2nd Department of Critical Care Medicine, Medical School, University of Athens, University Hospital ATTIKON, Athens, Greece.
J Crit Care. 2013 Oct;28(5):717-27. doi: 10.1016/j.jcrc.2013.04.006.
Fungal infections are common in critically ill patients and are associated with increased morbidity and mortality. Candida spp are the most commonly isolated fungal pathogens. The last 2 decades have seen an increased incidence of fungal infections in critical illness and the emergence of new pathogenic fungal species and also the development of more effective (better bioavailability) and safer (less toxicity, fewer drug interactions) drugs. The distinction between colonization and infection can be difficult, and problems diagnosing infection may delay initiation of antifungal treatment. A number of factors have been identified that can help to distinguish patients at high risk for fungal infection. The antifungal agents that are most frequently used in the intensive care unit are the first- and second-generation azoles and the echinocandins; amphotericin B derivatives (mainly the liposomal agents) are less widely used because of adverse effects. The choice of antifungal agent in critically ill patients will depend on the aim of therapy (prophylaxis, pre-emptive, empiric, definitive), as well as on local epidemiology and specific properties of the drug (antifungal spectrum, efficacy, toxicity, pharmacokinetic/pharmacodynamic properties, cost). In this article we will review all these aspects and propose an algorithm to guide selection of antifungal agents in critically ill patients.
真菌感染在危重病患者中很常见，并且与发病率和死亡率的增加有关。念珠菌属是最常分离到的真菌病原体。在过去的 20 年中，真菌感染在危重病中的发病率增加，新的致病性真菌物种出现，并且出现了更有效（更好的生物利用度）和更安全（更少的毒性，更少的药物相互作用）的药物。区分定植和感染可能很困难，并且诊断感染的问题可能会延迟抗真菌治疗的开始。已经确定了一些可以帮助区分真菌感染高危患者的因素。在重症监护病房中最常使用的抗真菌药物是第一代和第二代唑类药物和棘白菌素类药物；由于不良反应，两性霉素 B 衍生物（主要是脂质体制剂）的应用较少。在危重病患者中选择抗真菌药物将取决于治疗的目的（预防、先发制人、经验性、确定性），以及局部流行病学和药物的特定特性（抗真菌谱、疗效、毒性、药代动力学/药效学特性、成本）。在本文中，我们将回顾所有这些方面，并提出一个算法来指导重症患者抗真菌药物的选择。
