Nolla-Salas J, Sitges-Serra A, León-Gil C, Martínez-González J, León-Regidor M A, Ibáñez-Lucía P, Torres-Rodríguez J M
Unidad de Cuidados Intensivos, Hospital del Mar, Barcelona, Spain.
Intensive Care Med. 1997 Jan;23(1):23-30. doi: 10.1007/s001340050286.
To determine the incidence and prognosis of candidemia in non-neutropenic critically ill patients, to define mortality-related factors, and to evaluate the results of systemic antifungal therapy.
A prospective multicenter survey in which medical and/or surgical intensive care units (ICUs) in 28 hospitals in Spain participated.
All critically ill patients with positive blood cultures for Candida species admitted to the participating ICUs over a 15-month period were included.
Candidemia was defined as the presence of at least one positive blood culture containing Candida species. The follow-up period was defined as the time elapsed from the first positive blood culture for Candida species to discharge or death during hospitalization. Antifungal therapy was considered to be "early" when it was administered within 48 h of the date when the first positive blood culture was obtained and "late" when it was administered more than 48 h after the first positive blood culture.
Candidemia was diagnosed in 46 patients (mean age 59 years), with an incidence of 1 critically ill patient per 500 ICU admissions. The species most frequently isolated were Candida albicans (60%) and C. parapsilosis (17%). Fluconazole alone was given to 27 patients, amphotericin B alone to 10, and sequential therapy to 6. Three patients did not receive antifungal therapy. The overall mortality was 56% and the attributable mortality 21.7%. In the univariate analysis, mortality was significantly associated with a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score at the onset of candidemia (p = 0.04) and with the time elapsed between the episode of candidemia and the start of antifungal therapy 48 h or more later (p < 0.02). Patients with an APACHE II score lower than 21 at the onset of candidemia had a higher probability of survival than patients who were more seriously ill (p = 0.04). Patients with "early" antifungal therapy (< or = 48 h between the onset of candidemia and the start of antifungal therapy) had a higher probability of survival compared with patients with late therapy (p = 0.06). No significant differences were noted between the two groups on different antifungal therapy.
The incidence of candidemia in ICU patients was very low. An APACHE II score > 20 at the time of candidemia was associated with a higher mortality. Further studies with a large number of patients are needed to assess the effect of early antifungal therapy on the decrease in mortality associated with candidemia and to determine the appropriate dosage of fluconazole and duration of treatment.
确定非中性粒细胞减少的重症患者念珠菌血症的发病率和预后，明确与死亡率相关的因素，并评估全身抗真菌治疗的效果。
一项前瞻性多中心调查，西班牙28家医院的内科和/或外科重症监护病房（ICU）参与其中。
纳入在15个月期间入住参与调查的ICU且血培养念珠菌属阳性的所有重症患者。
念珠菌血症定义为至少一次血培养念珠菌属阳性。随访期定义为从首次血培养念珠菌属阳性至出院或住院期间死亡的时间。抗真菌治疗在首次血培养阳性日期后48小时内给予被视为“早期”，在首次血培养阳性48小时后给予则为“晚期”。
46例患者被诊断为念珠菌血症（平均年龄59岁），发病率为每500例ICU入院患者中有1例重症患者。最常分离出的菌种是白色念珠菌（60%）和近平滑念珠菌（17%）。27例患者仅接受氟康唑治疗，10例仅接受两性霉素B治疗，6例接受序贯治疗。3例患者未接受抗真菌治疗。总体死亡率为56%，归因死亡率为21.7%。单因素分析中，死亡率与念珠菌血症发作时较高的急性生理与慢性健康状况评分系统（APACHE）II评分显著相关（p = 0.04），且与念珠菌血症发作至抗真菌治疗开始间隔48小时或更长时间显著相关（p < 0.02）。念珠菌血症发作时APACHE II评分低于21分的患者比病情更严重的患者存活概率更高（p = 0.04）。与接受晚期治疗的患者相比，接受“早期”抗真菌治疗（念珠菌血症发作至抗真菌治疗开始间隔≤48小时）的患者存活概率更高（p = 0.06）。两组在不同抗真菌治疗方面未观察到显著差异。
ICU患者念珠菌血症的发病率非常低。念珠菌血症时APACHE II评分>20与较高的死亡率相关。需要对大量患者进行进一步研究，以评估早期抗真菌治疗对降低念珠菌血症相关死亡率的效果，并确定氟康唑的合适剂量和治疗持续时间。
