Clinical Analysis Of Pulmonary Candidiasis Related To Mechanical Ventilation

BackgroudVentilator-associated pneumonia(VAP) is a kind of special and common nosocomial pneumonia for patients who need mechanical ventilation,the morbility rate and case-fatality rate are high,so it became one of the focus for us.Domestic literature reported that Mortality rates of ventilator- associated pneumonia in patients with nosocomial infection range from 10 to 15%.ventilator-associated pneumonia (VAP) is common in the intensive care unit(ICU),affecting from 8 to 20%of ICU patients and up to 27%of mechanically ventilated patients.Mortality rates in patients with VAP range from 20 to 50%and may reach more than 70%when the infection is caused by multi-resistant and invasive pathogens.The incidence of VAP- attributable mortality is difficult to quantify due to the possible confounding effect of associated conditions,but VAP is thought to increase the mortality of the underlying disease by about 30%.VAP is also associated with considerable morbidity,including prolonged ICU length of stay,prolonged mechanical ventilation,and increased costs of hospitalization.Delayed diagnosis and subsequent delay in initiating appropriate therapy may be associated with worse outcomes in patients with VAP;on the other hand,an incorrect diagnosis may lead to unnecessary treatment and subsequent complications related to therapy.Early,accurate diagnosis is,therefore,fundamental in the management of patients With VAP.Many studies specific strategies aimed at reducing the duration of mechanical ventilation(a major risk factor for VAP),such as improved methods of sedation,use of protocols to facilitate and accelerate weaning,and intensive insulin therapy with tight control of blood glucose level,should be considered integral parts of any infection-control program.All are based on the application of strict protocols.In the study by van den Berghe et al,when compared to the control group,patients treated with intensive insulin therapy had a 46%reduction of bloodstream infections; decreased frequency of acute renal failure requiring dialysis by 41%;fewer antibiotic treatment days;and significantly shorter length of mechanical ventilation,ICU stay, and mortality.Similarly,noninvasive positive-pressure ventilation using a face mask should be employed whenever possible.Adoption of an antibiotic policy restricting the prescription of broad-spectrum agents and useless antibiotics is of major importance.Several studies clearly demonstrated that the use of antibiotics in the hospital setting was associated with an increased risk of nosocomial pneumonia and selection of resistant pathogens.Better utilization of antibiotics in the ICU can be achieved by implementing strict guidelines,avoiding treating patients without bacterial infection,using narrow-spectrum antibiotics whenever possible,and reducing the duration of treatment.On the same hand,since multiple studies have identified exposure to allogenic blood products as a risk factor for postoperative infection and pneumonia,transfusion of red blood cells and other allogenic blood products should follow a strict restricted transfusion trigger policy.There are many studies of ventilator- associated pneumonia,and formulate effective prophylaxis program,but these studies are hardly about fungus.recently,fungal pulmonary infection related to mechanical ventilation became a focus for researchers because of its high infection rate,death rate and the difficulty of diagnose.Also,thereis no studies about risk factors,case fatality rate and analysis the drug-resistant of pulmonary candidiasis related to mechanical ventilation.ObjectivesTo investigate the risk factors of pulmonary candidiasis in patients who accepted mechanical ventilation;the difference in risk factors between early-onset infection and late-onset infection of invasive pulmonary candidiasis in patients who accepted mechanical ventilation;and analysis the prognostic factors associated with mortality; analysis the drug resistant of them.Methods1.A retrospective case-control study was performed,including 114 cases of who have accepted mechanical ventilation more than 48 hours,divide into pulmonary candidiasis infection group including 50 cases(including final diagnosis and clinical diagnosis)and control group including 64 cases,perform univariate analysis(χ~2-test) and multivariate logistic regression analysis.2.the infected 50 cases were sorted to early-onset infection group including 28 cases and late-onset group including 22 cases,no-infected group as the control group,perform univariate analysis(χ~2-test) and multivariate logistic regression analysis.3.the infected 50 cases were sorted to case group who were dead and control group who were not dead,analysis the prognostic factors associated with mortality with univariate analysis(χ~2-test).4.Analysis the case fatality rate of infection group and control group.5.24 strains were performed drug sensitivity test by KB method,analysis the drug-resistant according to the susceptibility test.Results1.Among all patients,50(43.9%)patients had pulmonary candidiasis infection. univariate analysis show that eld,above 2 kind of disease,used over 2 kinds of antibiotic,time in hospital≥15days,change antibiotic≥2times,diabetic,Prophylactic antifungal treatment,blood albumin≤25g;multivariate logistic regression show that with more than two kinds of disease(OR=4.758,P=0.009),changes of antibiotics more than 2-times(OR=6.128,P=0.001),serum albumn less than 25 gram (OR=15.829,P=0.011)are the independent risk factors.Prophylactic antifungal treatment(OR=0.062,P=0.012)is a protective factor.2.univariate analysis show that the risk factors for early-onset invasive pulmonary candidiasis infection include above 2 kind of disease,change antibiotic≥2times a week,diabetic,Prophylactic antifungal treatment,electrolyte disturbances;the risk factors for late-onset invasive pulmonary candidiasis infection include eld,time in hospital≥15days,Prophylactic antifungal treatment,blood albumin≤25g.and multivariate logistic regression show that the independent risk factors for early-onset invasive pulmonary candidiasis infection include changes of antibiotics more than 2-times a week(OR=4.758,P=0.009),above 2 kind of disease(OR=6.128,P=0.001),at the same time,age(OR=5.684,P=0.000)and serum albumn less than 25 gram(OR=4.255,P=0.000) are the independent risk factors for late-onset infection.Prophylactic antifungal treatment(OR1=0.064,P1=0.004; OR2=0.561,P2=0.014) is a protective factor for both of them.3.The risk factors associated with prognosis include with more than two two kinds of disease(P=0.026),coma(P=0.001) and renal disfunction(P=0.002).4.the case fatality rate of infection group is higher than that of control group.5.Drug sensitivity test show that Candida albicans are sensitive for most of antifungal agents(100.0%).but half of the other candidiasis are almostly tolerated to fluconazol(50.0%) and Itraconazole(38.5%).Conclusions1.Underlaying condition and changes of antibiotics too more are the major risk factors of pulmonary candidiasis infection for patients accepted mechanical ventilation2.It is different in risk factors between early-onset infection and late-onset infection of invasive pulmonary candidiasis in patients who accepted mechanical ventilation.3.Since the case fatality rate of infection group is higher,we must find these risk factors as fast as we can,then we can start necessary treatment earlier,early and accurate treatment is important for improving prognosis.4.drug-resistant analysis help us treat the patients.