Diagnosis and Treatment of Leishmaniasis: Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH)
Diagnosis and Treatment of Leishmaniasis: Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH)
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DOI：
10.4269/ajtmh.16-84256
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发表时间：
2017-01-01
影响因子：
3.3
通讯作者：
Magill, Alan
中科院分区：
文献类型：
--
作者：
Aronson, Naomi;Herwaldt, Barbara L.;Magill, Alan
美国传染病学会（IDSA）和美国热带医学和卫生学会（ASTMH）的一个小组制定了利什曼病患者临床管理指南。该指南适用于在美国和加拿大执业的内科医生、儿科医生、家庭医生、皮肤科医生以及传染病专家（为简单起见，此处简称为北美）。该小组遵循了IDSA采用的指南制定过程，其中包括对证据质量（极低、低、中等或高）和推荐强度（弱或强）bbb进行分级的系统方法（图1）。在这些指南中，我们描述了我们对皮肤、粘膜和内脏利什曼病病例的诊断和管理方法，这是由利什曼原虫感染引起的三种主要临床综合征。可能需要专门知识的不太常见或罕见综合征超出了本指南的范围。只要有可能，我们的建议都是基于随机临床试验。然而，由于利什曼病的多样性，其中包括在世界许多地区发现的20种利什曼原虫引起的一系列疾病，许多建议都是基于观察性研究、轶事数据或专家意见。尽管对我们的一些建议和建议可能存在分歧，但我们所描述的方法在北美既有用又可行。皮肤利什曼病（CL）是世界上最常见的利什曼综合征，也是北美患者最可能遇到的利什曼综合征。CL的皮肤损伤通常是无痛的和慢性的，经常发生在被感染的沙蝇叮咬的部位。随着细胞介导免疫的发展，缓慢的自发愈合是通常的自然史，抗利什曼病治疗加速。巴西利什曼原虫（Viannia）引起的少数皮肤感染[V]。] braziliensis)和Viannia亚属的近缘种，包括L (V.) panamensis和L (V.) guyanensis，与伴发性或晚期粘膜利什曼病（ML）相关，可导致鼻口咽/喉粘膜的破坏性病变。目前还没有确定普遍适用的治疗方法；药物、剂量和治疗时间的选择应个体化。必须考虑寄生虫和宿主因素以及临床特征（表1）。内脏利什曼病（VL）反映了利什曼原虫在整个网状内皮系统的传播，如果不进行治疗，可能会危及生命。VL是艾滋病毒/艾滋病患者或其他原因引起的细胞介导免疫抑制的机会性感染。VL和CUML治疗的主要目标分别是预防死亡率和发病率。美国食品和药物管理局（FDA）批准的治疗利什曼病的唯一药物是静脉注射治疗VL的两性霉素B （L-AmB）和口服治疗由特定物种引起的CL、ML和VL的米替福辛。为预防旅行者中的利什曼病，目前没有疫苗或化学预防方法；建议采取个人防护措施，尽量减少接触沙蝇叮咬。我们对利什曼病的诊断和临床管理的建议如下。关于利什曼病的背景信息、对我们方法的描述以及支持我们建议的证据摘要可以在指南的全文、表格、图表和附录中在线找到。
Guidelines for the clinical management of persons with leishmaniasis were prepared by a Panel of the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH). The guidelines are intended for internists, pediatricians, family practitioners, and dermatologists, as well as infectious disease specialists, practicing in the United States and Canada (for simplicity, referred to here as North America). The Panel followed a guideline development process that has been adopted by IDSA, which includes a systematic method of grading both the quality of evidence (very low, low, moderate, or high) and the strength of the recommendation (weak or strong) [1] (Figure 1).In these guidelines, we describe our approaches to the diagnosis and management of cases of cutaneous, mucosal, and visceral leishmaniasis, the three main clinical syndromes caused by infection with Leishmania parasites. Less common or rare syndromes that may require specialized expertise are beyond the scope of these guidelines. Whenever possible, our recommendations are based on randomized clinical trials. However, because of the diversity encompassed by leishmaniasis, which includes a spectrum of diseases caused by >20 Leishmania species found in many areas of the world, many of the recommendations are based on observational studies, anecdotal data, or expert opinion. Although there may be disagreement with some of our recommenda- tions and suggestions, the approaches we describe have been both useful and feasible in North America.Cutaneous leishmaniasis (CL) is the most common leishmanial syndrome worldwide and the one most likely to be encountered in patients in North America. The skin lesions of CL are usually painless and chronic, often occurring at sites of infected sand fly bites. Slow spontaneous healing as cell mediated immunity develops is the usual natural history, accelerated by antileishmanial therapy. A minority of cutaneous infections caused by Leishmania (Viannia) braziliensis (L. [V.] braziliensis) and related species in the Viannia subgenus, including L (V.) panamensis and L. (V.) guyanensis, are associated with concomitant or late mucosal leishmaniasis (ML), which can cause destructive lesions of the naso-oropharyngeal/ laryngeal mucosa. No universally applicable treatment has been identified for CL; the choice of agent, dose, and duration of therapy should be individualized. Parasite and host factors must be considered, as well as clinical characteristics (Table 1).Visceral leishmaniasis (VL), which reflects dissemination of Leishmania parasites throughout the reticuloendothelial system, is potentially life threatening without treatment. VL is an opportunistic infection in persons with HIV/AIDS or other causes of cell-mediated immunosuppression.The primary goals of therapy for VL and CUML are to prevent mortality and morbidity, respectively. The only Food and Drug Administration (FDA)-approved medications for the treatment of leishmaniasis are intravenous liposomal amphotericin B (L-AmB) for VL and oral miltefosine for CL, ML, and VL caused by particular species. For prevention of leishmaniasis in travelers, no vaccines or chemoprophylaxis currently are available; personal protective measures to minimize exposure to sand fly bites are recommended.Our recommendations for the diagnosis and clinical management of leishmaniasis are listed below. Background information about leishmaniasis, a description of our methods, and the evidence summaries that support our recommendations can be found online in the full text, tables, figures, and appendix of the guidelines.