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[CID发表论文]:EORTC/MSGERC有关侵袭性真菌病的定义:ICU工作组的活动总结
2021年07月03日 指南导读, 进展交流 暂无评论

EORTC/MSGERC Definitions of Invasive Fungal Diseases: Summary of Activities of the Intensive Care Unit Working Group

Matteo Bassetti, Elie Azoulay, Bart-Jan Kullberg, et al

Clin Infect Dis 2021; 72(S2): S121-7

INVASIVE CANDIDIASIS

Defining Proven and Probable Invasive Candidiasis in the Intensive Care Unit

After several rounds of review and discussion, the proposed definition for proven IC by the ICU Working Group required definitive evidence of the organism in a normally sterile site. It should include at least 1 of the following:

  1. Histopathologic, cytopathologic, or direct microscopic examination of material from a normally sterile site, obtained by needle aspiration or biopsy showing budding cells consistent with Candida species (presence of pseudo-hyphae and/or true hyphae is highly suggestive of Candidaspecies, but these structures are not present in all Candida species and may also be seen in Trichosporon spp., Geotrichum spp., and Magnusiomyces capitatus [previously known as Geotrichum capitatum], thus confirmation by culture or PCR is necessary).
  2. Recovery of Candida spp. by culture of a specimen obtained by a sterile procedure (including a freshly placed [<24 hours] drain) from a normally sterile site showing a clinical or radiologic abnormality consistent with an infectious-disease process.
  3. Blood culture yielding Candida species.

The proposed definition of probable IC in the ICU was based on the presence of at least 1 clinical criterion (compatible ocular findings by fundoscopic examination, hepatosplenic lesions by computed tomography [CT], clinical or radiological [nonpulmonary] abnormalities consistent with an infectious-disease process that are otherwise unexplained) plus at least 1 mycological criterion (positive serum 1,3-β-D-glucan in 2 consecutive samples, recovery of Candida in an intra-abdominal specimen obtained surgically or within 24 hours from external drainage), plus at least 1 of the following host factors:

  1. Glucocorticoid treatment with prednisone equivalent of 20 mg or more per day
  2. Qualitative or quantitative neutrophil abnormality (inherited neutrophil deficiency, absolute neutrophil count ≤500 cells/mm3)
  3. Impaired gut wall integrity (eg, recent abdominal surgery, recent chemotherapy, biliary tree abnormality, recurrent intestinal perforations, ascites, mucositis, severe pancreatitis, parenteral nutrition)
  4. Impaired cutaneous barriers to bloodstream infection (eg, presence of central vascular access device, hemodialysis)
  5. Candida colonization, defined as recovery of Candida species in cultures obtained from 2 or more of the following: respiratory tract secretions, stool, skin, wound sites, urine, and drains that have been in place for 24 or more hours
  6. Hematopoietic stem cell transplantation (HSCT)
  7. Solid-organ transplant (SOT)

INVASIVE ASPERGILLOSIS

Defining Proven and Probable Invasive Aspergillosis in the Intensive Care Unit

After several rounds of review and discussion, the proposed definition for proven IA by the ICU Working Group includes definitive evidence of filamentous growth plus associated tissue damage, and should include at least 1 of the following:

  1. Histopathologic, cytopathologic, or direct microscopic examination of a specimen obtained by needle aspiration or biopsy in which hyphae compatible with Aspergillus spp. are seen accompanied by evidence of associated tissue damage (with necessary confirmation by means of culture or PCR)
  2. Recovery of Aspergillus spp. by culture of a specimen obtained by a sterile procedure from a normally sterile site and clinically or radiologically abnormal site consistent with an infectious-disease process

The proposed definition of probable IA was limited to probable IPA in the critical care setting and included mycological evidence of Aspergillus spp. [at least 1 of the following: (1) cytology, direct microscopy, and/or culture indicating presence of Aspergillus spp. in a lower respiratory tract specimen; (2) galactomannan antigen index >0.5 in plasma/serum and/or galactomannan antigen >0.8 in BALF], provided that clinical and host factor criteria were met. Specifically, there should be at least 1 clinical/radiological abnormality consistent with an otherwise unexplained pulmonary infectious-disease process:

  1. Dense, well-circumscribed lesions with or without a halo sign
  2. Air crescent sign
  3. Cavity
  4. Wedge-shaped and segmental or lobar consolidation
  5. Tracheobronchial ulceration, pseudomembrane, nodule, plaque, or eschar detected by bronchoscopy (for Aspergillus tracheobronchitis)

Plus at least 1 of the following host factors:

  1. Glucocorticoid treatment with prednisone equivalent of 20 mg or more per day
  2. Qualitative or quantitative neutrophil abnormality (inherited neutrophil deficiency, absolute neutrophil count of ≤500 cells/mm3)
  3. Chronic respiratory airway abnormality (chronic obstructive lung disease, bronchiectasis)
  4. Decompensated cirrhosis
  5. Treatment with recognized immunosuppressants (eg, calcineurin or mammalian target of rapamycin [mTOR] inhibitors, blockers of tumor necrosis factor [TNF] and similar antifungal immunity pathways, alemtuzumab, ibrutinib, nucleoside analogues) during the past 90 days
  6. Hematological malignancies/HSCT
  7. SOT
  8. Human immunodeficiency virus infection
  9. Severe influenza (or other severe viral pneumonia, such as coronavirus disease 2019 [COVID-19])

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