Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL 60612, USA.
J Antimicrob Chemother. 2012 Mar;67(3):707-14. doi: 10.1093/jac/dkr511. Epub 2011 Dec 18.
We sought to determine the impact of timing of appropriate antifungal therapy, as assessed by susceptibility results, on patient survival.
Patients ≥16 years of age with first episodes of candidaemia during 2001-09 were included. Clinical data were collected retrospectively, including time to appropriate antifungal therapy and patient survival.
The study population included 446 patients [243 (54%) female, mean age 53 years] with candidaemia, 380 (85%) of whom had antifungal susceptibility data. Candida albicans was the most common pathogen (221, 50%) followed by Candida glabrata (99, 22%), Candida parapsilosis (59, 13%), Candida tropicalis (48, 11%) and Candida krusei (6, 1%). Appropriate antifungal therapy consisted of fluconazole (177, 40%), an echinocandin (125, 28%), amphotericin B (41, 9%) and voriconazole (6, 1%); 97 (22%) failed to receive appropriate antifungal therapy. The 30 day mortality was 34% (151/446) and there was no clear relationship between time from positive culture to receipt of appropriate antifungal therapy and 30 day survival. On multivariable Cox regression, increased APACHE II score [hazard ratio (HR) 1.11, 95% CI 1.09-1.13, P<0.001], cirrhosis (HR 2.15, 95% CI 1.48-3.13, P<0.001) and HIV infection (HR 2.03, 95% CI 1.11-3.72, P=0.02) were independent predictors of mortality. A secondary analysis requiring patients in the early treatment group to have received ≥24 h of effective antifungal therapy did show a significant mortality benefit to receiving antifungal treatment within 72 h of a positive blood culture being drawn (30 day mortality for early treatment: 27% versus 40%, P=0.004; HR for mortality with delayed treatment on multivariable analysis: 1.41, 95% CI 1.01-1.98, P=0.045).
Candida bloodstream infection is associated with high mortality, despite timely receipt of appropriate antifungal therapy.
我们旨在评估根据药敏结果评估的适当抗真菌治疗时机对患者生存的影响。
纳入 2001 年至 2009 年期间首次发生念珠菌血症的年龄≥16 岁的患者。回顾性收集临床数据，包括适当抗真菌治疗的时间和患者生存情况。
本研究纳入了 446 例念珠菌血症患者[243 例（54%）为女性，平均年龄 53 岁]，其中 380 例（85%）有抗真菌药敏数据。最常见的病原体是白色念珠菌（221 例，50%），其次是光滑念珠菌（99 例，22%）、近平滑念珠菌（59 例，13%）、热带念珠菌（48 例，11%）和克柔念珠菌（6 例，1%）。适当的抗真菌治疗包括氟康唑（177 例，40%）、棘白菌素（125 例，28%）、两性霉素 B（41 例，9%）和伏立康唑（6 例，1%）；97 例（22%）未接受适当的抗真菌治疗。30 天死亡率为 34%（151/446），从阳性培养到接受适当抗真菌治疗的时间与 30 天生存率之间无明显关系。多变量 Cox 回归分析显示，APACHE II 评分增加（风险比[HR]1.11，95%可信区间 1.09-1.13，P<0.001）、肝硬化（HR 2.15，95%可信区间 1.48-3.13，P<0.001）和 HIV 感染（HR 2.03，95%可信区间 1.11-3.72，P=0.02）是死亡的独立预测因素。一项要求早期治疗组患者接受≥24 小时有效抗真菌治疗的二次分析显示，在血培养阳性后 72 小时内接受抗真菌治疗确实有显著的生存获益（早期治疗 30 天死亡率：27%比 40%，P=0.004；多变量分析中延迟治疗的死亡风险比[HR]：1.41，95%可信区间 1.01-1.98，P=0.045）。
尽管及时接受了适当的抗真菌治疗，念珠菌菌血症仍与高死亡率相关。
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