Medical Intensive Care Unit, Research Group on Acute Respiratory Failure in Hematology and Oncology Patients, Saint-Louis Hospital and Paris 7 Denis Diderot University, Paris, France; Grenoble 1 University, Medical Intensive Care Unit, Albert Michallon University Hospital, Grenoble, France; Grenoble 1 University, Albert Bonniot Institute, Team 11: Outcome of Airway Cancers and Mechanically Ventilated Patients, Grenoble, France.
Epidemiologic Clinical Unit, INSERM, Robert Debre Hospital and Paris 7 Denis Diderot University, Paris, France.
J Infect. 2014 Sep;69(3):284-92. doi: 10.1016/j.jinf.2014.04.010. Epub 2014 Jun 9.
To shed light on the meaning of Aspergillus-positive lower-respiratory-tract samples in non immunocompromized critically ill patients.
Multicentre matched case-control (1:5) study. We used prospectively collected data to identify risk factors for Aspergillus-positive specimens, as well as outcomes in Aspergillus-positive patients.
66 cases (5 with definite invasive pulmonary aspergillosis (IPA), 18 with probable IPA, and 43 colonisations) were matched to 330 controls. In the multivariate conditional logistic model, independent risk factors for at least one Aspergillus-positive respiratory-tract specimen were worse SAPSII at admission [OR, 1.10; 95%CI, 1.00-1.21], ARDS [OR, 2.64; 95%CI, 1.29-5.40]; long-term steroid therapy [OR, 4.77; 95%CI, 1.49-15.23]; steroid therapy started in the ICU [OR, 11.03; 95%CI, 4.40-27.67]; and bacterial infection [OR, 2.73; 95%CI, 1.37-5.42]. The risk of death, compared to the controls, was not higher in the cases overall [HR, 0.66; 95%CI, 0.41-1.08; p = 0.1] or in the subgroups with definite IPA [HR, 1.60; 95%CI, 0.43-5.94; p = 0.48], probable IPA [HR, 0.84; 95%CI, 0.28-2.50; p = 0.76], or colonisation [HR, 0.58; 95%CI, 0.33-1.02; p = 0.06]. In cases who received antifungal therapy, mortality was not lower than in untreated cases [HR, 0.67; 95%CI, 0.36-1.24; p = 0.20].
In critically ill immunocompetent patients, risk factors for presence of Aspergillus in lower respiratory tract specimens are steroid therapy (either chronic or initiated in the ICU), ARDS, and high severity of the acute illness. Prospective studies are warranted to further examine these risk factors and to investigate immune functions as well as the impact of antifungal therapy on patient outcomes.
阐明非免疫抑制危重症患者下呼吸道曲霉阳性样本的意义。
多中心匹配病例对照（1:5）研究。我们使用前瞻性收集的数据来确定曲霉阳性标本的危险因素，以及曲霉阳性患者的预后。
共纳入 66 例患者（5 例确诊侵袭性肺曲霉病（IPA），18 例拟诊 IPA，43 例定植），匹配 330 例对照。多变量条件逻辑回归模型显示，至少有一个曲霉阳性呼吸道标本的独立危险因素为：入院时 SAPSII 评分较差[比值比（OR），1.10；95%可信区间（CI），1.00-1.21]、急性呼吸窘迫综合征（ARDS）[OR，2.64；95%CI，1.29-5.40]、长期使用类固醇治疗[OR，4.77；95%CI，1.49-15.23]、在 ICU 开始使用类固醇治疗[OR，11.03；95%CI，4.40-27.67]、细菌感染[OR，2.73；95%CI，1.37-5.42]。与对照组相比，总体病例组的死亡率无显著差异[风险比（HR），0.66；95%CI，0.41-1.08；p=0.1]，或在确诊 IPA 亚组[HR，1.60；95%CI，0.43-5.94；p=0.48]、拟诊 IPA 亚组[HR，0.84；95%CI，0.28-2.50；p=0.76]、或定植亚组[HR，0.58；95%CI，0.33-1.02；p=0.06]。接受抗真菌治疗的病例组死亡率并不低于未治疗病例组[HR，0.67；95%CI，0.36-1.24；p=0.20]。
在免疫功能正常的危重症患者中，下呼吸道曲霉阳性标本的危险因素是类固醇治疗（慢性或 ICU 内起始）、ARDS 和急性疾病的严重程度。需要前瞻性研究进一步探讨这些危险因素，并研究免疫功能以及抗真菌治疗对患者预后的影响。
