中国南方地区乙肝肝衰竭患者医院内真菌感染的临床特征分析

摘要

目的:初步分析中国南方地区乙型病毒性肝炎(乙肝)导致的肝衰竭患者医院内真菌感染的临床特征.方法:收集2005年7月-2010年6月诊断为乙肝肝衰竭的876例住院患者 的临床资料,调查乙肝肝衰竭合并真菌感染患者的病死率,真菌感染的种类、部位等.分析乙肝肝衰竭患者合并真菌感染与长期使用多种抗生素、白细胞减少、侵入性操作与检查、人工肝治疗、病情轻重等因素的关系.观察检出真菌对常见抗真菌药物的药物敏感度.结果:876例乙肝肝衰竭患者,合并医院内真菌感染138例,病死率为65.2%(90/138);未合并真菌感染者病死率为50.3%(371/738),前者显著高于后者(P＜0.01).医院内真菌感染未得到控制者病死率为75.9%,明显高于治愈者的病死率(47.1%,P＜0.01).检出真菌中,最常见的是假丝酵母属的白假丝酵母(54.3%)和近平滑假丝酵母(11.6%).呼吸道和消化道是最常见的感染部位,分别占45.7%和30.4%.检出的138株真菌对两性霉素B的敏感度最高,其次是氟康唑、依曲康唑和酮康唑.138例合并医院内真菌感染者中,长期使用多种抗生素、白细胞减少、接受 侵袭性操作者所占比例均高于未合并医院内真菌感染者(P均＜0.05),两组接受人工肝治疗者所占比例相近(P＞0.05),合并医院内真菌感染患者终末期肝病模型(MELD)评分为(32.4±7.8)分,明显高于未合并医院内真菌感染者的(25.5±6.5)分(P＜0.05).结论:中国南方地区乙肝肝衰竭患者常并发医院内真菌感染.呼吸道与消化道是常见的感染部位.假丝酵母属是主要的感染菌株,感染病原学呈多样性分布.长期使用多种抗生素、白细胞减少、接受侵袭性操作、病情重等是发生医院内真菌感染的高危因素,而人工肝支持治疗并非其高危因素.%Objective： To analyze the clinical features of nosocomial mycotic infection in patients with hepatitis B virus-induced liver failure in South China Methods: Patients with hepatitis B virus-induced liver failure ( n = 876) were recruited from Jun 2005 to Jun 2010 in our department Mortality, category of fungi, position of infection and anti-fungi medicine sensitivity were investigated.Correlations between mycotic infection and clinical parameters , including broad-spectrum antibiotics usage, neutropenia, invasive medical manipulations, severity of liver disease and artificial liver support system ( ALSS) treatment, were analyzed.Results： Nosocomial mycotic infection was revealed in 138 patients with liver failure with a mortality of 65.2％ (90/138) , significantly higher than those without mycotic infection (50.3％ , P ＜0.01).Mortality of patients with uncontrolled mycotic infection was significantly higher than that of patients with controlled infection (75.9％ vs 47.1％ , P ＜0.01).Candida albicans and Smooth Monilia were detected as most prominent fungal trains (54.3％ and 11.6％ , respectively).Meanwhile, respiratory tract and digestive tract were the most common infected sites (45.7％ and 30.4％ , respectively).Amphotericin B, followed with by fluconazol, itraconazole and ketoconazole were proved to be the most sensitive antibiotics in these cases.Except for ALSS treatment, broad-spectrum antibiotic usage, neutropenia and invasive manipulations were revealed as risk factors of fungus infection (P ＜ 0.05 ).MELD score of patients with mycotic infection was significantly higher than those without mycotic infection ( 32.4 ± 7.8 vs 25.5 ± 6.5, P ＜ 0.05 ).Conclusions: Nosocomial mycotic infection, most frequently at respiratory and digestive tracts, is common in patients with hepatitis B virus-induced liver failure in South China.Although Candida mycoderma is revealed as the main infection strains, various pathogens are presented.Except for ALSS, broad-spectrum antibiotics usage, neutropenia, invasive manipulations and severe liver disease are risk factors for nosocomial mycotc infection.