■念珠菌血流感染(BSI)仍然是危重病和免疫抑制癌症患者BSI的主要原因之一。鉴于不断变化的流行病学和不断上升的抗性物种,治疗持续时间和从静脉(IV)逐步治疗到口服抗真菌药物的适当时机对于最大限度地控制疾病和总生存期至关重要.
■我们进行了一项多中心回顾性研究,来自巴西四家不同医疗机构的119名非中性粒细胞减少症患者,黎巴嫩,西班牙和美国,评估成年患者静脉治疗的持续时间和逐步采用口服治疗的适当时间,14岁及以上,有记录在案的念珠菌病。使用统计程序R和SASv9.4进行分析。描述性统计以频率和表格的形式呈现,Fisher精确检验用于测试分类变量之间的关联:有机体,癌症,国家,抗真菌药物和治疗持续时间,和下台的时间。
白色念珠菌占血流感染的45%,而非白色念珠菌占感染的55%。三种最常见的非白色念珠菌是:光滑念珠菌24%,近平滑念珠菌13%,热带念珠菌8%。大多数(57%)的患者被送进ICU,而52%有潜在的恶性肿瘤。多因素分析显示,入住ICU或需要化疗的潜在癌症与失败和死亡独立相关(p<0.001)。所有患者的平均总治疗持续时间为14天,有反应并存活的患者为16天。45名患者因念珠菌血症的临床和微生物学解决而被降级为氟康唑和/或伏立康唑。降压的平均(和中值)天为5天。与没有降级的患者(56%生存率)相比,降级的患者具有更有利的结果(78%生存率)(P=0.022)。然而,与接受>5天治疗(24%死亡率-p=0.75)的25例患者相比,20例患者在开始口服唑类药物之前接受了1~4天的首次IV治疗(20%死亡率),其结局与接受>5天治疗(24%死亡率-p=0.75)相当.
■我们的数据支持IDSA指南,即念珠菌菌血症的治疗总持续时间应在血培养阴性后至少14天。然而,在念珠菌菌血症的非中性粒细胞减少性癌症患者中,只要患者对血流感染有临床和微生物分析,就可以在早期(开始IV治疗后4天内)安全地逐步减少口服唑类药物治疗.
UNASSIGNED: Candida bloodstream infection (BSI) remains one of the leading causes of BSI in critically ill and immunosuppressed cancer patients. In light of the changing epidemiology and rising resistant species, duration of treatment and appropriate timing of stepdown therapy from intravenous (IV) to oral antifungal agents are crucial for utmost disease control and overall survival.
UNASSIGNED: We performed a multicenter retrospective
study, with 119 non-neutropenic patients enrolled from four different medical institutions in Brazil, Lebanon, Spain and the United States, to assess the duration of IV therapy and appropriate time to step-down to oral therapy in adult patients, 14 years of age and older, with documented candidemia. The analysis was done using the statistical program R and SAS v9.4. Descriptive statistics are presented as frequencies and tables and the Fisher exact test was used to test the association between the categorical variables: organism, cancer, country, antifungal drug and duration of therapy, and time of step-down.
UNASSIGNED: Candida albicans contributed to 45% of bloodstream infection versus 55% of infection caused by Candida non-albicans. The three most common Candida non-albicans are: Candida glabrata 24%, Candida parapsilosis 13% and Candida tropicalis 8%. Most (57%) of the patients were admitted to ICU, whereas 52% had underlying malignancy. Multivariate analysis showed that a stay at ICU or an underlying cancer requiring chemotherapy were independently associated with failure and death (p <0.001). The average total duration of therapy was 14 days in all patients and 16 days in those who responded and survived. Forty-five patients were stepped down to either fluconazole and/or voriconazole in association with clinical and microbiologic resolution of the candidemia. The average (and median) day of step-down was 5 days. Patients who had a stepdown had more favorable outcomes (78% survival) as compared to those with no stepdown (56% survival) (P = 0.022). However, the 20 patients who received 1-4 days of first IV treatment before a stepdown to oral azoles had a comparable outcome (20% mortality) to the 25 patients who received >5 days of treatment (24% mortality - p = 0.75).
UNASSIGNED: Our data support the IDSA guidelines in that the total duration of treatment for candidemia should be at least 14 days after a negative blood culture. However, in non-neutropenic cancer patients with candidemia, a step-down to oral azole therapy can safely take place early (within 4 days of initiating IV therapy) as long as the patient had clinical and microbiologic resolution of the bloodstream infections.