真菌性腹膜透析导管出口感染合并隧道感染1例  

Fungal peritoneal dialysis catheter-related exit-site infection combined with tunnel infection:A case report

作　　者：乔婕[1] 芦丽霞[1] 何玉婷 门春翠 楚新新 武蓓[1] 赵慧萍[1] 王梅[1] QIAO Jie;LU Li-xia;HE Yu-ting;MEN Chun-cui;CHU Xin-xin;WU Bei;ZHAO Hui-ping;WANG Mei(Department of Nephrology,Peking University People’s Hospital,Beijing 100044,China)

机构地区：[1]北京大学人民医院肾内科,北京100044

出　　处：《北京大学学报（医学版）》2023年第4期748-754,共7页Journal of Peking University:Health Sciences

基　　金：北京大学人民医院研究与发展基金(RDN 2013-02)。

摘　　要：腹膜透析(peritoneal dialysis,PD)导管相关感染(即出口感染和隧道感染)是PD相关腹膜炎的主要诱因之一,如不能有效控制,严重者可导致腹膜透析导管拔除、腹膜透析技术失败,因此积极预防和及时有效的诊治以减少导管相关感染是PD患者日常管理的重要目标。腹膜透析导管出口感染和隧道感染可由多种微生物引起,以细菌为主,真菌极为罕见,目前可用来指导治疗的公开数据很少,且国内尚未见报道。一旦继发真菌性腹膜炎,患者只能退出腹膜透析治疗。现将北京大学人民医院肾内科成功诊治的1例真菌性腹膜透析导管出口感染合并隧道感染的病例分享如下,患者女性,71岁,因“腹膜透析5年,出口处分泌物8天,加重1天”就诊。患者5年间多次患腹膜炎、PD导管出口感染及隧道感染,涉及多种病原体。8 d前评估患者出口见白色黏稠分泌物,距出口1 cm处皮肤暗红、发硬,浅层涤纶套完全脱出、摩擦出口边缘,Schaefer出口评分3分。因2个月前可疑出口感染,分泌物培养铜绿假单胞菌阳性,故再次留取分泌物细菌培养后,每日1次局部使用庆大霉素注射液外敷经验性治疗。1 d前评估出口发现皮下隧道段距出口2.5 cm处明显肿胀、轻压痛,可见白色中量黏稠分泌物,出口评分4分。化验腹膜透析流出液常规(-);先后两次复查出口分泌物细菌培养,近平滑念珠菌均阳性,故真菌性PD导管出口感染合并隧道感染诊断明确。立即寻找出口、隧道感染的原因及诱因,发现患者足部可疑灰趾甲病史,此次趾甲涂片真菌阳性、可见菌丝;并每日用手洗脚,同时每天坐矮板凳洗衣服,使出口及隧道长期受到挤压。基于上述诱因,给予综合性治疗:针对出口、隧道真菌感染,根据药敏结果给予氟康唑全身用药、辅以出口局部碘伏消毒后硝酸咪康唑乳膏外用;针对脱出的浅层涤纶套,局部予每日碘伏消毒;同时予足部�Peritoneal dialysis(PD)catheter-related infection(i.e.exit-site infection and tunnel infection)is one of the main causes of PD-related peritonitis.If it cannot be controlled effectively,it could lead to PD technique failure.Therefore,timely and effective diagnosis and treatment and active prevention so as to reduce PD catheter-related infection is an important treatment goal in PD patients.PD catheter exit-site infection(ESI)and tunnel infection can be caused by a variety of microorganisms,mainly bacteria,while fungi are very rare.Few public data can be used to guide treatment of PD catheter-related fungal infection,and there is no related report in China till now.Once fungal peritonitis occurred,the patient can only withdraw from PD treatment.Here,we report a case of fungal PD catheter ESI combined with tunnel infection which was successfully diagnosed and treated in our PD center.A 71-year-old woman came to clinic because of“PD for 5 years,secretions from exit site for 8 days and aggravation for 1 day”.The patient suffered from peritonitis,ESI and tunnel infection for many times in the past 5 years,involving a variety of pathogens.Eight days before,she found white viscous discharge from exit site.The subcutaneous cuff completely came out of it and rubbed its skin.The Schaefer exit-site score was 3 points.Due to the suspected ESI 2 months before,the discharge swab for bacterial culture was positive for Pseudomonas aeruginosa,so the exit site swab for bacterial culture was done again,and gentamicin injection was applied topically once a day for empirical treatment.The exit site was evaluated one day before:The subcutaneous tunnel was significantly swollen and slightly tender at 2.5 cm away from the exit site,and with white medium amount of viscous secretions.The exit-site score increased to 4 points.Routine test of dialysis effluent was(-).The bacterial culture of the exit-site discharge was rechecked twice,and Candida parapsilosis was positive for two times,so the diagnosis of fungal PD catheter ESI combined

关 键 词：腹膜透析 出口感染 隧道感染 真菌 

分 类 号：R459.5[医药卫生—治疗学]