Chamilos Georgios, Kontoyiannis Dimitrios P
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M. D. Anderson Cancer Center, Houston, USA.
Curr Opin Infect Dis. 2006 Aug;19(4):380-5. doi: 10.1097/01.qco.0000235166.16421.e5.
Despite expansion of the antifungal armamentarium over the past decade, the mortality rate for invasive fungal infections remains high in severely immunocompromised patients. Furthermore, in recent years, difficult-to-treat invasive infections caused by rare molds and yeasts have emerged in high-risk patients receiving antifungal prophylaxis or empirical treatment. Antifungal combinations are increasingly used in clinical practice to improve outcomes for refractory mycoses because of the suboptimal efficacy of current antifungal agents. Herein we review recent advances in the area of antifungal combinations in high-risk patients to separate empiricism from evidence-based medicine.
Thus far, the benefits of combination antifungal therapy have been difficult to prove for invasive fungal infections other than cryptococcal meningitis. The recent introduction of a new class of antifungal agents (the echinocandins) and extended-spectrum triazoles has rejuvenated interest in studying those combinations for difficult-to-treat aspergillosis, as recent observational studies show promise.
In view of the evolving epidemiology of invasive fungal infections, combination antifungal therapy could be most valuable in preemptive management of carefully selected high-risk patients; however, this should be studied in appropriate trials.
尽管在过去十年中抗真菌药物不断增加，但严重免疫功能低下患者侵袭性真菌感染的死亡率仍然很高。此外，近年来，在接受抗真菌预防或经验性治疗的高危患者中出现了由罕见霉菌和酵母菌引起的难以治疗的侵袭性感染。由于目前抗真菌药物的疗效欠佳，抗真菌联合治疗在临床实践中越来越多地用于改善难治性真菌病的治疗效果。在此，我们综述高危患者抗真菌联合治疗领域的最新进展，以区分经验治疗与循证医学。
到目前为止，除隐球菌性脑膜炎外，抗真菌联合治疗对其他侵袭性真菌感染的益处难以证明。最近一类新型抗真菌药物（棘白菌素）和广谱三唑类药物的引入，重新激发了人们对研究这些联合用药治疗难治性曲霉病的兴趣，因为最近的观察性研究显示出了前景。
鉴于侵袭性真菌感染的流行病学不断变化，抗真菌联合治疗在对精心挑选的高危患者进行抢先治疗中可能最有价值；然而，这应该在适当的试验中进行研究。
