真菌感染流行病学新趋势

李光辉复旦大学附属华山医院深部真菌感染流行病学新趋势GlobalburdenofcommonlifethreateninginfectionsTB20121420000Malaria2013584000欧洲三国真菌感染呈增多趋势ClinMicrobiolInfect2013;19:E343–E353临床上最常见的真菌感染A.念珠菌病B.隐球菌病C.曲霉病D.接合菌病E.组织胞浆菌病美国侵袭性真菌感染发病率病原菌例/百万/年死亡病例念珠菌72.833.9隐球菌65.512.7曲霉12.423.3接合菌1.730.0Otherhyalohyphomycetes1.214.3暗色真菌1.0Pfaller&Dikema,ClinMicrobiolRev2007.院内真菌感染的病原体以念珠菌居多，各临床科室发病率有所不同PfallerMAetal.CritRevMicrobiol.2010;36(1):1-53.普通病房血液恶性肿瘤骨髓移植HIV新生儿监护病房实体器官移植实体肿瘤外科(非移植)合计(n=3,640)(n=1,010)(n=377)(n=263)(n=54)(n=886)(n=863)(n=1,906)(n=6031)念珠菌属81.742.631.632.796.357.289.291.275隐球菌属4.02.10.048.70.06.41.61.04.5其它酵母菌*1.23.32.73.40.01.01.20.81.4曲霉菌属8.333.850.74.91.926.04.93.412.3接合菌1.15.26.41.11.91.70.00.61.4其它霉菌*1.67.66.41.50.04.71.31.52.7地方性真菌1.91.20.51.60.02.60.80.71.62004-2008年间美国IFD病原体在各临床科室的分布(%)*其它酵母包括6例马拉色菌属，26例肺孢子菌，12例红酵母，21例啤酒酵母和6例毛孢子菌*其它霉菌包括2例支顶孢菌,9例交链孢霉,3例双极孢菌，53例镰刀霉，10例拟青霉菌,13例赛多孢子菌，6例足分枝霉菌和1例白色簇孢霉院内深部真菌感染最主要病原体TherapeuticsandClinicalRiskManagement2014:1095–105侵袭性念珠菌病发病率0.2~1.96/千住院患者，0.9~4.4/万住院日侵袭性念珠菌病发病率TherapeuticsandClinicalRiskManagement2014:1095–1050.21~2.49/千住院患者，0.004~3.7/万住院日,1.81~26.2/10万人口侵袭性念珠菌病发病率TherapeuticsandClinicalRiskManagement2014:1095–1050.47~32/千住院患者，0.7~23.1/万住院日,1.52~11/10万人口临床上最常见的念珠菌菌种A.白念珠菌B.热带念珠菌C.光滑念珠菌D.近平滑念珠菌E.克柔念珠菌全球念珠菌菌种分布(%)TherapeuticsandClinicalRiskManagement2014:1095–105白念占44%~70.9%，热带5.4%~10.9%，近平滑4.8%~17.3%，光滑10.2%~18.2%，克柔1.9%~3.0%北美念珠菌菌种分布(%)TherapeuticsandClinicalRiskManagement2014:1095–105白念占38%~48.9%，热带7.3%~11%，近平滑11%~17.1%，光滑11%~26.7%，克柔1.9%~3.4%拉丁美洲念珠菌菌种分布(%)TherapeuticsandClinicalRiskManagement2014:1095–105白念占27.4%~52.2%，热带10.9%~26.7%，近平滑10.3%~38.5%，光滑3.7%~10%，克柔0.4%~4.7%欧洲念珠菌菌种分布(%)TherapeuticsandClinicalRiskManagement2014:1095–105白念占36.5%~70%，热带2%~24.1%，近平滑1%~36.9%，光滑3.9%~25.8%，克柔1.0%~4.8%丹麦真菌血症流行病学及菌种分布ClinMicrobiolInfect2013;19:E343–E353瑞士2004-2009念珠菌血症菌种分布ThemostfrequentlyisolatedspeciesC.albicans(675;61.9%)C.glabrata(191;17.5%)C.tropicalis(64;5.9%)C.parapsilosis(59;5.4%)accountingfor90.7%ofthetotalnumberofisolates.Theremaining9.3%ofthespeciesC.dubliniensis(33;3%),C.krusei(22;2%),C.lusi-taniaeC(12;1.1%),C.guilliermondii(9;0.8%),C.kefyr(8;0.7%),C.pelliculosa(6;0.6%),C.famata(4;0.4%),C.norvegensis(3;0.3%),C.inconspicua(2;0.2%)C.rugosa(2;0.2%)ClinMicrobiolInfect2014;20:698–705前瞻性、观察性、7家医院10个医学中心中心研究纳入2004年1月到2009年12月6年期间瑞士1090例念珠菌血症的患者白念：非白念=61.9%：38.1%1991-2000年白念珠菌占68.1%亚太区念珠菌菌种分布(%)TherapeuticsandClinicalRiskManagement2014:1095–105白念占35.6%~64.4%，热带5.1%~27.1%，近平滑7.4%~23.8%，光滑12.3%~17.9%，克柔1.2%~4.2%IncidenceandSpeciesDistributionofCandidaemiainAsia:ALaboratory-BasedSurveillanceStudyTheepidemiologyofcandidaemiavariesbetweenhospitalsandgeographicregions.AlthoughtherearemanystudiesfromAsia,alarge-scalecross-sectionalstudyacrossAsiahasnotbeenperformed.Weconducteda12-month,laboratory-basedsurveillanceofcandidaemiaat25hospitalsfromChina,HongKong,India,Singapore,TaiwanandThailand.Theincidenceandspeciesdistributionofcandidaemiaweredetermined.Therewere1,601episodesofcandidaemiaamong1.2milliondischarges.Theoverallincidencewas1.22episodesper1,000dischargesandvariedamongthehospitals(range,0.16-4.53per1,000discharges)andcountries(range,0.25-2.93per1,000discharges).ThenumberofCandidabloodisolatesandthetotalnumberoffungalisolateswerehighlycorrelatedamongthe6countries(R²=0.87)and25hospitals(R²=0.77).TherewasamoderatecorrelationbetweenincidenceofcandidaemiaandtheICU/totalbedratio(R²=0.47),althoughICUscontributedtoonly23%ofcandidaemiacases.Of1,910bloodisolatesevaluated,C.albicanswasmostfrequentlyisolated(41.3%),followedbyC.tropicalis(25.4%),C.glabrata(13.9%)andC.parapsilosis(12.1%).TheproportionofC.tropicalisamongbloodisolateswashigherinhaemato-oncologywardsthanotherswards(33.7%vs24.5%,p=0.0058)andwasmorelikelytobeisolatedfromtropicalcountriesthanotherAsiancountries(46.2%vs18.9%,p=0.04).Inconclusion,theICUsettingscontribute,atleastinpart,totheincidencevariationamonghospitals.ThespeciesdistributionisdifferentfromWesterncountries.Bothgeographicandhealthcarefactorscontributetothevariationofspeciesdistribution.ClinMicrobiolInfectPublishedOnline:June19,2015Theoverallincidencewas1.22episodesper1,000dischargesOf1,910bloodisolatesevaluated,C.albicanswasmostfrequentlyisolated(41.3%),followedbyC.tropicalis(25.4%),C.glabrata(13.9%)andC.parapsilosis(12.1%).非洲和中东念珠菌菌种分布(%)TherapeuticsandClinicalRiskManagement2014:1095–1052010-2014CHIF-NET：非白念比例超过白念2014CHIFNET：非白念比例超白念27省,62家医院00.10.20.30.40.50.620022003200420052006白念珠菌光滑念珠菌近平滑念珠菌热带念珠菌克柔念珠菌美国近平滑念珠菌血症呈逐年增加趋势ForrestGNetal.JournalofInfection2008;56:126-129.回顾性调查分析：2002-2006年美国一家大型医疗中心1000例患者日五种主要念珠菌导致的念珠菌血症每1000例患者日念珠菌血症发生率2002-2006近平滑念珠菌的独特之处作为非白念珠菌中的重要一员，近平滑念珠菌与其它非白念相比，死亡率相对较低那么，近平滑念珠菌有一些什么样的独特之处呢？在导管及其他植入装置中形成生物膜易通过手部在院内传播更易累及病情危重的新生儿易于在全胃肠外营养液中生长TrofaDetal.ClinMicrobiolRev.2008Oct;21(4):606-25.光滑念珠菌对棘白菌素类耐药性值得关注调查总共纳入了1669名由光滑念珠菌引起血流感染的患者我们检测了菌株对氟康唑、伏立康唑、阿尼芬净、卡泊芬净以及米卡芬净的体外敏感性0%10%20%30%40%9.7%9.3%9.3%8.0%氟康唑*阿尼芬净卡泊芬净米卡芬净光滑念珠菌对三唑类药物和棘白菌素类药物均产生了耐药性，且比例相当耐药率(%)*对氟康唑耐药的162株光滑念珠菌之中•有18株(11.1%)同时对一种或几种棘白菌素类药物产生了耐药•