Impact of Therapeutic Strategies on the Prognosis of Candidemia in the ICU
Impact of Therapeutic Strategies on the Prognosis of Candidemia in the ICU
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DOI：
10.1097/ccm.0000000000000221
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发表时间：
2014-06-01
影响因子：
8.8
通讯作者：
Almirante, Benito
中科院分区：
文献类型：
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作者：
Puig-Asensio, Mireia;Peman, Javier;Almirante, Benito
目的：了解西班牙ICU中念珠菌血流感染的流行病学、影响死亡率的变量和对真菌的耐药率。设计：前瞻性、观察性、多中心人群研究。地点：29家医院的内外科ICU，分布在西班牙5个大都市地区。患者：从2010年5月至2011年4月，在任何监测区ICU住院期间发生念珠菌血流感染的成年患者(18岁)。使用Logistic回归模型分析与早期(0-7d)和晚期(8-30d)死亡率相关的预后因素。测量和主要结果：我们检测到773例念珠菌血症，其中752例纳入总体队列。其中168例(22.3%)发生在成人ICU患者。念珠菌的顺序为：白色念珠菌(52%)、近缘念珠菌(23.7%)、光滑念珠菌(12.7%)、热带念珠菌(5.8%)、克鲁斯假丝酵母菌(4%)、其他(1.8%)。对氟康唑的总敏感率为79.2%。白念珠菌血症首次发作后7天和30天的累积死亡率分别为16.5%和47%。多因素分析显示，早期适当的抗真菌治疗和拔除导管(优势比，0.27；95%CI，0.08~0.91)、急性生理学和慢性健康评估II评分(优势比，1.11；95%CI，1.04~1.19)和腹部来源(优势比，8.15；95%CI，1.75~37.93)与早期死亡率独立相关。年龄(优势比，1.04；95%CI，1.01~1.07)、插管(优势比7.24，95%CI，2.24~23.40)、肾脏替代治疗(优势比6.12；95%CI，2.24~16.73)、原发来源(优势比2.51；95%CI，1.06~5.95)是影响ICU患者晚期死亡率的主要因素。总体死亡率仍然很高，主要与宿主因素有关。及时进行充分的抗真菌治疗和拔除导管可能是降低早期死亡率的关键。
Objectives: To determine the epidemiology of Candida bloodstream infections, variables influencing mortality, and antifungal resistance rates in ICUs in Spain.Design: Prospective, observational, multicenter population-based study.Setting: Medical and surgical ICUs in 29 hospitals distributed throughout five metropolitan areas of Spain.Patients: Adult patients ( 18 yr) with an episode of Candida bloodstream infection during admission to any surveillance area ICU from May 2010 to April 2011.Interventions:Candida isolates were sent to a reference laboratory for species identification by DNA sequencing and susceptibility testing using the methods and breakpoint criteria promulgated by the European Committee on Antimicrobial Susceptibility Testing. Prognostic factors associated with early (0-7 d) and late (8-30 d) mortality were analyzed using logistic regression modeling.Measurements and Main Results: We detected 773 cases of candidemia, 752 of which were included in the overall cohort. Among these, 168 (22.3%) occurred in adult ICU patients. The rank order of Candida isolates was as follows: Candida albicans (52%), Candida parapsilosis (23.7%), Candida glabrata (12.7%), Candida tropicalis (5.8%), Candida krusei (4%), and others (1.8%). Overall susceptibility to fluconazole was 79.2%. Cumulative mortality at 7 and 30 days after the first episode of candidemia was 16.5% and 47%, respectively. Multivariate analysis showed that early appropriate antifungal treatment and catheter removal (odds ratio, 0.27; 95% CI, 0.08-0.91), Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.11; 95% CI, 1.04-1.19), and abdominal source (odds ratio, 8.15; 95% CI, 1.75-37.93) were independently associated with early mortality. Determinants of late mortality were age (odds ratio, 1.04; 95% CI, 1.01-1.07), intubation (odds ratio, 7.24; 95% CI, 2.24-23.40), renal replacement therapy (odds ratio, 6.12; 95% CI, 2.24-16.73), and primary source (odds ratio, 2.51; 95% CI, 1.06-5.95).Conclusions: Candidemia in ICU patients is caused by non-albicans species in 48% of cases, C. parapsilosis being the most common among these. Overall mortality remains high and mainly related with host factors. Prompt adequate antifungal treatment and catheter removal could be critical to decrease early mortality.