美国太平洋西北地区隐球菌感染患者的治疗和结局。
Treatment and outcomes among patients with Cryptococcus gattii infections in the United States Pacific Northwest.
机构信息
Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
Scientific Education and Professional Development Office, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America ; Oregon Public Health Division, Portland, Oregon, United States of America.
出版信息
PLoS One. 2014 Feb 19;9(2):e88875. doi: 10.1371/journal.pone.0088875. eCollection 2014.
BACKGROUND
Cryptococcus gattii is a fungal pathogen causing an emerging outbreak in the United States Pacific Northwest (PNW). Treatment guidelines for cryptococcosis are primarily based on data from C. neoformans infections; applicability to PNW C. gattii infection is unknown. We evaluated the relationship between initial antifungal treatment and outcomes for PNW C. gattii patients.
METHODS
Cases were defined as culture-confirmed invasive C. gattii infections among residents of Oregon and Washington States during 2004-2011. Clinical data were abstracted from medical records through one year of follow-up. Recommended initial treatment for central nervous system (CNS), bloodstream, and severe pulmonary infections is amphotericin B and 5-flucytosine; for non-severe pulmonary infections, recommended initial treatment is fluconazole. Alternative initial treatment was defined as any other initial antifungal treatment.
RESULTS
Seventy patients survived to diagnosis; 50 (71%) received the recommended initial treatment and 20 (29%) received an alternative. Fewer patients with pulmonary infections [21 (64%)] than CNS infections [25 (83%)] received the recommended initial treatment (p = 0.07). Among patients with pulmonary infections, those with severe infections received the recommended initial treatment less often than those with non-severe infections (11% vs. 83%, p<0.0001). Eight patients with severe pulmonary infections received alternative initial treatments; three died. Four patients with non-severe pulmonary infections received alternative initial treatments; two died. There was a trend towards increased three-month mortality among patients receiving alternative vs. recommended initial treatment (30% vs. 14%, p = 0.12), driven primarily by increased mortality among patients with pulmonary disease receiving alternative vs. recommended initial treatment (42% vs. 10%, p = 0.07).
CONCLUSIONS
C. gattii patients with pulmonary infections--especially severe infections--may be less likely to receive recommended treatment than those with CNS infections; alternative treatment may be associated with increased mortality. Reasons for receipt of alternative treatment among C. gattii patients in this area should be investigated, and clinician awareness of recommended treatment reinforced.
背景
新型隐球菌是一种真菌病原体，导致美国太平洋西北地区（PNW）爆发疫情。隐球菌病的治疗指南主要基于新型隐球菌感染的数据；其对 PNW 新型隐球菌感染的适用性尚不清楚。我们评估了初始抗真菌治疗与 PNW 新型隐球菌患者结局之间的关系。
方法
病例定义为 2004-2011 年期间俄勒冈州和华盛顿州居民中经培养确认的侵袭性新型隐球菌感染。通过一年的随访，从病历中提取临床数据。中枢神经系统（CNS）、血流和严重肺部感染的推荐初始治疗是两性霉素 B 和 5-氟胞嘧啶；非严重肺部感染的推荐初始治疗是氟康唑。替代初始治疗定义为任何其他初始抗真菌治疗。
结果
70 名患者存活至诊断；50 名（71%）接受了推荐的初始治疗，20 名（29%）接受了替代治疗。肺部感染患者[21 名（64%）]比 CNS 感染患者[25 名（83%）]接受推荐的初始治疗的比例更少（p=0.07）。在肺部感染患者中，严重感染患者接受推荐初始治疗的比例低于非严重感染患者（11%对 83%，p<0.0001）。8 例严重肺部感染患者接受了替代初始治疗；其中 3 人死亡。4 例非严重肺部感染患者接受了替代初始治疗；其中 2 人死亡。接受替代治疗的患者与接受推荐初始治疗的患者相比，三个月死亡率呈上升趋势（30%对 14%，p=0.12），主要是因为接受替代治疗的肺部疾病患者死亡率高于接受推荐初始治疗的患者（42%对 10%，p=0.07）。
结论
与 CNS 感染患者相比，新型隐球菌肺部感染患者（尤其是严重感染患者）可能不太可能接受推荐的治疗；替代治疗可能与死亡率增加有关。应调查该地区新型隐球菌患者接受替代治疗的原因，并加强临床医生对推荐治疗的认识。
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