Fungemia in Massively Burned Patients

　　　　　在1989年1月至1992年3月間，林口長庚醫院灼傷中心共治療1322位病人。灼傷面積大於40%體表面積之嚴重灼傷共有152人。有24位嚴重灼傷病人在住院中曾有一處或一次以上之微生物培養檢查發現黴菌。其中有14位在血液中培養出黴菌，且全為念珠菌屬，平均灼傷面積為58%。有10位病人出現全身性散播之現象（明顯之敗血症感染徵候，且除血液外，另有二處培養出相同之黴菌）。經手術清創及拔除感染或不必要之周邊與中心靜脈導，尿管，和胃管等可能感染源外，並且給予Amphotericin B等抗黴菌藥物治療。其中3位因併發多器官衰竭而死亡。3位黴菌血症病人為導管引致之過性黴菌血症，於拔除導管後，並未給予抗黴菌藥物，黴菌血症即消失，亦無死亡病例。本報告中嚴重灼傷併黴菌血症患者之死亡率為21%, 較文獻報告為低，與同灼傷面積之灼傷病人死亡率亦相近。
　　　　　This is a retrospective study of fungemia in the Linkou burn center of Chang Gung Memorial Hospital. A total of fourteen cases with at least two consecutive positive blood cultures for fungus were reviewed. The rate of fungemia in massive burn patients (burn area over 40% of total body surfacearea) was 9.2% (14/152). The mortality rate was 21.4% (3/14). In order to discuss the predisposing factors, diagnosis, treatment, and mortality, these fourteen patients were divided into three groups: clinically disseminated infection, isolated fungemia, or transient catheter related fungemia according to their clinical course retrospectively. The result of this study shows: 1) the indwelling catheter is an important port of entry other than the extensive burn wound in fungemia; 2) with close monitoring and careful dosing, amphotericin B was the drug of choice to treat disseminated fungal infection; 3) the mortality rate can be decreased by aggressive early escharectomy and grafting, avoidance of invasive central line if possible, and judicious use of antibiotics and antifungal agents.