia were studied by the univariate method, followed by logistic regression analysis to identify the risk factors for hypothermia onset.FindingsOf a total of 1,788 patients were enrolled in the study, 113 (6.32%) exhibited hypothermia (<36°C) in the PACU. The hypothermic and nonhypothermic groups displayed significant differences (P < .05) in the anesthesia method used as well as the American Society of Anesthesiologists physical classification status. The body temperature at the time the patients were admitted to the operating room influenced the occurrence of postoperative hypothermia (P < .01). These parameters were recognized as independent risk factors for postoperative hypothermia in the PACU.ConclusionsSignificant risk factors for the onset of hypothermia were general anesthesia and higher American Society of Anesthesiologists grade. However, epidural anesthesia was found to have a protective effect.     

国产两性霉素B治疗侵袭性真菌感染

目的观察国产静脉用两性霉素B对血液系统恶性肿瘤患者侵袭性真菌感染(IFI)的临床疗效及安全性。方法40例恶性血液病患者使用华北制药厂生产的两性霉素B,剂量为5￣50mg/d,用药天数8￣66d,中数22d。结果两性霉素B临床总有效率为75%,真菌清除率63.6%,不良反应发生率中寒战、发热57.5%,低血钾40%,消化道反应20%,肾功能损害15%。结论两性霉素B抗菌谱较广,且疗效好,为治疗IFI的高效药物,但因其不良反应较大,限制其使用。研究表明:只要合理用药,定期监测肝肾功能,该药仍是一相对较为安全有效的药物。     

定量PCR检测在恶性血液病患者合并侵袭性真菌感染早期诊断中的意义

为探讨定量PCR在恶性血液病患者合并侵袭性真菌感染诊断中的应用价值,分别对40例恶性血液病患者血清中的真菌DNA进行定量PCR测定并结合半乳甘露聚糖(GM)试验及相关临床检查进行实验研究。选取烟曲霉菌高度保守的28S rRNA区段序列为目的基因设计引物和探针,提取患者血清中真菌DNA进行定量PCR检测。测定结果表明:定量PCR检测敏感性为0.89,特异性为0.85,阳性预测值为0.89,阴性预测值为0.85;GM检测敏感性为0.83,特异性为0.80,阳性预测值为0.88,阴性预测值为0.73;联合应用定量PCR和GM检测,其中1项为阳性或2项均为阳性的敏感性为0.94,特异性为0.85,阳性预测值0.89,阴性预测值0.92。结论:真菌定量PCR试验可应用于恶性血液病患者侵袭性真菌感染的诊断,与GM试验联合应用可提高诊断敏感性。     

定量PCR方法用于恶性血液病患者侵袭性真菌感染的诊断研究

本研究建立恶性血液病合并侵袭性真菌感染患者的外周血真菌定量PCR检测方法并初步评价其诊断价值。选取真菌高度保守的区段序列18Sr DNA-ITS1区设计引物及探针,提取真菌菌株DNA进行定量PCR验证引物及探针的敏感性和特异性,利用pGEM-T质粒制备真菌DNA标准品并对患者血液中真菌DNA进行定量测定。结果表明:12株曲霉菌和14株念珠菌定量PCR结果均为阳性;真菌在血浆、单个核细胞和全血中分布差异无统计学意义(p0.05)。真菌定量PCR的ROC曲线分析显示,用于临床诊断侵袭性真菌感染的诊断界值为8copies/ml全血,其敏感性、特异性、阳性预测值、阴性预测值、Kappa值分别为0.84,0.9,0.955,0.692,0.679。结论:真菌定量PCR检测可作为恶性血液病患者侵袭性真菌感染的早期诊断手段。     

应用MDRA评分和PCT动态变化诊治侵袭性真菌感染32例临床分析

目的:探讨联合MDRA评分和PCT动态变化对诊治侵袭性真菌感染(IFI)成功率的影响。方法:回顾性分析2013年4月-2014年4月重症监护病房(ICU)收治的真菌感染患者32例的临床资料,利用美国西弗吉尼亚大学医学院建立的真菌感染危险因素评分系统(Multi-disease Risk Assessment Program,MDRA)评分标准进行评分,观察MDRA评分和PCT动态变化对诊治侵袭性真菌感染的价值。结果:32例真菌感染患者的MDRA评分均30分,符合经验治疗的标准,但PCT值轻度升高并处于低水平及动态检测发现PCT值进行性降低的病例抗真菌治疗有效,而PCT值高,及进行性升高的病例抗真菌治疗无效。结论:侵袭性真菌感染的诊治不能教条地照搬MDRA评分标准,结合PCT的动态检测值水平有助于提高诊治的正确率。     

Development of a Nomogram for Carbapenem-Resistant Enterobacteriaceae Acquisition Risk Prediction Among Patients in the Intensive Care Unit of a Secondary Referral Hospital

PurposeThis study aimed to identify the risk factors of carbapenem-resistant Enterobacteriaceae (CRE) acquisition to build a nomogram for CRE acquisition risk prediction and evaluate its performance.MethodsThis unmatched case-control study included 352 adult patients (55 patients and 297 controls) admitted to the intensive care unit (ICU) of a 453-bed secondary referral hospital between January 1, 2018, and September 31, 2019, in Busan, South Korea. The nomogram was built with the identified risk factors using multiple logistic regression analysis. Its performance was analyzed using calibration-in-the-large, the slope of the calibration plot, concordance statistic (c-statistic), and the sensitivity and specificity of the training set, subsets, and a new test set.ResultsThe risk factors of CRE acquisition among ICU patients at a secondary referral hospital were Acute Physiology and Chronic Health Evaluation II score at the time of admission, use of a central venous catheter and a nasogastric tube, as well as use of cephalosporin antibiotics. At 20.0% of the predicted CRE acquisition risk in the training set, the calibration-in-the-large was 0, slope of the calibration plot was 1, c-statistic was .93, sensitivity was 85.5%, and specificity was 84.8%. The performance was relatively good in the subsets and new test set.ConclusionThe nomogram can be used to monitor the CRE acquisition risk for ICU patients who have a similar case mix to patients in the study hospitals. Future studies need to involve more rigorous methodology and larger samples.     

重症监护患者获得性肺炎的相关因素分析

目的:探讨重症监护病房(ICU)患者发生获得性肺炎的危险因素、病原体分布及药敏情况。方法:对我院重症监护病房2000年11月～2002年1月住院的52例获得性肺炎患者的临床和细菌学资料进行回顾性分析。结果:①52例患者获得性肺炎的发病危险因素有:机械通气、侵入性治疗、意识障碍、应用制酸剂、高龄,其发病相对危险度分别为7.82、5.58、2.68、2.53、1.24;②痰培养共检出病原菌128株:G~-杆菌93株(占72.66％),G~ 球菌22株(占17.19％),真菌13株(占10.16％);③128株致病菌对所选的抗生素有很高的耐药率。结论:机械通气、侵入性治疗、意识障碍、应用制酸剂、高龄是ICU获得性肺炎的主要危险因素;G~-杆菌是获得性肺炎的主要致病菌,真菌感染有增加趋势。