Grasela T H, Goodwin S D, Pasko M T, Walawander C A, Raebel M A
Center for Pharmacoepidemiology Research, State University of New York (SUNY) at Buffalo.
Ann Pharmacother. 1994 Feb;28(2):252-60. doi: 10.1177/106002809402800219.
To evaluate the use of antifungal agents in hospitalized patients prior to marketing of fluconazole and to assess characteristics associated with their use.
A cohort of hospitalized patients receiving topical or systemic antifungal therapy was monitored concurrently.
Sixty-nine hospitals ranging in size from 100 to more than 500 beds, 70.1 percent affiliated with medical schools.
Participating clinical pharmacists each identified 15 consecutive patients receiving systemic antifungal therapy and 5 consecutive patients receiving topical antifungal therapy at their institutions. Data collection began October 1989 and ended March 1990.
All data collected were observational in nature, and no patient intervention was required.
Characteristics of patients receiving antifungal therapy were compared using t-tests and chi-square tests. Utilization and patterns of use of antifungal therapy were reported.
The most common risk factors necessitating antifungal therapy, in descending order, were: administration of broad-spectrum antibiotics and/or presence of invasive catheters, carcinoma, AIDS, leukemia or lymphoma, diabetes mellitus, solid organ or bone marrow transplantation, and chronic obstructive pulmonary disease. Five hundred seventeen patients received systemic therapy and 464 (89.7 percent) received a single systemic agent. Of these, 242 (52.2 percent) received amphotericin B, 215 (46.3 percent) received ketoconazole, 6 (1.3 percent) received flucytosine, and 1 (0.2 percent) received intravenous miconazole. Fifty-three patients received two systemic agents either concurrently or consecutively. Ketoconazole was most often used for presumed or documented oral, urogenital, or esophageal infections and amphotericin B was the preferred agent for disseminated infections and fungemia (p < 0.001). Almost half of the patients receiving amphotericin B or ketoconazole (48.3 percent) received these drugs as empiric therapy. Documented infections were more likely to be treated with amphotericin B (54.8 percent) than with ketoconazole (27.4 percent) (p < 0.001). The predominant fungal isolates were Candida albicans, Candida spp., and unspecified yeasts. Amphotericin B toxicity led to discontinuation of drug therapy in only 5.1 percent of cases. Two hundred sixty-nine patients (34.2 percent) received topical antifungal therapy only. Nystatin oral suspension was prescribed to 65.3 percent of the patients, clotrimazole troches to 23.0 percent, amphotericin B irrigation to 10.9 percent, and nystatin tablets to 0.8 percent.
The utilization patterns of antifungal agents in this survey follow established therapeutic guidelines. Prior to the introduction of fluconazole, amphotericin B was the agent of choice for documented systemic fungal infections. Ketoconazole was more often used for prophylaxis of fungal infections and treatment of oral and esophageal infections.
评估氟康唑上市前住院患者抗真菌药物的使用情况，并评估与药物使用相关的特征。
对接受局部或全身抗真菌治疗的住院患者队列进行同步监测。
69家医院，床位规模从100张到500多张不等，70.1%的医院附属于医学院。
参与研究的临床药师各自在其所在机构确定了15例连续接受全身抗真菌治疗的患者和5例连续接受局部抗真菌治疗的患者。数据收集始于1989年10月，结束于1990年3月。
所有收集的数据本质上都是观察性的，无需对患者进行干预。
使用t检验和卡方检验比较接受抗真菌治疗患者的特征。报告抗真菌治疗的使用情况和使用模式。
需要抗真菌治疗的最常见风险因素，按降序排列为：使用广谱抗生素和/或存在侵入性导管、癌症、艾滋病、白血病或淋巴瘤、糖尿病、实体器官或骨髓移植以及慢性阻塞性肺疾病。517例患者接受了全身治疗，464例（89.7%）接受了单一全身用药。其中，242例（52.2%）接受了两性霉素B，215例（46.3%）接受了酮康唑，6例（1.3%）接受了氟胞嘧啶，1例（0.2%）接受了静脉注射咪康唑。53例患者同时或先后接受了两种全身用药。酮康唑最常用于疑似或确诊的口腔、泌尿生殖系统或食管感染，两性霉素B是播散性感染和真菌血症的首选药物（p<0.001）。几乎一半接受两性霉素B或酮康唑治疗的患者（48.3%）接受这些药物作为经验性治疗。确诊感染的患者接受两性霉素B治疗的可能性（54.8%）高于酮康唑（27.4%）（p<0.001）。主要的真菌分离株为白色念珠菌、念珠菌属和未明确的酵母菌。两性霉素B的毒性仅导致5.1%的病例停药。269例患者（34.2%）仅接受了局部抗真菌治疗。65.3%的患者开具了制霉菌素口服混悬液，23.0%开具了克霉唑含片，10.9%开具了两性霉素B冲洗剂，0.8%开具了制霉菌素片。
本次调查中抗真菌药物的使用模式遵循既定的治疗指南。在氟康唑引入之前，两性霉素B是确诊系统性真菌感染的首选药物。酮康唑更常用于真菌感染的预防以及口腔和食管感染的治疗。
