内科重症监护病房患者真菌感染与抗真菌药物使用的相关性分析

摘要

目的：通过分析内科重症监护病房（ MICU）患者真菌感染与抗真菌药物使用的相关性，指导临床医生更好地把握治疗时机进行正确的早期经验性抗真菌治疗。方法对2OO9年5月-2O13年3月在我院呼吸科MICU住院的真菌阳性和/或应用抗真菌药的278例患者相关病历资料进行回顾性分析。278例患者中，真菌阳性但未应用抗真菌药的患者71例；真菌阳性且应用抗真菌药的患者93例；真菌阴性但应用抗真菌药的患者114例。结果以慢性阻塞性肺疾病急性加重期（ AECOPD）（22.7%，63/278）为主的呼吸系统疾病继发的真菌感染最常见，白色念珠菌（186株）为主要致病菌。临床上主要应用唑类抗真菌药（67.6%，192/284），并以早期经验性治疗（19O 例）为主。在164例真菌阳性的患者中，比较应用抗真菌药组和未用抗真菌药组患者的预后发现，应用真菌药与否对患者的预后影响不大（P=O.183）。而在71例真菌阳性但未进行抗真菌治疗的患者中，通过对比有临床表现组和无临床表现组发现，无临床表现患者的预后好于有临床表现的患者（ P=O. OO8）。在2O7例应用抗真菌药的患者中，查到真菌前（即经验性治疗）与查到真菌后（即先发治疗和目标治疗）开始抗真菌治疗的患者预后差异无统计学意义（ P=O.365）。在19O例经验性抗真菌治疗的患者中，真菌阳性组与真菌阴性组的患者预后差异无统计学意义（ P=O.667）。结论对于具有真菌感染高危因素的重症患者，不应过分依赖病原学结果，应以患者是否具有真菌感染相应的临床表现作为是否开始抗真菌治疗的主要依据。当患者出现真菌感染相应的临床表现，但无真菌学依据时，应以临床表现为主，积极进行经验性抗真菌治疗。但是当真菌阳性时，应仔细审视患者是否具有真菌感染相应的临床表现而决定是否开始治疗。%Objective Toguideclinicianstobettergraspthecorrecttimingoftreatmentofearlyempiricalantifungal therapybyanalyzingthecorrelationoffungalinfectionsandtheusageofantifungalagentsofMICUpatients.Methods Retrospec-tively analyze the relevant medical records of 278 patients with mycology positive and/or the usage of antifungal agents,who were hospitalized in our MICU from May 2OO9 to March 2O13. Among the 278 patients,mycology positive patients without using anti-fungal agents were 71,mycology positive patients with antifungal agents were 93,mycology negative without using antifungal a-gentswere114.Results FungalinfectionsecondarytoAECOPD(22.7%,63/278)respiratorydiseasewasmostcommonand monilia albicans was the main pathogen(186 strains). The most frequently used medicine was Azole antifungal agents(67. 6%192/284 )and it was mainly treated by early empirical therapy(19O). There was little impact on prognosis between application of antifungal agents and unused antifungal agents groups in the 164 mycology positive patients(P=O. 183). It was better prog-nosis with clinical manifestations than without clinical manifestations in the 71 mycology positive but not using antifungal patients ( P=O. OO8). There was no significant difference of prognosis between empirical therapy group and preemptive and target therapy group in the 2O7 patients with application of antifungal agents(P=O. 365). There was no significant difference of the prognosisbetween mycology positive group and mycology negative group among the 19O patients taking early empirical treatment ( P =O.667).Conclusion Whentostartearlyempiricalantifungaltherapyismainlybasedonthecorrespondingmanifestationsof fungal infection,rather than etiology result,especially for the MICU patients with high risk factors.