血液肿瘤患儿侵袭性真菌感染诊治和管理策略

doi:10.12372/jcp.2023.23e0416

摘要/Abstract

摘要：

侵袭性真菌病(IFD)是血液肿瘤治疗过程中最常见的感染类型之一，对于血液肿瘤患儿预后具有重要影响。近年来随着病原分子检测技术的发展以及新型抗真菌药物的应用，血液肿瘤患儿IFD的预后已经得到很大的改善，但是仍面临诊断困难、病情复杂以及治疗药物选择难的挑战。文章根据目前的研究进展和最新的诊疗指南，阐述血液肿瘤患儿IFD的风险因素、临床特征、治疗方案、预后情况等，以期更好地帮助广大儿科医师了解血液肿瘤患儿IFD的预防、管理及治疗。

关键词: 侵袭性真菌感染, 血液肿瘤, 诊治策略, 治疗, 儿童

Abstract:

Invasive fungal disease (IFD) is one of the most common types of infection in the treatment of hematologic malignancies and has a significant impact on the prognosis of pediatric patients with hematologic malignancies. In recent years, with the development of pathogen molecular detection techniques and the application of new antifungal drugs, the prognosis of IFD in pediatric patients with hematologic malignancies has been greatly improved. However, challenges such as diagnostic difficulties, complex disease conditions, and the selection of treatment drugs still exist. This article summarizes the current research progress and the latest diagnostic and therapeutic guidelines to elucidate the risk factors, clinical features, treatment strategies, and prognosis of IFD in pediatric patients with hematologic malignancies, aiming to better assist pediatricians in understanding the prevention, management, and treatment of IFD in pediatric patients with hematologic malignancies.

Key words: invasive fungal disease, hematologic malignancies, diagnostic and therapeutic guidelines, treatment, child

沈楠, 杜白露. 血液肿瘤患儿侵袭性真菌感染诊治和管理策略[J]. 临床儿科杂志, 2023, 41(8): 571-577.

SHEN Nan, DU Bailu. Strategies for the diagnosis, treatment, and management of invasive fungal infections in children with hematologic neoplasms[J]. Journal of Clinical Pediatrics, 2023, 41(8): 571-577.

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风险水平	风险因素
高风险（>10%）	AML、复发性急性白血病、高风险急性淋巴细胞白血病（ALL）^1）、异体HSCT、GVHD
低风险（<5%）	标准风险或低风险ALL、非霍奇金淋巴瘤、自体HSCT
极低风险	霍奇金淋巴瘤、小儿实体肿瘤、脑肿瘤
未知	CAR-T细胞治疗、其他免疫疗法

病原体	一线治疗	替代方案
念珠菌病
念珠菌血症	棘白菌类、两性霉素B脂质体	伏立康唑、伊曲康唑、氟康唑
播散性念珠菌病	中性粒细胞缺乏：棘白菌类、两性霉素B脂质体、伏立康唑无中性粒细胞缺乏：氟康唑、伊曲康唑	— ?
中枢神经系统念珠菌病	两性霉素B脂质体、伏立康唑	氟康唑
曲霉菌病
初始治疗	伏立康唑	两性霉素 B 脂质体
挽救治疗	两性霉素 B 脂质体、泊沙康唑、伊曲康唑	卡泊芬净、米卡芬净
预防治疗	泊沙康唑、伏立康唑、伊曲康唑	卡泊芬净、米卡芬净
毛霉病
初始治疗	两性霉素B脂质体、两性霉素B脂质体联合泊沙康唑	泊沙康唑静脉制剂
挽救治疗	泊沙康唑静脉制剂	泊沙康唑肠溶片或口服混悬液
其他少见真菌
耶氏肺孢子菌	复方磺胺甲噁唑	克林霉素联合伯氨喹、卡泊芬净
马尔尼菲篮状菌	两性霉素B脂质体联合/不联合伊曲康唑	伏立康唑
镰刀菌病	伏立康唑、伏立康唑联合两性霉素B脂质体、伏立康唑联合两性霉素B脂质复合物	两性霉素B脂质体、两性霉素B脂质复合物
赛多孢子菌病	伏立康唑	伏立康唑联合两性霉素B脂质体或两性霉素B脂质复合物
播散性暗色丝孢霉病	泊沙康唑、伏立康唑联合棘白菌类、伏立康唑联合特比萘芬	两性霉素B脂质体联合/不联合棘白菌类或特比萘芬
帚霉感染	伏立康唑	两性霉素B脂质体联合/不联合伏立康唑
播散性青霉菌病	两性霉素B脂质体（联合/不联合其它抗真菌药物）	—