儿童念珠菌血症检测后的辅助诊断研究：儿科真菌网络多中心队列研究观察实践的二次分析。
Adjunctive Diagnostic Studies Completed Following Detection of Candidemia in Children: Secondary Analysis of Observed Practice From a Multicenter Cohort Study Conducted by the Pediatric Fungal Network.
机构信息
Department of Pediatrics, University of California San Francisco, San Francisco, California, USA.
Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
出版信息
J Pediatric Infect Dis Soc. 2023 Sep 27;12(9):487-495. doi: 10.1093/jpids/piad057.
BACKGROUND
Adjunctive diagnostic studies (aDS) are recommended to identify occult dissemination in patients with candidemia. Patterns of evaluation with aDS across pediatric settings are unknown.
METHODS
Candidemia episodes were included in a secondary analysis of a multicenter comparative effectiveness study that prospectively enrolled participants age 120 days to 17 years with invasive candidiasis (predominantly candidemia) from 2014 to 2017. Ophthalmologic examination (OE), abdominal imaging (AbdImg), echocardiogram, neuroimaging, and lumbar puncture (LP) were performed per clinician discretion. Adjunctive diagnostic studies performance and positive results were determined per episode, within 30 days from candidemia onset. Associations of aDS performance with episode characteristics were evaluated via mixed-effects logistic regression.
RESULTS
In 662 pediatric candidemia episodes, 490 (74%) underwent AbdImg, 450 (68%) OE, 426 (64%) echocardiogram, 160 (24%) neuroimaging, and 76 (11%) LP; performance of each aDS per episode varied across sites up to 16-fold. Longer durations of candidemia were associated with undergoing OE, AbdImg, and echocardiogram. Immunocompromised status (58% of episodes) was associated with undergoing AbdImg (adjusted odds ratio [aOR] 2.38; 95% confidence intervals [95% CI] 1.51-3.74). Intensive care at candidemia onset (30% of episodes) was associated with undergoing echocardiogram (aOR 2.42; 95% CI 1.51-3.88). Among evaluated episodes, positive OE was reported in 15 (3%), AbdImg in 30 (6%), echocardiogram in 14 (3%), neuroimaging in 9 (6%), and LP in 3 (4%).
CONCLUSIONS
Our findings show heterogeneity in practice, with some clinicians performing aDS selectively, potentially influenced by clinical factors. The low frequency of positive results suggests that targeted application of aDS is warranted.
背景
辅助诊断研究（aDS）被推荐用于识别念珠菌血症患者的隐匿性播散。儿科环境中 aDS 的评估模式尚不清楚。
方法
本研究对 2014 年至 2017 年期间进行的一项多中心比较有效性研究进行了二次分析，该研究前瞻性招募了年龄在 120 天至 17 岁的侵袭性念珠菌病（主要为念珠菌血症）患者。根据临床医生的判断，进行眼科检查（OE）、腹部影像学（AbdImg）、超声心动图、神经影像学和腰椎穿刺（LP）。每个病例在念珠菌血症发病后 30 天内确定辅助诊断研究的表现和阳性结果。通过混合效应逻辑回归评估 aDS 表现与病例特征之间的关联。
结果
在 662 例儿科念珠菌血症病例中，490 例（74%）进行了 AbdImg，450 例（68%）进行了 OE，426 例（64%）进行了超声心动图，160 例（24%）进行了神经影像学，76 例（11%）进行了 LP；每个病例的 aDS 表现因地点不同而变化，最高可达 16 倍。念珠菌血症持续时间较长与进行 OE、AbdImg 和超声心动图相关。免疫功能低下状态（58%的病例）与 AbdImg 相关（调整后的优势比[aOR]2.38；95%置信区间[95%CI]1.51-3.74）。念珠菌血症发病时入住重症监护病房（30%的病例）与进行超声心动图相关（aOR 2.42；95%CI 1.51-3.88）。在评估的病例中，15 例（3%）报告 OE 阳性，30 例（6%）报告 AbdImg 阳性，14 例（3%）报告超声心动图阳性，9 例（6%）报告神经影像学阳性，3 例（4%）报告 LP 阳性。
结论
我们的研究结果表明，实践中存在异质性，一些临床医生选择性地进行 aDS，这可能受到临床因素的影响。阳性结果的频率较低表明，有必要有针对性地应用 aDS。
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