高危心脏移植受者目标性抗真菌预防对早期侵袭性真菌感染的影响。
Impact of targeted antifungal prophylaxis in heart transplant recipients at high risk for early invasive fungal infection.
机构信息
1 Infectious Diseases Service, Department of Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland. 2 Transplantation Center, Department of Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland. 3 Service of Cardiology, Department of Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland. 4 Service of Cardiovascular Surgery, Department of Surgery, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland. 5 Institute of Microbiology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland. 6 Address correspondence to: Frederic Tissot, M.D., Infectious Diseases Service, Department of Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.
出版信息
Transplantation. 2014 Jun 15;97(11):1192-7. doi: 10.1097/01.tp.0000441088.01723.ee.
BACKGROUND
Invasive fungal infection (IFI) is associated with high mortality after heart transplantation (HTx). After two undiagnosed fatal cases of early disseminated fungal infections in our heart transplant program, a retrospective analysis was conducted to identify risk factors for the development of IFI and implement a new antifungal prophylaxis policy.
METHODS
Clinical characteristics of HTx recipients hospitalized in our center (2004-2010) were recorded (Period 1), and risk factors associated with IFI were investigated using Cox regression analysis. From October 2010 to October 2012 (Period 2), targeted caspofungin prophylaxis was administered to all recipients at high risk for IFI, based on the results of the Period 1 analysis.
RESULTS
During Period 1, 10% (6/59) of the patients developed IFI at a median onset of 9 days after transplantation. By multivariate analysis, the use of posttransplant extracorporeal membrane oxygenation (ECMO) was the strongest predictor for fungal infection (OR, 29.93; 95% CI, 1.51-592.57, P=0.03), whereas renal replacement therapy (RRT) and Aspergillus colonization were significant predictors only by univariate analysis. During Period 2, only 4% (1/26) of the patients developed IFI. In patients at high risk for IFI, antifungal prophylaxis was administered to 17% (4/23) in Period 1 versus 100% (13/13) in Period 2 (P<0.01). By survival analysis, antifungal prophylaxis was associated with a reduction in 90-day IFI incidence (HR, 0.14; 95% CI, 0.03-0.84, P=0.03) and 30-day mortality (HR, 0.25; 95% CI, 0.09-0.8, P=0.02).
CONCLUSION
Extracorporeal membrane oxygenation was identified an important risk factor for IFI after HTx, and its use may require targeted administration of antifungal prophylaxis in the immediate posttransplant period.
背景
侵袭性真菌感染（IFI）与心脏移植（HTx）后死亡率高有关。在我们的心脏移植项目中出现两例早期播散性真菌感染的未确诊致死病例后，我们进行了回顾性分析，以确定发生 IFI 的危险因素，并实施新的抗真菌预防策略。
方法
记录了在我们中心住院的 HTx 受者的临床特征（2004-2010 年；第 1 期），并使用 Cox 回归分析调查了与 IFI 相关的危险因素。从 2010 年 10 月至 2012 年 10 月（第 2 期），根据第 1 期分析的结果，对所有 IFI 高危受者进行靶向卡泊芬净预防。
结果
第 1 期，10%（6/59）的患者在移植后 9 天内发生 IFI。多变量分析显示，移植后体外膜氧合（ECMO）的使用是真菌感染的最强预测因素（OR，29.93；95%CI，1.51-592.57，P=0.03），而肾脏替代治疗（RRT）和曲霉菌定植仅通过单变量分析是显著预测因素。第 2 期，仅 4%（1/26）的患者发生 IFI。在 IFI 高危患者中，第 1 期给予抗真菌预防的患者为 17%（4/23），第 2 期为 100%（13/13）（P<0.01）。生存分析显示，抗真菌预防与降低 90 天 IFI 发生率（HR，0.14；95%CI，0.03-0.84，P=0.03）和 30 天死亡率（HR，0.25；95%CI，0.09-0.8，P=0.02）相关。
结论
ECMO 被确定为 HTx 后 IFI 的一个重要危险因素，其使用可能需要在移植后立即进行靶向抗真菌预防。
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