侵袭性真菌感染。
Invasive Fungal Infection.
机构信息
National Reference Center for Invasive Fungal Infections, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute (HKI), Jena; Clinic of Internal Medicine II, University Hospital Jena; Institute for Hygiene and Microbiology, University of Würzburg, Chair of Medical Microbiology and Mycology, Würzburg; Department of Internal Medicine II, University Hospital of Würzburg; InfectControl 2020, Jena/Würzburg; Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Department I of Internal Medicine, at the University Hospital of Cologne, European Excellence Center for Medical Mycology (ECMM), DGerman Center for Infection Research(DZIF) Partner Site Bonn Köln, Cologne University.
出版信息
Dtsch Arztebl Int. 2019 Apr 19;116(16):271-278. doi: 10.3238/arztebl.2019.0271.
BACKGROUND
The incidence of invasive fungal infection is approximately 6 cases per 100 000 persons per year. It is estimated that only half of such infections are detected during the patient's lifetime, making this one of the more common overlooked causes of death in intensive-care patients. The low detection rate is due in part to the complexity of the diagnostic work-up, in which the clinical, radiological, and microbiological findings must be considered. Fungi with resistance to antimycotic drugs have been found to be on the rise around the world.
METHODS
This review is based on pertinent publications retrieved from a selective search in PubMed, with special attention to guidelines on the diagnosis and treatment of invasive fungal infections caused by Candida spp., Aspergillus spp., Mucorales, and Fusarium spp.
RESULTS
The clinical risk factors for invasive fungal infection include, among others, congenital immune deficiency, protracted (>10 days) marked granulocytopenia (<0.5 x 109/L), allogeneic stem-cell transplantation, and treatment with immunosuppressive drugs or corticosteroids. High-risk groups include patients in intensive care and those with structural pulmonary disease and/or compli- cated influenza. The first line of treatment, supported by the findings of randomized clinical trials, consists of echinocandins for in- fections with Candida spp. (candidemia response rates: 75.6% for anidulafungin vs. 60.2% for fluconazole) and azole antimycotic drugs for infections with Aspergillus spp. (response rates: 52.8% for voriconazole vs. 31.6% for conventional amphotericin B). The recommended first-line treatment also depends on the local epidemiology. This challenge should be met by interdisciplinary collaboration. Therapeutic decision-making should also take account of the often severe undesired effects of antimycotic drugs (including impairment of hepatic and/or renal function) and the numerous interactions that some of them have with other drugs.
CONCLUSION
Invasive fungal infections are often overlooked in routine hospital care. They should be incorporated into antimicro- bial stewardship programs as an essential component. There is also a pressing need for the development of new classes of antimycotic drug.
背景
侵袭性真菌感染的发病率约为每 10 万人每年 6 例。据估计，此类感染只有一半在患者有生之年被检测到，这使得侵袭性真菌感染成为重症监护患者中较为常见的被忽视的死亡原因之一。低检测率部分归因于诊断工作的复杂性，其中必须考虑临床、影像学和微生物学发现。在世界各地，发现具有抗真菌药物耐药性的真菌呈上升趋势。
方法
本综述基于在 PubMed 中进行的选择性搜索中检索到的相关出版物，特别关注关于念珠菌属、曲霉菌属、毛霉目和镰刀菌属引起的侵袭性真菌感染的诊断和治疗指南。
结果
侵袭性真菌感染的临床危险因素包括先天性免疫缺陷、长期（>10 天）明显中性粒细胞减少症（<0.5×109/L）、异基因干细胞移植以及免疫抑制药物或皮质类固醇治疗。高危人群包括重症监护病房患者以及患有结构性肺病和/或复杂流感的患者。基于随机临床试验结果，一线治疗包括棘白菌素类药物治疗念珠菌属感染（念珠菌血症的反应率：安尼卡汀为 75.6%，氟康唑为 60.2%）和唑类抗真菌药物治疗曲霉菌属感染（反应率：伏立康唑为 52.8%，两性霉素 B 为 31.6%）。推荐的一线治疗还取决于当地的流行病学。这一挑战需要通过跨学科合作来应对。治疗决策还应考虑到抗真菌药物的严重不良反应（包括肝肾功能损害）以及其中一些药物与其他药物的众多相互作用。
结论
侵袭性真菌感染在常规医院护理中经常被忽视。它们应作为重要组成部分纳入抗菌药物管理计划。还迫切需要开发新类别的抗真菌药物。
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