Tsuruta Ryosuke, Mizuno Hidekazu, Kaneko Tadashi, Oda Yasutaka, Kaneda Kotaro, Fujita Motoki, Inoue Takeshi, Kasaoka Shunji, Maekawa Tsuyoshi
Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan.
Ann Pharmacother. 2007 Jul;41(7):1137-43. doi: 10.1345/aph.1K010. Epub 2007 May 29.
The Japanese Guidelines for the Diagnosis and Treatment of Deep-Seated Mycosis were established in 2003. Proven Candida infection (CI) is defined as at least one positive blood culture yielding a Candida species. Clinically documented CI requires documentation of more than 2 sites of colonization and a positive plasma beta-D-glucan test. Possible CI is diagnosed by one of the above criteria in febrile, nonneutropenic critically ill patients.
To assess the use of definitions of clinically documented and possible CI for guiding preemptive antifungal therapy in critically ill patients.
The patients treated in our intensive care unit (ICU) for at least 48 hours between 2000 and 2004 were investigated. The administration of antifungal agents and ICU mortality were compared among proven, clinically documented, and possible CI groups for age, sex, APACHE II score, diagnosis, length of ICU stay, treatment, number of colonization sites, and plasma beta-D-glucan level.
Six patients were diagnosed with proven CI, 25 were diagnosed with clinically documented CI, and 104 with possible CI. The patients with clinically documented CI were compared with those with possible CI, and statistically significant differences were found in the following variables: APACHE II score (p = 0.018), length of ICU stay (p < 0.01), use of ventilator (p = 0.027), tracheotomy (p = 0.027), number of colonization sites (p < 0.001), plasma beta-D-glucan level (p < 0.001), and administration of antifungal agents (p < 0.001); incidence of mortality was not statistically significant (p = 0.33). The shorter length of ICU stay, use of ventilator, and continuous hemodiafiltration were risk factors for death after adjusting for APACHE II score, admission before/after 2003, antifungal therapy, and other factors. Although the frequency of the administration of preemptive antifungal therapy was higher after 2003 than before, the mortality rate did not differ significantly.
The use of the definitions of clinically documented and possible CI may be beneficial for determining when it is appropriate to initiate preemptive antifungal therapy. However, use of the guidelines did not lead to prevention of possible CI proceeding to clinically documented CI or to improved mortality.
《日本深部真菌病诊断与治疗指南》于2003年制定。确诊的念珠菌感染（CI）定义为至少一次血培养念珠菌属阳性。临床记录的CI需要记录2个以上定植部位且血浆β-D-葡聚糖检测呈阳性。在发热、非中性粒细胞减少的重症患者中，符合上述任一标准即可诊断为可能的CI。
评估临床记录的CI和可能的CI定义在指导重症患者抢先抗真菌治疗中的应用。
对2000年至2004年期间在我们重症监护病房（ICU）治疗至少48小时的患者进行调查。比较确诊、临床记录和可能的CI组在年龄、性别、急性生理与慢性健康状况评分系统II（APACHE II）评分、诊断、ICU住院时间、治疗、定植部位数量和血浆β-D-葡聚糖水平方面的抗真菌药物使用情况和ICU死亡率。
6例患者被诊断为确诊的CI，25例为临床记录的CI，104例为可能的CI。将临床记录的CI患者与可能的CI患者进行比较，发现以下变量存在统计学显著差异：APACHE II评分（p = 0.018）、ICU住院时间（p < 0.01）、呼吸机使用情况（p = 0.027）、气管切开术（p = 0.027）、定植部位数量（p < 0.001）、血浆β-D-葡聚糖水平（p < 0.001）和抗真菌药物使用情况（p < 0.001）；死亡率无统计学显著差异（p = 0.33）。在调整APACHE II评分、2003年前后入院情况、抗真菌治疗及其他因素后，较短的ICU住院时间、呼吸机使用和持续血液滤过是死亡的危险因素。尽管2003年后抢先抗真菌治疗的使用频率高于之前，但死亡率无显著差异。
临床记录的CI和可能的CI定义的应用可能有助于确定何时开始抢先抗真菌治疗是合适的。然而，使用该指南并未预防可能的CI发展为临床记录的CI，也未改善死亡率。
