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

彭  亮; 刘  静; 高志良

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，调查乙肝肝衰竭患者合并真菌感染的病死率，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菌属的白假丝酵母菌（54.3%）和近平滑假丝酵母菌（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。假丝酵母菌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。

Abstract: Objective: To analysis the clinical features of hospital onset of mycotic infection in liver failure patients caused by hepatitis B in South China. Methods: 876 hepatitis B inpatients with liver failure were recruited from Jun 2005 to Jun 2010 in our department. Mortality, category of fungi, position of infection and sensitivity to anti-fungi medicine of mycotic infection were investigated. Relationship of mycotic infection and some clinical factors were analysised such as using of broad-spectrum antibiotic, neutropenia, invasive medical manipulations, severity of liver disease and artificial liver support system (ALSS) treatment. Results: 138 of 876 liver failure inpatients were final diagnosed for hospital onset of mycotic infection with mortality of 65.2% (90/138), which is significantly higher (P<0.01) than those without mycotic infection (50.3%, 371/738). Mortality of patients whose mycotic infection were not controlled was 75.9% and obviously higher (P<0.01) than those whose mycotic infection were controlled (47.1%). The most common infection strains were Candida albicans (54.4%) and Smooth Monilia. Respiratory tract and digestive tract were most common infection positions (45.7% and 30.4%). Susceptibility rate of all fungi to amphotericin B were the highest followed by fluconazol, Itraconazole and ketoconazole. Use of broad-spectrum antibiotic, neutropenia and invasive medical manipulations were high risk factors (P <0.05) of fungus infection except artificial liver support system (ALSS) treatment (P>0.05). MELD scores of patients with mycotic infection (32.4±7.8) were significantly higher than those without mycotic infection (25.5±6.5, P <0.05). Conclusions: Hospital onset of mycotic infection were common in hepatitis B inpatients with liver failure in South China. Respiratory tract and digestive tract were the common infection position. Candida mycoderma were the main infection strains but diversification tendency had been found in etiology. Some clinical factors such as using of broad-spectrum antibiotic, neutropenia, invasive medical manipulations and severity of liver disease were high risk factors of fungus infection except ALSS treatment.