9 个主动监测点成人念珠菌血症治疗实践-美国，2017-2018 年。
Treatment Practices for Adults With Candidemia at 9 Active Surveillance Sites-United States, 2017-2018.
机构信息
Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
出版信息
Clin Infect Dis. 2021 Nov 2;73(9):1609-1616. doi: 10.1093/cid/ciab512.
BACKGROUND
Candidemia is a common opportunistic infection causing substantial morbidity and mortality. Because of an increasing proportion of non-albicans Candida species and rising antifungal drug resistance, the Infectious Diseases Society of America (IDSA) changed treatment guidelines in 2016 to recommend echinocandins over fluconazole as first-line treatment for adults with candidemia. We describe candidemia treatment practices and adherence to the updated guidelines.
METHODS
During 2017-2018, the Emerging Infections Program conducted active population-based candidemia surveillance at 9 US sites using a standardized case definition. We assessed factors associated with initial antifungal treatment for the first candidemia case among adults using multivariable logistic regression models. To identify instances of potentially inappropriate treatment, we compared the first antifungal drug received with species and antifungal susceptibility testing (AFST) results from initial blood cultures.
RESULTS
Among 1835 patients who received antifungal treatment, 1258 (68.6%) received an echinocandin and 543 (29.6%) received fluconazole as initial treatment. Cirrhosis (adjusted odds ratio = 2.06; 95% confidence interval, 1.29-3.29) was the only underlying medical condition significantly associated with initial receipt of an echinocandin (versus fluconazole). More than one-half (n = 304, 56.0%) of patients initially treated with fluconazole grew a non-albicans species. Among 265 patients initially treated with fluconazole and with fluconazole AFST results, 28 (10.6%) had a fluconazole-resistant isolate.
CONCLUSIONS
A substantial proportion of patients with candidemia were initially treated with fluconazole, resulting in potentially inappropriate treatment for those involving non-albicans or fluconazole-resistant species. Reasons for nonadherence to IDSA guidelines should be evaluated, and clinician education is needed.
背景
念珠菌血症是一种常见的机会性感染，可导致严重的发病率和死亡率。由于非白念珠菌念珠菌属物种的比例增加和抗真菌药物耐药性的上升，美国传染病学会（IDSA）于 2016 年改变了治疗指南，建议在成人念珠菌血症患者中使用棘白菌素类药物而非氟康唑作为一线治疗药物。我们描述了念珠菌血症的治疗方法和对更新后的指南的遵守情况。
方法
在 2017-2018 年期间，新兴传染病计划（EIP）在美国 9 个地点使用标准化的病例定义进行了主动的人群为基础的念珠菌血症监测。我们使用多变量逻辑回归模型评估了与成人首次念珠菌血症病例初始抗真菌治疗相关的因素。为了确定潜在不适当治疗的情况，我们将首次接受的抗真菌药物与初始血培养的物种和抗真菌药敏试验（AFST）结果进行了比较。
结果
在接受抗真菌治疗的 1835 例患者中，1258 例（68.6%）接受了棘白菌素类药物治疗，543 例（29.6%）接受了氟康唑作为初始治疗。肝硬化（调整后的优势比=2.06；95%置信区间，1.29-3.29）是唯一与初始接受棘白菌素类药物（而非氟康唑）治疗显著相关的基础医疗状况。超过一半（n=304，56.0%）接受氟康唑初始治疗的患者培养出了非白念珠菌物种。在 265 例初始接受氟康唑治疗且氟康唑 AFST 结果阳性的患者中，有 28 例（10.6%）有氟康唑耐药分离株。
结论
相当一部分念珠菌血症患者最初接受氟康唑治疗，导致对涉及非白念珠菌或氟康唑耐药物种的患者进行了潜在不适当的治疗。应评估不遵守 IDSA 指南的原因，并需要对临床医生进行教育。
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