Lortholary Olivier, Fernández-Ruiz Mario, Perfect John R
Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, APHP, Necker Enfants Malades University Hospital, Paris, France
Institut Pasteur, National Reference Center for Mycoses and Antifungals, Molecular Mycology Unit, CNRS URA 3012, Paris, France.
J Antimicrob Chemother. 2016 Nov;71(suppl 2):ii31-ii36. doi: 10.1093/jac/dkw394.
Compared with major invasive mycoses such as aspergillosis and candidiasis, the antifungal stewardship management strategies of other fungal diseases have different opportunities and considerations. Cryptococcosis, fusariosis and mucormycosis are globally prevalent invasive fungal diseases (IFDs), but are not currently included in antifungal prophylaxis guidelines for immunocompromised hosts. Since the implementation of biomarkers as part of diagnostic screening strategies, the concept of pre-emptive antifungal therapy has emerged for these IFDs. Management of cryptococcosis, the most common IFD worldwide, generally utilizes a pre-emptive or therapeutic strategy that does not involve prophylaxis or empirical antifungal treatment strategies. Antifungal stewardship outcomes for cryptococcosis may vary according to the availability of local resources. Invasive fusariosis, the second-most common form of non-Aspergillus mould infection among haematological malignancy patients, can be managed with pre-emptive (or diagnostic-driven) approaches based on the monitoring of serum galactomannan (GM) antigen in increased-risk populations. The success of antimicrobial stewardship programmes in decreasing the burden of invasive fusariosis in selected patient populations depends on the development and implementation of rapid diagnostic strategies for early and appropriate administration of therapy. Mucormycosis may emerge as a breakthrough IFD in haematology or solid organ transplant recipients receiving antifungals that lack activity against Mucorales. The concept of pre-emptive antifungal therapy has thus arisen for mucormycosis in the haematology setting because of the recent availability of circulating Mucorales DNA measurement. These examples demonstrate the challenges of implementing antifungal stewardship programmes in areas with limited resources, as well as in IFDs that are difficult to diagnose and treat.
与曲霉病和念珠菌病等主要侵袭性真菌病相比，其他真菌病的抗真菌管理策略有不同的机遇和考量。隐球菌病、镰刀菌病和毛霉病是全球流行的侵袭性真菌病（IFD），但目前未被纳入免疫功能低下宿主的抗真菌预防指南。自从将生物标志物作为诊断筛查策略的一部分实施以来，针对这些侵袭性真菌病出现了抢先抗真菌治疗的概念。隐球菌病是全球最常见的侵袭性真菌病，其管理通常采用抢先或治疗策略，不涉及预防或经验性抗真菌治疗策略。隐球菌病的抗真菌管理结果可能因当地资源的可获得性而有所不同。侵袭性镰刀菌病是血液系统恶性肿瘤患者中第二常见的非曲霉菌 mould 感染形式，可以基于对高危人群血清半乳甘露聚糖（GM）抗原的监测，采用抢先（或诊断驱动）方法进行管理。抗菌管理计划在降低特定患者群体中侵袭性镰刀菌病负担方面的成功取决于快速诊断策略的开发和实施，以便早期并适当地给予治疗。毛霉病可能在接受对毛霉目无活性的抗真菌药物的血液学或实体器官移植受者中作为突破性侵袭性真菌病出现。由于最近可进行循环毛霉目 DNA 测量，因此在血液学环境中针对毛霉病出现了抢先抗真菌治疗的概念。这些例子表明在资源有限的地区以及在难以诊断和治疗的侵袭性真菌病中实施抗真菌管理计划面临的挑战。
