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首页 重症患者侵袭性真菌感染诊断与治疗指南(2007)

重症患者侵袭性真菌感染诊断与治疗指南(2007).doc

重症患者侵袭性真菌感染诊断与治疗指南(2007)

一行情人泪_
2017-09-26 0人阅读 举报 0 0 0 暂无简介

简介:本文档为《重症患者侵袭性真菌感染诊断与治疗指南(2007)doc》,可适用于自然科学领域

重症患者侵袭性真菌感染诊断与治疗指南()重症患者侵蒃性菌感染蒃治蒃指南真断与,中蒃重症分医学会医学会通信作者:哈蒃蒃科大附第二院医学属医于蒃江,,主任蒃~医Email:drkaijiangsohucomICU患者是侵蒃性菌感染真(invasivefungalinfections,IFI)的高蒃人群~且IFI正成蒃蒃致ICU患者死亡的重要病因之一。前~外有些者把当国内学IFI蒃侵蒃性菌病称真invasivefungaldisease,IFD,,蒃此有蒃。蒃使重症工作者蒃尚争医学IFI有一全面、系蒃的蒃蒃~中蒃个医学会重症分蒃蒃相蒃蒃家~依据近年外究蒃展和蒃床蒃~制定了重症患者侵蒃性菌医学会来国内研践真感染蒃和治蒃指南~旨在指蒃蒃范我断与国ICU生的蒃床蒃蒃蒃工作。医医践一、ICU患者IFI的流行病学,ICU患者IFI的蒃病率,在蒃去的十年中几ICU患者IFI的蒃病率不升高~蒃占院蒃得断医性感染的,,。以念珠菌蒃主的酵母蒃菌和以曲蒃主的蒃菌是真霉状真IFI最常蒃的病原菌~分蒃占和。在美~国念珠菌血症已蒃居院血源性感染的第内位。究蒃示~研器官移植受者菌感染的蒃病率蒃真,~而AIDS患者蒃生菌感染的可能性高真达。管抗菌尽真的非蒃物治蒃措施越越受到重蒃~且不有新的抗菌蒃物蒃世~但来断真IFI的蒃病率仍呈明蒃上升蒃蒃。,ICU患者IFI的重要病原菌,ICU患者IFI的病原菌主要包括念珠菌和曲。霉ICU患者IFI仍以念珠菌蒃主~其中白念珠菌是最常蒃的病原菌(占,)。但近年非白念珠菌来(如光滑念珠菌、蒃蒃念珠菌、近平滑念珠菌等)感染的比例在逐蒃增加。侵蒃性曲感染的蒃生率亦在逐蒃上升霉,占所有IFI的,。曲多存在于潮蒃暗且霉湿缺乏通蒃的蒃境中~其蒃子蒃浮于空中易被患者吸入。曲气霉属中最常蒃的是烟曲、曲及黑霉黄霉曲~焦曲土曲蒃少蒃。霉霉与霉另外~蒃多蒃、蒃蒃、接合菌中的根毛的感染率霉属霉属霉属与霉属亦有所升高。,ICU患者IFI的病死率,ICU患者IFI的病死率高~很蒃次于血液系蒃蒃瘤患者。侵蒃性念珠菌感染的病死率达,~而念珠菌血症的粗病死率甚至高达,~其中光滑念珠菌和蒃蒃念珠菌感染的病死率明蒃高于白念珠菌等其他念珠菌。尽管ICU患者侵蒃性曲感染蒃生率低~但其病死率高~是免疫功能抑制患者死亡的主霉要原因。,ICU患者IFI的高危因素,在ICU中~IFI除了可蒃生于存在免疫抑制基蒃疾病中蒃蒃少蓄蒃。,用法与用量:推荐蒃量ABLC蒃mgkg重体,ABCD蒃,mgkg重体,LAmB蒃,mgkg重。体起始蒃量蒃每天mgkg重体,蒃蒃治蒃的推荐蒃量蒃每天mgkg重体,蒃治蒃蒃确每天mgkg重或体mgkg重体,蒃静脉注蒃蒃不蒃少于h。,注意事蒃:蒃毒性蒃著降低,蒃液反蒃亦大大少减,但仍需蒃蒃蒃功能。二、蒃蒃,氟康蒃,,适蒃蒃,深部念珠菌病、急性蒃球菌性蒃膜炎、侵蒃性念珠菌病的蒃防与治蒃。,蒃代蒃力学响清,口服迅速吸收~蒃食蒃蒃物吸收无影。蛋白蒃合率低~蒃蒃除~血蒃半衰期蒃,h~血中蒃物可蒃透析清除。,用法与用量,侵蒃性念珠菌病,mgd~念珠菌病的蒃防,,mgd,蒃程不宜超蒃,周。,注意事蒃,蒃期治蒃者注意肝功能。,伊曲康蒃,,适蒃蒃,曲、念珠菌、蒃霉属属球菌和蒃蒃胞蒃菌等引起的IFI。,蒃代蒃力学,蛋白蒃合率蒃~血蒃半衰期蒃,h。蒃肝P蒃系广胆与泛代蒃~代蒃蒃物蒃汁尿液排泄。,用法与用量,第,天mg,静脉注射~每天次~第,天mg,静脉注射~每天次蒃注蒃蒃不得少于h~之后序蒃使用口服液~mg每天次。,注意事蒃,蒃期治蒃蒃蒃注意蒃蒃肝功能~不得其他与静脉与肝毒性蒃物合用~蒃蒃不得其他蒃物采用同一通路。,伏立康蒃,,适蒃蒃,免疫抑制患者的蒃重菌感染、真霉氟急性侵蒃性曲病、由康蒃耐蒃的念珠菌引起的侵蒃性感染、蒃刀霉菌引起的感染等。,蒃代蒃力学,高危患者中呈非蒃性蒃代蒃力学~蛋白蒃合率蒃~蒃蒃分布容蒃蒃Lkg重~除体清半衰期蒃,h。,用法与用量,蒃荷蒃量,蒃静脉予mgkg重体,每h次~蒃用次。蒃注速度不得超蒃每小蒃mgkg重~体在,h蒃内完。蒃持蒃量:蒃静脉予mgkg重体,每h次。,注意事蒃,中,重度蒃功能不全患者重蒃蒃蒃。慎静脉三、棘白菌素蒃,卡泊芬蒃,,适蒃蒃,蒃蒃性中性粒蒃胞减真并少患者疑似菌感染的蒃蒃性治蒃~用于治蒃侵蒃性念珠菌病、念珠菌血症及其他蒃法蒃控制或不能耐受的侵蒃性曲菌病。霉,蒃代蒃力学,血蒃蒃度与蒃量呈等比例增蒃~蛋白蒃合率,~除清半衰期蒃,h。,用法与用量,首日蒃予一次mg蒃荷蒃量,随后mgd蒃持~蒃注蒃蒃不得少于h~蒃程依患者病情而定。,注意事蒃,蒃肝功能受蒃的患者重慎用蒃。,米卡属霉属真芬蒃,是一蒃新型水溶性棘白菌素蒃脂蒃~蒃念珠菌、曲菌引起的深部菌感染有蒃抗菌作广用~蒃耐蒃蒃蒃物的白念珠菌、光滑念珠菌、克柔念珠菌及其他念珠菌均有良好的抗菌活性~但不能抑制新型蒃球菌、毛蒃子菌、蒃蒃或蒃合菌。属属属与霉目前主要用于念珠菌曲菌所致的属真体内广与胆深部菌感染。本品分布泛~血蒃蒃蒃蒃度蒃高~主要在肝蒃代蒃~蒃汁排泄~与异其他蒃物相互作用少。主要不良反蒃是肝功能常,但蒃生率不高。其并用于治蒃食管念珠菌病的推荐蒃量蒃mgd~蒃防造血干蒃胞移植患者念珠菌感染的推荐蒃量蒃mgd。四、氟胞蒃蒃,适蒃蒃,少蒃一很两霉用蒃~一般蒃合性素B蒃用于全身念珠菌病、蒃球菌病。,蒃代蒃力学几达,口服迅速~乎完全吸收~蒃口和非胃蒃道蒃蒃均可到相同的血蒃蒃度~蛋白蒃合率低~蒃蒃分布泛广~蒃蒃蒃以原形消除~血蒃半衰期蒃,h。,用法与用量,若蒃功能正常~初始蒃量,mgkg重分体次蒃蒃~h次~若蒃功能不全~初始蒃量mgkg重~但体随后的用量与清达蒃期需蒃整~以使血峰蒃蒃度到,mgL。,注意事蒃,每周蒃蒃血肌蒃水平次~蒃整合适蒃量~蒃律蒃蒃血蒃胞蒃数与当与两霉肝功能~性素B蒃用蒃~性素两霉B会氟使胞蒃蒃的除率清降低。中蒃重症分侵蒃性菌感染指南工作蒃医学会医学会真蒃蒃,王蒃霞中科院中蒃和科大国医学学国医学医北京蒃和院感染科,成蒃按姓氏排列笔划,,于蒃江哈蒃蒃科大附第二院医学属医ICU,~方强浙江大附学属医第一院ICU,~大蒃中科院中蒃和科大刘国医学学国医学医医北京蒃和院加强蒃科,~安友仲北京大人学医民院ICU,~李若瑜北京大第一院学医皮蒃科,~邱海波蒃南大学属医附中大院ICU,~徐英春中科院中蒃和科大国医学学国医学医北京蒃和院蒃蒃科,~黎毅敏广医学属医广研州院第一附院州呼吸疾病究所ICU,表CVVH、CVVHD或CVVHDF及IHD蒃抗菌蒃物的蒃真量蒃整蒃物名称CVVHCVVHD或CVVHDFIHD氟康蒃,mg~,mg~于每次血液透析后每h一次每h一次蒃蒃一次伏立康蒃mgkg重体~口服~mgkg重体~口服~每h一次每h一次伊曲康蒃,,血液透析前蒃蒃卡泊芬蒃无需蒃整蒃量两霉性素B两霉性素B脱氧胆酸蒃,mgkg重体~,mgkg重体~每h一次每h一次,mgkg重体~,mgkg重体~两霉体性素脂蒃蒃合每h一次每h一次,mgkg重体~,mgkg重体~每h一次两霉性素B脂蒃体每h一次注,CVVH,蒃蒃静脉静脉,血液蒃蒃~CVVHD,蒃蒃静脉静脉,血液透析~CVVHDF,蒃蒃静脉,静脉血液透析蒃蒃~IHD,蒃歇性血液透析~CVVH、CVVHD或CVVHDF蒃~置蒃液、透析液均蒃Lh参献考文,MartinGS,ManninoDM,EatonS,MossMTheEpidemiologyofSepsisintheUnitedStatesfromthroughNEnglJMed:EdmondMB,WallaceSE,McClishDK,etalNosocomialbloodstreaminfectionsinUnitedStateshospitals:athreeyearanalysisClinInfectDis:RentzAM,HalpernMT,BowdenRTheimpactofcandidemiaonlengthofhospitalstay,outcome,andoverallcostofillnessClinInfectDis:SlavinMA,AustralianMycologyInterestGroupTheepidemiologyofcandidaemiaandmouldInfectiousinAustraliaJAntimicrobChemotherS:KauffmanCAFungalInfectionsProcAmThoracSoc():TortoranoAM,PemanJ,BernhardtH,etalEpidemiologyofcandidaemiaineurope:resultsofmonthEuropeanConfederationofMedicalMycology(ECMM)hospitalbasedsurveillancestudyEurJClinMicrobiolInfectDisApr():MeerssemanW,VandecasteeleSJ,WilmerA,etalInvasiveaspergillosisincriticallyillpatientswithoutmalignancyAmJRespirCritCareMed:–DenningDWAspergillosisinnonimmunocompromisedcriticallyillpatientsAmJRespirCritCareMed:GarnachoMonteroJ,AmayaVillarR,OrtizLeybaC,etalIsolationofAspergillussppfromtherespiratorytractincriticallyillpatients:riskfactors,clinicalpresentationandoutcomeCritCare:RLewisM,KallenbachJ,RuffP,etalInvasivepulmonaryaspergillosiscomplicatinginfluenzaApneumoniainapreviouslyhealthypatientChest:KaramGH,GriffinFMInvasivepulmonaryaspergillosisinnonimmunocompromised,nonneutropenichostsRevInfectDis:VallesJ,MesallesE,MariscalD,etalAyearstudyofseverehospitalacquiredpneumoniarequiringICUadmissionIntensiveCareMed:VandewoudeKH,BlotSI,DepuydtP,etalClinicalrelevanceofAspergillusisolationfromrespiratorytractsamplesincriticallyillpatientsCriticalCare():RVandewoudeKH,VogelaersD,BlotSIAspergillosisintheICUThenewstcenturyproblemMedMycolSepSuppl:HarteminkKJ,PaulMA,SpijkstraJJ,etalImmunoparalysisasacauseforinvasiveaspergillosisIntensiveCareMed,:AsciogluS,RexJH,dePauwB,etalDefiningopportunisticinvasivefungalinfectionsinimmunocompromisedpatientswithcancerandhematopoieticstemcelltransplants:aninternationalconsensusClinInfectDis:MermelLA,FarrBM,SherertzRJ,etalGuidelinesfortheManagementofIntravascularCathete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