真菌评分在侵袭性念珠菌感染诊断中的应用价值

Ningxia Medical UniversityThesis for Application of Master’s DegreeEvaluation of fungal score in the diagnosis of Invasive CandidainfectionStudent’s Name:Xu YujieSuprevisor:Ma XiaoweiSubject Category:MedicineMajor:Emergency MedicineSpecialty:Critical Care MedicineSchool:Department of Clinical MedicimeCompletion Date:Mar. 2015真菌评分在侵袭性念珠菌感染诊断中的应用价值摘要目的：本研究旨在通过评价弗吉尼亚评分、Sevilla评分及Candida score评分三种预测危重症患者罹患侵袭性念珠菌感染的评分方法在侵袭性念珠菌感染诊断中的临床应用，探讨真菌评分在临床诊断侵袭性念珠菌感染的应用价值,为临床早期诊断与治疗侵袭性念珠菌感染提供有效依据。

方法：1、回顾性收集2011年1月到2014年12月宁夏医科大学总医院ICU科收治的106例侵袭性念珠菌感染高危患者的临床资料(个体的一般情况、患者预后、既往病史、细菌学相关培养等），以2007年中华医学会重症医学分会制定的“重症患者侵袭性真菌感染的诊断和治疗指南”制定的诊断标准，将患者分为确诊、临床诊断、拟诊和非感染四组；2、按照真菌评分系统制定的标准，对四组患者进行弗吉尼亚评分、Sevilla 评分及Candida score评分三种评分（评分阳性标准：弗吉尼亚评分≥30分，Sevilla评分≥12分，Candida score评分≥3分，评分阳性认为患者感染侵袭性念珠菌风险大）。

将确诊、临床诊断组作为阳性对照，将非感染组作为阴性对照，分别计算三种评分方法的灵敏度、特异度、阳性预测值、阴性预测值，评价三种评分方法的临床应用价值。

结果：1、纳入的106例患者中，5例确诊为侵袭性念珠菌感染，44例临床诊断为侵袭性念珠菌感染，9例拟诊为侵袭性念珠菌感染，48例为非侵袭性念珠菌感染。

三种评分阳性结果在确诊、临床诊断、拟诊和非感染侵袭性念珠菌感染四组中所占比例分别是：①弗吉尼亚评分:60%、65.9%、55.6%、60.4%；②Sevilla评分：60.0%、50.0%、0%、8.3%；③Candida score评分：80%、72.7%、33.3%、29.2%。

2、将确诊、临床诊断组作为阳性对照，将非感染组作为阴性对照,三种评分的灵敏度、特异度、阳性预测值、阴性预测值分别是：①弗吉尼亚评分:0.86、0.40、0.52、0.53；②Sevilla评分:0.55、0.96、0.93、0.68；③Candida score评分：0.74、0.71、0.72、0.72。

3、三种评分方法联合应用，（1）平行试验：①弗吉尼亚评分联合Sevilla评分灵敏度为0.84，特异度为0.4，阳性预测值0.59，阴性预测值0.70，约登指数0.24。

②Sevilla 评分联合Candida score评分灵敏度为0.80，特异度为0.71，阳性预测值0.77，阴性预测值0.77，约登指数为0.51。

③弗吉尼亚评分联合Candida score评分灵敏度为0.80，特异度为0.35，阳性预测值0.55，阴性预测值0.63，约登指数为0.15。

（2）序列试验：①弗吉尼亚评分联合Sevilla评分灵敏度为0.37，特异度为0.98，阳性预测值0.95，阴性预测值0.60，约登指数为0.35。

②Sevilla评分联合Candida score评分灵敏度为0.45，特异度为0.98，阳性预测值0.96，阴性预测值0.66，约登指数为0.43。

③弗吉尼亚评分联合Candida score评分灵敏度为0.59，特异度为0.79，阳性预测值0.80，阴性预测值0.66，Youden指数为0.38。

结论：1、弗吉尼亚评分灵敏度较高，但特异度较低，单独使用误诊率偏高。

2、Sevilla评分具有较好的灵敏度和特异度，可单独应用指导侵袭性念珠菌感染的早期诊断。

3、Candida score评分诊断侵袭性念珠菌感染与指南制定标准确诊、临床诊断侵袭性念珠菌感染总符合率最高，临床有应用价值。

4、Sevllia 评分与Candida score评分联合应用时，灵敏度及特异度均较单独使用增高，综合诊断能力好，联合应用指导早期诊断侵袭性念珠菌感染的临床意义更大。

关键词：真菌评分，侵袭性念珠菌感染，诊断Evaluation of fungal score in the diagnosis of Invasive CandidainfectionABSTRACTObjective: The study is designed to assess the ability of Virginia score,Sevilla score and Candida score which identify patients with high risk of invasive candida infection in clinical application,and provide efective basis of clinical esrly diagnosis and treatment of invasive candida infection.Methods: 1. Retrospectively collecting clinical data of 106 patients with high risk of invasive candida infection(general information of the individual, prognosis, medical history, bacteriology related training, etc) treated in the ICU department of Ningxia medical university general hospital from January 2011 to December 2014.,taking "Severe invasive fungal infection in patients with the diagnosis and treatment guidelines" formulated in intensive medical branch of Chinese medical association in 2007 as diagnostic criteria, we divided the patients into proven,probable,possible and non-invasive candida infections four groups.2.According to the standard of the fungal scoring system,marking the four groups of patients with Virginia score,Sevilla score and Candida score(positive:Virginia score≥30 points, Sevilla scoring≥ 12 points, Candida score≥ 3 points.Positive means the patients are at high risk of invasive candida infection) Taking the proven and probable two groups as the positive contrast,the non-invasive infection group as a negative control,we calculated and compare the difference of the three fungal scoring systems in sensitivity, specific, positive predictive value, negative predictive value, positive likelihood ratio,negative likelihood ratio and Youden index,and then evaluate the clinical value of them.Results:1. In 106 patients,5 cases were diagnosed as proven,44 cases as probable, 9 cases as possible and 48 cases as non-invasive infection. The positive results of the threefungal scoring systems in the proven,probable,possible and non-invasive candida infections are:Virginia score:60%,65.9%,55.6%,60.4%; Sevilla score: 60.0%,50.0%,0%,8.3%; Candida score:80%,72.7%,33.3%,29.2%.2.Taking the proven and probable two groups as the positive contrast,the non-invasive infection group as a negative control, the Sensitivity, specificity, positive predictive value, and negative predictive values of the three fungal scoring systems are:Virginia score: 0.86, 0.40, 0.52,0.53; Sevilla score:0.55,0.96,0.93,0.68;Candida score:0.74,0.71,0.72,0.72.3. Combine the three scoring systems: parallel test: Virginia score combined with Sevilla score:sensitivity is 0.84,specificity is 0.4, positive predictive value is 0.59, negative predictive value is 0.70, the Youden index of 0.24. Sevilla score combined CS :sensitivity is 0.80, specificity is 0.71, positive predictive value is 0.77, negative predictive value is 0.77, the Youden index is 0.51. Virginia score combined with CS: sensitivity is 0.80, specificity is 0.35, positive predictive value is 0.55, negative predictive value is 0.63, the Youden index is 0.15. Sequence test: Virginia score combined with Sevilla score: sensitivity is 0.37, specificity is 0.98, positive predictive value is 0.95, negative predictive value is 0.60, the Youden index is 0.35. Sevilla score combined CS:sensitivity is 0.45,specificity is 0.98, positive predictive value is 0.96, negative predictive value is 0.66, the Youden index is 0.43. Virginia score combined with CS: sensitivity degree is 0.59, specificity is 0.79, positive predictive value is 0.80, negative predictive value is 0.66, the Youden index is 0.38.Conclusion:1.Virginia score has higher sensitivity but low specificity, the misdiagnosis rate is high.2.There is well sensitivity and specificity both in sevilla scoring , which could guide the early diagnosis of invasive candida infection separately;3. Compared with the guide, there is highest total diagnosis coincidence rate in Candida score, which is conducive to clinical application ;4. Combined Sevilla scoring with CS , the sensitivity and specificity increased than usedalone, the comprehensive diagnosis is competent to guide the early diagnosis of invasive candida infection better .Keywords: Fungal score, Invasive Candida infections, diagnosis中英文缩略词表缩写英文全称中文全称ICI Invasive candida infection 侵袭性念珠菌感染APACHE II Acute physiology and chronic healthevaluation II score 急性生理和慢性健康状况评分IIICU Intensive care unit 危重病加强医疗科MDRA Multi diseases risk assessment program多种疾病风险评估方案CS Candida score 念珠菌评分Se Sensitivity 灵敏度Sp Specificity 特异度PPV Positive predictive value 阳性预测值NPV Negative predictive value 阴性预测值+LR Positive likelihood ratio 阳性似然比-LR Negative likelihood ratio 阴性似然比ROC Receive operating characteristic curve 受试者工作特征曲线IFI Invasive fungal infections 侵袭性真菌感染IFIRSS Invasive fungal infections risk scoring system 侵袭性真菌感染风险评分系统目录前言 (1)材料与方法 (4)结果 (8)讨论 (15)结论 (21)参考文献 (22)文献综述 (26)综述参考文献 (31)前言侵袭性念珠菌感染（Invasive Candida infection ICI）是指念珠菌侵入人体组织或血液,并在其中生长繁殖导致组织损害、器官功能障碍和炎症反应的病例改变及病理生理过程。