CVC與真菌生物被膜-

CVC相關(guān)性念珠菌感染與治療策略山東大學(xué)齊魯醫(yī)院重癥醫(yī)學(xué)科丁士芳內(nèi)容念珠菌生物被膜形成生物被膜念珠菌耐藥機(jī)制念珠菌生物被膜危害棘白菌素藥物治療CVC相關(guān)念珠菌感染優(yōu)勢(shì)生物被膜相關(guān)念珠菌感染ThePathogenesisofCandidaInfectionsinaHumanSkinModel:ScanningElectronMicroscopeObservations.ISRNDermatol.2011;2011:150642Candidaalbicans-EndothelialCellInteractions:aKeyStepinthePathogenesisofSystemicCandidiasis.INFECTIONANDIMMUNITY,2008,76(10):4370–4377BiofilmformationbythefungalpathogenCandidaalbicans:development,architecture,anddrugresistance[J].JBacteriol,2001,183(18):5385Candidaalbicansmorphogenesisandhostdefence:discriminatinginvasionfromcolonization.NatRevMicrobiol.;10(2):112–122.Hyphalgrowthinhumanfungalpathogensanditsroleinvirulence.IntJMicrobiol.2012;2012:517529.血和主動(dòng)脈瓣培養(yǎng)為近平滑念珠菌，靜脈聯(lián)合滴注兩性霉素B和科塞斯，2周后癥狀消失、血培養(yǎng)無(wú)真菌生長(zhǎng)Candidaparapsilosisbioprostheticvalveendocarditisinducingaorticvalvestenosis.。TexHeartInstJ.2013;40(4):502-4偽膜性口咽部念珠菌感染OralCandidaalbicansisolatesfromHIV-positiveindividualshavesimilarinvitrobiofilm-formingabilityandpathogenicityasinvasiveCandidaisolates.BMCMicrobiol.2011Nov4;11:247.NIHinPA-03-047報(bào)道80%微生物感染與生物被膜形成相關(guān)多數(shù)研究以浮游念珠菌為主，念珠菌危害主要與其形成生物被膜有關(guān)真菌生物被膜生物被膜是指細(xì)(真)菌吸附于機(jī)體腔道或生物材料表面，分泌多糖基質(zhì)、纖維蛋白、脂蛋白等，將自身包繞其中形成的膜樣多細(xì)(真)菌復(fù)合體生物膜不斷釋放脫落細(xì)(真)菌，形成新的感染灶，引起感染持續(xù)狀態(tài)，導(dǎo)致細(xì)(真)菌耐藥、感染被徹底治愈機(jī)會(huì)減少、臨床治療失敗死而復(fù)生，生命不息生根發(fā)芽，咬定青山不放松(臭名昭著)鋼筋混凝土構(gòu)成的社區(qū)群體念珠菌生物被膜相關(guān)感染隨時(shí)間延長(zhǎng)，形成類似生物被膜白色念珠菌皮膚感染模型生根發(fā)芽，咬定青山不放松ThePathogenesisofCandidaInfectionsinaHumanSkinModel:ScanningElectronMicroscopeObservations.ISRNDermatol.2011;2011:150642Candidaalbicans-EndothelialCellInteractions:aKeyStepinthePathogenesisofSystemicCandidiasis.INFECTIONANDIMMUNITY,2008,76(10):4370–4377熱帶念珠菌白色念珠菌beta-glucan與念珠菌生物被膜beta-1,3和beta-1,6glucans(50to60%),mannoproteins(30to40%),andchitin(0.6to9%).PutativeRoleof-1,3GlucansinCandidaalbicansBiofilmResistance.ANTIMICROBIALAGENTSANDCHEMOTHERAPY,2007,51(2):510–520NatRevMicrobiol.;10(2):112–122念珠菌生物被膜相關(guān)感染BiofilmFormationbytheFungalPathogenCandidaalbicans:Development,Architecture,andDrugResistance。OURNALOFBACTERIOLOGY,Sept.2001,p.5385–5394 Vol.183,No.18產(chǎn)生物被膜的念珠菌菌株附著的有機(jī)玻璃或硅膠片，在0.05%(v/v)

Calcofluor-White浸染1min，該染料特異性與真菌細(xì)胞壁中的幾丁質(zhì)和葡聚糖特異性結(jié)合熒光顯微鏡下觀察早期(0to11h),微小菌落中期(12to30h),類似細(xì)胞壁構(gòu)成無(wú)定形物質(zhì)覆蓋菌落成熟期(38to72h),菌落被覆蓋生物材料影響念珠菌生物被膜構(gòu)成BiofilmFormationbytheFungalPathogenCandidaalbicans:Development,Architecture,andDrugResistance。OURNALOFBACTERIOLOGY,Sept.2001,p.5385–5394 Vol.183,No.18代謝活躍細(xì)胞，胞漿內(nèi)FUN-1呈橘紅色，ConA主要與真菌細(xì)胞壁多糖中的甘露糖結(jié)合，成綠色a單個(gè)白色念珠菌粘附b8h后，白念趨向粘附聚集c11h后，形成微菌落d成熟期，微菌落被類似細(xì)胞壁物質(zhì)覆蓋硅膠片形成厚約10~12um白色念珠菌菌株層，其上形成厚約450um、富含念珠菌菌絲和細(xì)胞外基質(zhì)的基質(zhì)層強(qiáng)行剝離基質(zhì)層，可見念珠菌菌落念珠菌生物被膜模型FungalBiofilmsandDrugResistance.EmergingInfectiousDiseases?/eid?Vol.10,No.1,January2004FungalBiofilms:RelevanceintheSettingofHumanDisease.CurrFungalInfectRep.2010December1;4(4):266–275.白色念珠菌在多孔濾網(wǎng)形成生物被膜，顯示孢子和菌絲被細(xì)胞外基質(zhì)包繞SEMofaC.albicansbiofilmgrownonacelluloseacetatefilterinaperfusedbiofilmfermentor.SEMrevealedacomplexmixtureofyeastsandhyphaeenmeshedinadensematrixmaterial.Eachbiofilmconsistedmainlyofacellmonolayer,butinsomeareasbiofilmswerethreecellsdeep.大鼠白色念珠菌相關(guān)CVC感染模型(24h)顯示酵母細(xì)胞與菌絲倍細(xì)胞外基質(zhì)覆蓋Scanningelectronmicroscopyimageofmature(24-h)Candidaalbicansbiofilmsformedonaratcentralvenouscathetermodelshowedanetworkcomprisingyeastcellsandhyphaesurroundedbymoderateamountsofexopolymericmatrix.5μm念珠菌形成生物被膜存在差異瑞典臨床微生物實(shí)驗(yàn)室2005年9月-2006年8月收集393株念珠菌，40%白色念珠菌形成生物被膜，88.7%非白念形成生物膜(p＜0.05)非白念容易形成復(fù)雜、厚密生物被膜Prevalenceofbiofilmformationinclinicalisolatesofcandidaspeciescausingbloodstreaminfection.Mycoses.2013May;56(3):264-72.產(chǎn)生物被膜念珠菌的超微結(jié)構(gòu)

beta-1,3

glucan的作用形成生物被膜過程中，念珠菌形態(tài)發(fā)生改變生物被膜念珠菌細(xì)胞壁厚度為浮游念珠菌的2倍ThecellwallsoftheinvivobiofilmcellswereuptotwotimesthickerthanplanktoniccellsInaddition,theperiplasmiclayerwasmoreprominentinthebiofilmcellsPutativeRoleof-1,3GlucansinCandidaalbicansBiofilmResistance.ANTIMICROBIALAGENTSANDCHEMOTHERAPY,2007,51(2):510–520beta-glucan在產(chǎn)生物被膜念珠菌的作用形成生物被膜念珠菌細(xì)胞壁β-1,3glucan含量顯著高于靜止期和對(duì)數(shù)生長(zhǎng)期念珠菌(P<0.001)PutativeRoleof-1,3GlucansinCandidaalbicansBiofilmResistance.ANTIMICROBIALAGENTSANDCHEMOTHERAPY,2007,51(2):510–520beta-glucan在產(chǎn)生物被膜念珠菌的作用生物被膜念珠菌合成、釋放更多β-1,3glucan示意圖ACandidaBiofilm-InducedPathwayforMatrixGlucanDelivery:ImplicationsforDrugResistance.PLoSPathog8(8):e1002848生物被膜念珠菌細(xì)胞膜固醇成分改變生物被膜與浮游白念珠菌麥角固醇水平在6h時(shí)相同，生物膜成熟期減少50%，而浮游細(xì)胞在6～12h減少18%，其他固醇水平在兩者之間也有明顯差異麥角固醇比例改變影響抗真菌藥物進(jìn)入念珠菌通透性，進(jìn)而防止或阻滯抗真菌藥物進(jìn)入念珠菌細(xì)胞壁改變固醇成分比例影響生物被膜內(nèi)念珠菌對(duì)氟康唑耐藥性MechanismofFluconazoleResistanceinCandidaalbicansBiofilms:Phase-SpecificRoleofEffluxPumpsandMembraneSterols.InfectImmun.2003August;71(8):4333–4340.念珠菌耐抗真菌藥物機(jī)制(1)細(xì)胞外基質(zhì)阻止藥物滲透入深部組織；(2)營(yíng)養(yǎng)和生長(zhǎng)速度限制，敏感性下降；(3)藥物與生物被膜接觸，誘導(dǎo)表達(dá)耐藥基因與浮游念珠菌比較，生物被膜念珠菌對(duì)氟康唑耐藥性高達(dá)1000倍Astickysituation:

untangling

the

transcriptional

network

controlling

biofilm

development

in

Candida

albicans.

Transcription.

2012;3(6):315-22.TRENDSinMicrobiologyVol.11No.1January2003金剛罩！鐵布衫！反導(dǎo)系統(tǒng)！鋼筋混凝土構(gòu)成的社區(qū)群體,阻擋藥物穿透ThedensityofthematurebiofilmmayactasaphysicalbarrierECMisproducedto“soak”anddepleteantifungalagents.念珠菌生物被膜影響氟康唑分布

念珠菌耐抗真菌藥物機(jī)制B絕大部分氟康唑分布在非白色念珠菌生物被膜、非白色念珠菌細(xì)胞壁或細(xì)胞漿內(nèi)極少或無(wú)氟康唑分布生物被膜念珠菌細(xì)胞壁結(jié)合氟康唑是浮游念珠菌的4~5倍，意味相當(dāng)一部分氟康唑分布在生物被膜和細(xì)胞壁，不能進(jìn)入細(xì)胞漿，增加念珠菌耐藥性Roleofmatrixglucaninantifungalresistanceofnon-albicanscandidabiofilms.AntimicrobAgentsChemother.2013Apr;57(4):1918-20抗真菌藥物對(duì)生物被膜念珠菌療效兩性霉素B對(duì)生物被膜念珠菌MIC增加脂質(zhì)體兩性霉素B對(duì)生物被膜念珠菌MIC無(wú)顯著變化氟康唑和伏立康唑?qū)Ω∮文钪榫鶰IC低，對(duì)生物被膜念珠菌MIC極高米卡芬凈和卡泊芬凈對(duì)浮游和生物被膜念珠菌MIC無(wú)顯著差異MICsinCandidabiofilmsincrease100–1000timescomparedwithplanktoniccells.AntifungalSusceptibilityofCandidaBiofilms:UniqueEfficacyofAmphotericinBLipidFormulationsandEchinocandins.ANTIMICROBIALAGENTSANDCHEMOTHERAPY,June2002,p.1773–1780Vol.46,No.6真菌耐藥機(jī)制細(xì)胞膜通透性改變，Erg11基因突變和過表達(dá)，作用唑類藥物的Cdr1,Cdr2(ABCT)過表達(dá)，特異性作用氟康唑的Mdr1(MF)過表達(dá)多烯類耐藥少見，可通過ERG3功能缺失，導(dǎo)致麥角固醇合成障礙，不能形成藥物-脂質(zhì)復(fù)合體，避免內(nèi)容物丟失Clinical,Cellular,andMolecularFactorsThatContributetoAntifungalDrugResistance.CLINICALMICROBIOLOGYREVIEWS,.1998,11(2):382–402FungalBiofilmResistance.InternationalJournalofMicrobiology.2012,528521,抗真菌藥物藥代動(dòng)力學(xué)-藥效動(dòng)力學(xué)Pharmacokinetic–pharmacodynamicoptimizationoftriazoleantifungaltherapy.CurrOpinInfectDis24(suppl2):S14–S29CritCareMed2013;41:580–637InternationalJournalofAntimicrobialAgents39(2012)1–102003，2008，2012膿毒癥指南：初始經(jīng)驗(yàn)性抗感染治療包括一種或多種對(duì)可能致病菌(細(xì)菌，和/或真菌，或病毒)敏感，且以足夠藥物濃度抵達(dá)導(dǎo)致膿毒癥的感染部位的藥物(I-B)抗生物被膜活性藥物改善患者預(yù)后Riskfactorsandoutcomesofcandidemiacausedbybiofilm-formingisolatesinatertiarycarehospital.PLoSOne.2012;7(3):e33705.

生物被膜組無(wú)生物被膜組Pvalue住院死亡率51.2%(43/84)31.7%(39/123)0.004感染相關(guān)死亡率44.1%(37/84)27.6%(34/123)0.012005年-2007年，84例為形成生物被膜念珠菌血癥，123例為不能形成生物被膜念珠菌血癥兩者患者30天生存率不同(p=0.004)生物被膜念珠菌血癥患者分別接受卡泊芬凈和氟康唑治療，其30天生存率不同(p=0.05)重癥患者侵襲性念珠菌感染

危險(xiǎn)因素：解剖生理屏障完整性破壞Revisitingthesourceofcandidemia:skinorgut?ClinInfectDis2001;33:1959–67.侵襲性念珠菌感染常由腸道念珠菌大量繁殖進(jìn)入血流所致最易受累：腎、心、腦、肺急性胰腺炎并腹腔真菌感染

齊魯醫(yī)院病例男性患者，68歲2007年7月22日急性胰腺炎。7月31日收住ICU，8月2日剖腹探查，術(shù)中見腹腔內(nèi)大量滲液、腸系膜根部有膿苔、肝腎隱窩處組織炎性壞死8月2日腹腔引流液

孢子和假菌絲；8月3日腹水培養(yǎng)

白假絲酵母高碘酸—無(wú)色品紅(PAS)法染色顯示術(shù)中送檢網(wǎng)膜組織存在大量真菌菌絲及孢子重癥患者侵襲性念珠菌感染

危險(xiǎn)因素：解剖生理屏障完整性破壞據(jù)美國(guó)CDC統(tǒng)計(jì),ICU醫(yī)院獲得性感染約20%為血流感染(BSI)，87%與中心靜脈導(dǎo)管(CVC)有關(guān)血管內(nèi)導(dǎo)管分離的病原體，白色念珠菌占第二位ICU患者最突出特點(diǎn)是其解剖生理屏障完整性破壞,定植體表皮膚和體腔粘膜表面的條件致病真菌，以及環(huán)境中真菌侵入原本無(wú)菌深部組織和血液NucciM,AnaissieE.Revisitingthesourceofcandidemia:skinorgut?ClinInfectDis2001;33:1959–67.股靜脈置管血管內(nèi)侵襲性操作相關(guān)真菌血癥導(dǎo)管感染方式：(1)皮膚表面細(xì)菌、真菌在穿刺時(shí)或之后，通過皮下致導(dǎo)管皮內(nèi)段至導(dǎo)管尖端定植，隨后引起局部或全身感染(2)另一感染灶微生物血行播散到導(dǎo)管、黏附定植，引起CRBSI(3)微生物污染導(dǎo)管接頭和內(nèi)腔(手污染)，導(dǎo)致腔內(nèi)細(xì)菌繁殖、感染世界臨床藥物,2011年,第07期中國(guó)真菌學(xué)雜志，2006年，第1卷，第五期VallésJ,etal.InfectDisClinNorthAm,2009,23:557-569中心靜脈導(dǎo)管相關(guān)真菌血癥與生物膜(A)×450;(B)×1100;(C)×4500.由塔狀或蘑菇狀微菌落組成，其余空間被網(wǎng)狀分布的胞外多聚基質(zhì)所占據(jù)一張牢不可破的網(wǎng)AssessmentofthetypesofcatheterinfectivitycausedbyCandidaspeciesandtheirbiofilmformation.FirststudyinanintensivecareunitinAlgeria.IntJGenMed.2013;6:1–7.

×35中心靜脈導(dǎo)管相關(guān)真菌血癥與生物膜24h大鼠頸內(nèi)靜脈置管白色念珠菌生物被膜模型生物被膜內(nèi)存活念珠菌、菌絲DevelopmentandcharacterizationofaninvivocentralvenouscatheterCandidaalbicansbiofilmmodel.InfectImmun.2004Oct;72(10):6023-31.掃描電鏡顯示中心靜脈導(dǎo)管腔內(nèi)形成念珠菌生物被膜相關(guān)感染念珠菌孢子形成假菌絲、菌絲和細(xì)胞外基質(zhì)(A)×50;(B)×1000唑類藥物作用機(jī)制ckCYP51活性部位(白色)；氟康唑結(jié)合位點(diǎn)(藍(lán)色)；伏立康唑結(jié)合位點(diǎn)(黃色).伏立康唑結(jié)合位點(diǎn)比氟康唑多RegulatoryCircuitryGoverningFungalDevelopment,DrugResistance,andDisease.MICROBIOLOGYANDMOLECULARBIOLOGYREVIEWS,June2011,p.213–267Vol.75,No.2Stress,

drugs,and

evolution:the

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signaling

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drugresistance.EukaryotCell.2008;7(5):747-64.Dodds-AshleyES,etal.ClinInfectDis.2006;43:S28-39.NettJetal.Antimicrob.AgentsChemother.2007;51:510-520破壞生物被膜有助改善氟康唑療效超大劑量氟康唑(為浮游念珠菌MIC1000倍)對(duì)生物被膜念珠菌感染無(wú)效大劑量β-1,3glucanase能破壞念珠菌生物被膜小劑量β-1,3glucanase不能破壞念珠菌生物被膜小劑量β-1,3glucanase聯(lián)合超大劑量氟康唑，清除念珠菌生物被膜TheActivityofmicafunginandvoriconazoleagainstCandidaalbicansBiofilmsRepresentativescanningelectronmicrographsofSEVsofCandidaalbicans.(A)Controlat72hwithdensebiofilmnetwork;(B)markedlyreducednumberoforganismsduetoflucytosineat24h;(C)limitedeffectofvoriconazoleonorganismloadat72h;(D)markedlydeformedcellsafterexposuretomicafunginfor48h.ActivitiesandUltrastructuralEffectsofAntifungalCombinationsagainstSimulatedCandidaEndocardialVegetations.ANTIMICROBIALAGENTSANDCHEMOTHERAPY,July2008,p.2367–2376Vol.52,No.7伏立康唑與氟康唑交叉耐藥性采用最新K-B法判斷標(biāo)準(zhǔn)耐氟康唑念珠菌，對(duì)伏立康唑保持高的耐藥率伏立康唑BIResultsfromtheARTEMISDISKGlobalAntifungalSurveillanceStudy,1997to2007:a10.5-yearanalysisofsusceptibilitiesofCandidaSpeciestofluconazoleandvoriconazoleasdeterminedbyCLSIstandardizeddiskdiffusion.JClinMicrobiol.2010;48(4):1366-77.兩性霉素B作用機(jī)制AntifungalResistanceandNewStrategiestoControlFungalInfections.InternationalJournalofMicrobiologyVolume2012,ArticleID713687,26pagesPharmacokineticsandPharmacodynamicsofAmphotericinBDeoxycholate,LiposomalAmphotericinB,andAmphotericinBLipidComplexinanInVitroModelofInvasivePulmonaryAspergillosis.ANTIMICROBIALAGENTSANDCHEMOTHERAPY.2010,54(8):3432–3441ProcNatlAcadSciUSA.2011;108(17):6733–6738.70–100nmindiameter千里之堤潰于蟻穴兩性霉素B主要在肝、脾、肺、骨髓和腎臟分布兩性霉素B脂質(zhì)體劑型分布在肝、脾、肺、骨髓，較少分布在腎臟兩性霉素B與氟康唑

不能抑制生物被膜念珠菌生長(zhǎng)C.kruseiATCC6258C.parapsilosisATCC22019C.albicansHK1Sa(A)Control(B)exposedto600ug/mlamphotericinBfor4h(C)exposedto600ug/mlfluconazolefor4hThewrinkled,shrunk,ruptured,andballooningeffectofthedrugonyeastcellsInVitroMethodToStudyAntifungalPerfusioninCandidaBiofilms.JOURNALOFCLINICALMICROBIOLOGY,2005,43(2):818–825兩性霉素B脂質(zhì)體抑制生物被膜念珠菌生長(zhǎng)RabbitModelofCandidaalbicansBiofilmInfection:LiposomalAmphotericinBAntifungalLockTherapy.ANTIMICROBIALAGENTSANDCHEMOTHERAPY,2004,48(5):1727–17327d兔頸靜脈生物膜模型3d兔頸靜脈生物膜模型對(duì)照兩性霉素B脂質(zhì)體1mg/100ul氟康唑1mg/100ul念珠菌感染兔CVC3天后，每天導(dǎo)管內(nèi)局部灌注8h，連續(xù)7天氟康唑生物被膜有所減少，但念珠菌感染部位生物被膜形態(tài)與對(duì)照組相似(念珠菌生長(zhǎng))脂質(zhì)體兩性霉素B幾乎完全清除CVC表面生物被膜相關(guān)念珠菌，1~2處殘存感染部位缺乏生物被膜(無(wú)念珠菌生長(zhǎng))脂質(zhì)體兩性霉素B有效治療生物被膜念珠菌感染，但機(jī)制不明，脂質(zhì)體無(wú)真菌抑制作用棘白菌素類藥物作用機(jī)制Stress,

drugs,and

evolution:the

role

of

cellular

signaling

in

fungal

drugresistance.EukaryotCell.2008;7(5):747-64.Resistancetoechinocandin-classantifungaldrugs.DrugResistUpdat.2007June;10(3):121–130.Stress,

drugs,and

evolution:the

role

of

cellular

signaling

in

fungal

drugresistance.EukaryotCell.2008;7(5):747-64.Resistancetoechinocandin-classantifungaldrugs.DrugResistUpdat.2007June;10(3):121–130.Fungalechinocandinresistance.FungalGenetBiol.

2010;47(2):117-26.ChoiHWetal.AntimicrobAgentsChemother2007;51:1520-23棘白菌素類抗真菌藥物作用靶點(diǎn)為真菌細(xì)胞壁β-1.3-葡聚糖，生物被膜基質(zhì)中含有β-1.3-葡聚糖通過減少、抑制β-葡聚糖產(chǎn)生，破壞生物被膜完整性，有利控制念珠菌生物被膜感染卡泊芬凈抑制生物被膜念珠菌存活I(lǐng)nVitroActivityofCaspofunginagainstCandidaalbicansBiofilms.ANTIMICROBIALAGENTSANDCHEMOTHERAPY.2002,46(11):3591–3596卡泊芬凈治療組(0.5ug/ml)生物被膜內(nèi)念珠菌菌絲少、孢子形態(tài)異常未治療組，存在大量活性代謝念珠菌(從綠色到紅色，以紅色為主)；卡泊芬凈治療組(0.5ug/ml)，為彌漫性綠色，提示存在大量死亡念珠菌UppuluriPetal.Antimicrob.AgentsChemother.2011;55:3591-3593抗真菌藥物抑制生物被膜相關(guān)念珠菌播散超大劑量氟康唑不能抑制生物被膜內(nèi)白色念珠菌生長(zhǎng)高濃度兩性霉素B僅僅中等程度抑制生物被膜內(nèi)白色念珠菌生長(zhǎng)卡泊芬凈抑制生物被膜內(nèi)白色念珠菌生長(zhǎng)作用最強(qiáng)抗真菌藥物對(duì)生物被膜念珠菌療效綠色念珠菌細(xì)胞壁，紅色代表有活性念珠菌。黃色提示念珠菌無(wú)活性，A-D依次為對(duì)照組、卡泊芬凈、脂質(zhì)體兩性霉素B、伏立康唑卡泊芬凈治療組念珠菌細(xì)胞壁嚴(yán)重破壞，且無(wú)活性；兩性霉素B脂質(zhì)體治療組念珠菌胞漿內(nèi)彌漫性黃染，提示念珠菌無(wú)活性；伏立康唑組念珠菌亦無(wú)活性，但形態(tài)破壞較卡泊芬凈組輕AntifungalSusceptibilityofCandidaBiofilms:UniqueEfficacyofAmphotericinBLipidFormulationsandEchinocandins.ANTIMICROBIALAGENTSANDCHEMOTHERAPY,June2002,46(6):1773–1780浮游白色念珠菌暴露抗真菌藥物24h后形態(tài)變化抗真菌藥物對(duì)生物被膜念珠菌療效A-D依次為對(duì)照組、卡泊芬凈、脂質(zhì)體兩性霉素B、伏立康唑卡泊芬凈治療組念珠菌細(xì)胞壁嚴(yán)重破壞，且無(wú)活性兩性霉素B脂質(zhì)體治療組念珠菌胞漿內(nèi)彌漫性黃染，提示念珠菌無(wú)活性，且念珠菌皺縮盡管伏立康唑組有少量無(wú)活性念珠菌，且細(xì)胞壁輕度受損，但伏立康唑組念珠菌受影響最小AntifungalSusceptibilityofCandidaBiofilms:UniqueEfficacyofAmphotericinBLipidFormulationsandEchinocandins.ANTIMICROBIALAGENTSANDCHEMOTHERAPY,June2002,46(6):1773–1780生物被膜相關(guān)白色念珠菌生長(zhǎng)48h暴露抗真菌藥物48h后形態(tài)變化抗真菌藥物對(duì)生物被膜念珠菌療效評(píng)價(jià)伏立康唑、泊沙康唑、卡泊芬凈、阿尼芬凈治療白色念珠菌、近平滑念珠菌生物被膜感染療效伏立康唑和泊沙康唑MIC分別為>256and>64mg/liter卡泊芬凈和阿尼芬MIC分別為<1and<2mg/literDifferentialActivitiesofNewerAntifungalAgentsagainstCandidaalbicansandCandidaparapsilosisBiofilms.ANTIMICROBIALAGENTSANDCHEMOTHERAPY.2008,51(1)：357–360白色念珠菌近平滑念珠菌棘白菌素類藥物治療重癥患者念珠菌感染優(yōu)勢(shì)5,(6)-carboxyfluoresceindiacetate(CFDA),羧基熒光素二醋酸酯5(6)-CFDA是膜透性染料，可通過孵化進(jìn)入細(xì)胞。一旦進(jìn)入細(xì)胞后，CFDA被細(xì)胞內(nèi)酯酶水解形成羧基熒光素bis-(1,3-dibutylbarbituricacid)trimethineoxonol(DiBAC),DiBAC4(3)是一種檢測(cè)細(xì)胞膜電位的親脂性陰離子熒光染料，它本身無(wú)熒光，當(dāng)進(jìn)人細(xì)胞與胞漿內(nèi)的蛋白質(zhì)結(jié)合后才發(fā)出熒光。DiBAC4(3)進(jìn)入細(xì)胞，細(xì)胞內(nèi)熒光強(qiáng)度增加，即膜電位增加表示細(xì)胞去極化;反之，細(xì)胞內(nèi)熒光強(qiáng)度降低即膜電位降低表示細(xì)胞超極化耐氟康唑念珠菌對(duì)棘白菌素敏感性高卡泊芬凈對(duì)耐氟康唑念珠菌，仍保持殺菌活性與唑類無(wú)交叉耐藥AntifungalSpeciesSusceptibleS-DDIntermediateResistantCaspofunginC.albicans≤0.25-0.5≥1C.glabrata≤0.12-0.25≥0.5C.krusei≤0.25-0.5≥1C.parapsilosis≤24-≥8C.tropicalis≤0.25-0.5≥1Activitiesofmicafunginagainst315invasiveclinicalisolatesoffluconazole-resistantCandidaspp.JClinMicrobiol.2006Feb;44(2):324-6.

1.ExpertOpin.Pharmacother.FungicidalversusFungistatic:what'sinaword?2008,9(6):927-935.2.EurJClinMicrobiolInfectDis.2004;23:805–812.TheAntifungalEchinocandinCaspofunginAcetateKillsGrowingCellsofAspergillusfumigatusInVitro.ANTIMICROBIALAGENTSANDCHEMOTHERAPY,Sept.2002,p.3001–3012Vol.46,No.9Currentpharmacologicalconceptsforwiseuseofechinocandinsinthetreatmentofcandidainfectionsinsepticcriticallyillpatients.ExpertRev.Antiinfectther.2013,11(3):989-9971.ExpertOpin.Pharmacother.FungicidalversusFungistatic:what'sinaword?2008,9(6):927-935.2.EurJClinMicrobiolInfectDis.2004;23:805–812.棘白菌素類藥物治療重癥患者念珠菌感染優(yōu)勢(shì)

殺菌劑vs抑菌劑治療侵襲性念珠菌感染，初始治療選用殺菌作用的抗真菌藥物與氟康唑比較，棘白菌素類藥物治療優(yōu)勢(shì)RapidfungicidalactivityAnti-biofilmactivityUnchangedactivityagainstCandidaspp.ShowingdecreasedsusceptibilitytofluconazoleandtootherazolesAnti-cytokineandanti-chemokineactivity2009指南推薦中心靜脈導(dǎo)管相關(guān)血流感染處理原則對(duì)于經(jīng)驗(yàn)性治療疑似導(dǎo)管相關(guān)念珠菌血癥，選用棘白菌素類藥物，或者，在部分患者，選用氟康唑(A-II)Forempiricaltreatmentofsuspectedcatheter-relatedcandidemia,useanechinocandinor,inselectedpatients,fluconazole.A-II氟康唑用于近3個(gè)月內(nèi)唑類無(wú)藥物暴露史，且克柔念珠菌或光滑念珠菌感染風(fēng)險(xiǎn)非常低(A-III)Fluconazolecanbeusedforpatientswithoutazoleexposureintheprevious3monthsandinhealthcaresettingswheretheriskofCandidakruseiorCandidaglabratainfectionisverylow.A-IIIClinicalPracticeGuidelinesfortheDiagnosisandManagementofIntravascularCatheter-RelatedInfection:2009UpdatebytheInfectiousDiseasesSocietyofAmerica.ClinicalInfectiousDiseases2009;49:1–45AntifungalLockTherapy.AntimicrobAgentsChemother.2013Jan;57(1):1-8.2009IDSA抗念珠菌治療指南

未提及念珠菌生物被膜危害近期有唑類藥物暴露史且伴有嚴(yán)重感染、感染性休克，選擇棘白菌素類藥物懷疑中心靜脈導(dǎo)管導(dǎo)致發(fā)熱，如果可能，及早拔出靜脈導(dǎo)管一旦為念珠菌導(dǎo)管相關(guān)感染，立即抗真菌治療，療程至臨床癥狀消失和血培養(yǎng)最后一次陽(yáng)性后兩周(D級(jí))44ClinicalPracticeGuidelinesfortheManagementofCandidiasis:2009UpdatebytheInfectiousDiseasesSocietyofAmerica.ClinicalInfectiousDiseases2009;48:503–35抗念珠菌治療(2011ATSGuideline)

未提及念珠菌生物被膜危害懷疑中心靜脈導(dǎo)管導(dǎo)致發(fā)熱，應(yīng)立即拔除導(dǎo)管(A級(jí))治療持續(xù)到末次血培養(yǎng)陽(yáng)性兩周后(D級(jí))若當(dāng)?shù)胤前啄钪榫l(fā)生率>10%或當(dāng)?shù)匕啄钪榫鷮?duì)氟康唑耐藥率高，強(qiáng)烈建議采用以兩性霉素B或棘白菌素類藥物為基礎(chǔ)的治療AnOfficialAmericanThoracicSocietyStatement:TreatmentofFungalInfectionsinAdultPulmonaryandCriticalCarePatients.AmJRespirCritCareMed.2011,183:96–1282012ESCMID非粒缺成人患者

侵襲性念珠菌感染指南血培養(yǎng)酵母菌陽(yáng)性(AII)或經(jīng)驗(yàn)治療(CIIu)開始抗真菌治療Stronglyrecommended:棘白菌素(A-I)Moderatelyrecommended:L-AMBor伏立康唑(B-I)Marginallyrecommended:氟康唑orABLC(C-I)recommendationagainstuse(D):AMB伊曲康唑泊沙康唑聯(lián)合治療ClinMicrobiolInfect2012;18(Suppl.7):1–8ClinMicrobiolInfect2012;18(Suppl.7):9–18ClinMicrobiolInfect2012;18(Suppl.7):19–37u-uncontrolledtrials2009IDSA2012