Cherif Honar, Kalin Mats, Björkholm Magnus
Division of Hematology, Karolinska University Hospital and Institutet, Stockholm, Sweden.
Eur J Haematol. 2006 Oct;77(4):288-92. doi: 10.1111/j.1600-0609.2006.00712.x. Epub 2006 Jul 19.
Historically, treatment of invasive fungal infections (IFI) has consisted of amphotericin B. However, new therapeutic agents have recently been introduced. At the same time, the relatively low incidence of IFI and the progress in the diagnostic accuracy of IFI have made routine use of empirical antifungal therapy questionable.
With the aim to define the present trends in the use of antifungal agents for the treatment of IFI, we prospectively observed type, safety, and efficacy of given antifungal treatment in patients with hematological malignancies during a recent 18-month period. We also analyzed the impact of restricted use of empirical antifungal therapy on IFI-related mortality.
A total of 279 episodes of neutropenia and fever following the chemotherapy were recorded. Treatment of IFI was given during the management of 41 (14%) episodes. Voriconazole (27 episodes) and caspofungin (14 episodes) were the only antifungal agents used as initial therapy. The rate of antifungal therapy success outcome was 78%. The overall 4-week mortality rate was 8%. Two patients died of invasive pulmonary aspergillosis. Empirical antifungal therapy was given in 13 episodes with persistent febrile neutropenia (PFN) and resulted in successful outcome in 92% of cases. In general, antifungal agents were well tolerated and only two patients had to discontinue treatment because of severe adverse event. In 127 episodes of PFN, antifungal therapy was deemed unnecessary and accordingly was not administered. In this subgroup of patients, no IFI-related mortality occurred.
A better tolerability and efficacy of voriconazole and caspofungin together with the availability of an oral formulation of voriconazole most probably contributed to the observed shift in the use of antifungal agents. A restricted use of empirical antifungal therapy was, in this setting, not associated with an increased IFI-related mortality.
从历史上看，侵袭性真菌感染（IFI）的治疗一直使用两性霉素B。然而，最近引入了新的治疗药物。与此同时，IFI相对较低的发病率以及IFI诊断准确性的提高使得经验性抗真菌治疗的常规使用受到质疑。
为了确定目前使用抗真菌药物治疗IFI的趋势，我们前瞻性地观察了近期18个月期间血液系统恶性肿瘤患者接受的抗真菌治疗的类型、安全性和疗效。我们还分析了经验性抗真菌治疗的限制性使用对IFI相关死亡率的影响。
共记录了279例化疗后中性粒细胞减少和发热的病例。在41例（14%）病例的治疗过程中给予了IFI治疗。伏立康唑（27例）和卡泊芬净（14例）是仅用作初始治疗的抗真菌药物。抗真菌治疗成功的比例为78%。总体4周死亡率为8%。两名患者死于侵袭性肺曲霉病。13例持续性发热性中性粒细胞减少（PFN）患者接受了经验性抗真菌治疗，92%的病例治疗成功。总体而言，抗真菌药物耐受性良好，只有两名患者因严重不良事件不得不停止治疗。在127例PFN病例中，认为不需要抗真菌治疗，因此未给予治疗。在该亚组患者中，未发生IFI相关死亡。
伏立康唑和卡泊芬净具有更好的耐受性和疗效，以及伏立康唑口服制剂的可用性，很可能促成了观察到的抗真菌药物使用转变。在这种情况下，经验性抗真菌治疗的限制性使用与IFI相关死亡率的增加无关。
