Upper respiratory tract mycoses: current status and problems

In the new age of medicine came from the developed area of ​​medical mycology. The last decades even called "golden age" of medical mycology, implying the progress made in diagnosis and treatment of fungal infections - yeast infections of man.

Mainstreaming fungal infections, which has become particularly noticeable since the mid XX century, due to a number of reasons: first, the increasing number of diseases associated with immunodeficiency, the success of antibiotic therapy (the place of bacteria in the ecosystem occupied by micromycetes), the introduction of new medical technologies, etc. At the moment, described about 100 species of pathogenic and 400 opportunistic fungi [1,2,3].

In the past two decades in foreign countries, Russia, Kazakhstan and Ukraine registered growth in the number of superficial and deep mycoses, including the ENT [3,4,5]. In our country no such data. Currently, there is a problem in Belarus organization and development of laboratory services mycological and clinical mycology (education and training). Development of transplantation, hematology and oncology in general, environmental degradation (effects of ionizing radiation) leads eventually to the formation of a population of people with secondary immunodeficiency and increased susceptibility to fungal diseases. The problem of fungal infections affect primarily infectious diseases, gynecologists, Dermatovenereologists, hematologists, oncologists, pulmonologists, otolaryngologists. Need for more widespread adoption and coverage of medical mycology in medical universities of the country.

Problem identification and treatment of fungal infections in otolaryngology has become increasingly important for several reasons: widespread, more severe course of this disease, changes in the spectrum of mycobiota and increase resistance to fungal antimycotic drugs [4,5]. Fungal infections of the upper respiratory tract infection (TTP) are much more often than diagnosed. Mucosa and skin VAR are the first barrier and the most frequent site of colonization for mycotic infections [6,7]. Often the etiologic role of fungi in inflammatory diseases of the VAR is estimated not to reflect a misconception of the nature of disease and, consequently, leads to a waste treatment. Diagnosis of these diseases presents certain difficulties, since there are no pathognomonic clinical signs, and the main proof of mycosis is the detection of the pathogen in the patient's substrates [5,8]. Over the last decade has seen a change in the spectrum mycobiota and increasing levels of resistance Candida ═ Candida albicans and strains ═ non - albicans to fluconazole, which is the drug of choice for treating most clinical forms of candidiasis [9]. Effective therapy for fungal infections VDP is an essential species identification and susceptibility of pathogens to antifungal drugs [4,10]. The lack of recent data in the literature of a fungal, corrosive TTP is a condition often incorrect diagnosis of fungal infections and the choice of antimycotic drug.

Since the monograph VJ Kunelskoy "Mycoses in otorhinolaryngology" (1989) has been 20 years, many questions pathogenesis, diagnosis and treatment need to be revised [11]. Selection of a suitable antimycotics on the basis of determining the sensitivity of the pathogen in vitro is more cost effective than empirical substitution of one drug by another [4.9]. Lack of available methods for determining the sensitivity of fungi and the lack of technical equipment does not allow for them in every clinical microbiology laboratory.

Objective: to study the spectrum of TTP mycobiota in diseases of upper respiratory tract and the level of resistance to the main antimycotic drugs clinically important strains of rational empirical treatment of fungal infections in otorhinolaryngology.

Materials and methods

We performed mycological examination of 147 patients aged 18 to 64 years with clinical signs of fungal infection of TTP that were examined and treated in the ENT clinic GoGMU and consultative outpatient department RSPC Radiation Medicine and Human Ecology in 2006 2008yy. Collection of material produced prior to the antibiotic and antimycotic therapy. Transportation is carried out for 2-3 hours in a tube of transport medium Amiesa. Identification, to determine the sensitivity of fungi and data analysis were performed with a microbiological analyzer miniAPI firm bioMerieux (France). Used for identification plates (strips) that contain dehydrated biochemical substrates (16 to 32testov). Excluded culture without clinical significance. Susceptibility to antifungal drugs (flyutsitozinu, amfoteritsinuV, fluconazole, itraconazole and voriconazole) was performed on strips (ATB FUNGUS-3) from bioMerieux (France) cells were adapted to the requirements of the standard method of dilution of the Institute of Clinical Laboratory Standards (CLSI) - NCCLS M- 44, United States. For quality control used in determining the sensitivity of the control strains of the American Collection of Microorganisms (ATCC).

Results and Discussion

Patients assigned to nosological forms as follows: laringomikoz - 41 (27.9%), faringomikoz - 45 (30.6%), faringolaringomikoz - 35 (23.8%), fungal rhinosinusitis - 26 (30.6%) (Figure .1). ═

In Fig. 1. Nosological structure of mycosis TTP

The main demographic characteristics of patients are presented in Table 1.

Table 1

It should be noted that in patients with laryngo-and faringolaringomikozami dominate men (87.8% and 74.3% respectively) at 51 ╠ 4,5 years. This fact is likely due to similar reasons, as well as chronic hyperplastic laryngitis.

The dominant species in the laryngo-and faringomikozah are Candida albicans (72%), C. krusei (10%). Rarely isolated C. Parapsilosis (2,8%), C. Valida (2,8%), C. Tropicalis (1,4%) and C. Glabrata (1,4%), Geotrichum ═ capitatum (4%), Aspergillus ═ spp. and Penicillium ═ spp. (5,5%) (Fig. 2). Fungal rhinosinusitis increasingly important Mycobiota mold: Aspergillus ═ fumigatus (niger, flavus) (60%), Penicillium ═ spp. (20%), Alternaria (3,3%); rarer C. albicans (10%) and C. non - albicans (6,7%) (Fig. 3).

In Fig. 2. The spectrum of mycobiota in laryngo-and faringomikozah.

In Fig. 3. The spectrum of mycobiota in rhinosinusitis

As a result, sensitivity to antimycotic drugs produced the following results. As a leading agent of candidiasis, C. Albicans retains high sensitivity to fluconazole (86%) and itraconazole (82%). The increasing importance of the etiologic fungus in faringolaringomikozah of Candida ═ non - albicans (18,4%) recorded a relatively high level of resistance to fluconazole: C. krusei (100%), C. valida (67%), C. t ropicalis (60%) and C.glabrata (33%). Stability ═ Candida ═ non - albicans to itraconazole does not exceed 17%. All isolates of Candida fungi ═ (100%) susceptible to amphotericin B and voriconazole,. Geotrichum ═ capitatum are sensitive only to amphotericin B and voriconazole. Mold resistant (100%) to fluconazole, amphotericin B sensitive (100%), voriconazole (100%), itraconazole (98%). Based on the data on the etiology and fungal pathogens антимикотикорезистентности TTP, as well as considering their own clinical experience [12], we can conclude the feasibility, efficacy and safety of itraconazole (mikotroks) in the treatment of this disease.

Findings

1. Given the prevalence of Candida TTP is necessary to introduce the practice of clinical microbiology laboratories available standard methods for identification and susceptibility of pathogens Candida.

2. When faringolaringomikozah leading etiologic agent in our region is C.albicans (72%) and C. krusei (10%). Mycobiota mold (Aspergillus ═ spp., Penicillium ═ spp.) has a dominant role in fungal rhinosinusitis (83.3%).

3. The data on the activity of fluconazole in vitro allow you to continue using it as a drug of choice for treating most forms of Candida TTP.

4. To conduct antimycotic therapy in detecting mold mycobiota drug of choice is itraconazole. Drugs for the treatment of fungal infections reserve TTP in the present conditions are voriconazole and amphotericin B.

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