Short Course Versus Standard Course Antifungal Therapy for Pediatric Candidemia: A Multi-Center Randomized Controlled Trial

侵袭性念珠菌病是最常见的侵袭性真菌病，而单纯念珠菌病是最常见的侵袭性真菌病 常见的演示文稿。成人随机对照试验和儿童前瞻性观察研究 初步证实使用棘球菌素抗真菌药物治疗可改善结果。当这些数据告诉我们 在最初的治疗选择上，关于合适的治疗持续时间的数据仍然很少。当前 指南建议对念珠菌血症进行总共14天的抗真菌治疗，而不考虑临床表现和 最初的反应，但这是基于意见，而不是比较数据。几项研究已经证明，较短的时间 对于许多严重细菌的治疗，持续时间的抗菌治疗是安全有效的 感染。然而，目前还没有比较研究来评估较短疗程和标准疗程的治疗。 任何侵袭性真菌疾病。很大比例的儿童侵袭性念珠菌病是单纯性念珠菌血症。 初治棘球绦虫治疗的临床改善较快。据推测，这些患者 不需要14天的治疗，反而会以更短的时间得到有效的治疗。初级阶段 这项随机对照试验的目的是确定在治疗后是否还需要7天的治疗 完成最初7天的棘球菌素治疗儿童念珠菌血症。受试者最初接受的是一种 临床症状改善和血培养清除的棘球绦虫将在7天内随机分成1组 两臂：1)停止治疗，或2)继续治疗共14天。这一主要目标将包括 一种新的结果衡量标准--结果排序的可取性(DOORT)，它同时捕捉到了收益 以及治疗的负面后果。我们将比较随机接受治疗的儿童的门结果 7天的单用棘球菌素(短程)与7天后再用7天的棘球菌素治疗的对比 抗真菌治疗(标准疗程)。我们假设随机接受短程治疗的受试者 平均而言，与随机接受标准疗程治疗的受试者相比，门槛测量更高。第二个 目的评估一种新的生物标志物--T2 Candida®试验的实用性，以提供支持证据 短程治疗的有效性。我们之前证明了T2 Candida®检测可以快速诊断 儿童侵袭性念珠菌病。然而，没有关于负性生物标记物的效用的数据来支持 停止治疗。目标2将对受试者的14天门测量与否定或肯定进行比较 T2Candida®生物标记物在各研究组治疗第7天。我们假设T2假丝酵母菌阴性 第7天的生物标记物将与第14天更高的门测量相关联。这项研究将利用 儿科真菌网络(PFN)，一个由美国37个地点组成的多学科组织，也是唯一一个 致力于儿科侵袭性真菌病的小组。这将是第一个随机对照试验 任何侵袭性真菌疾病的最佳治疗时间，以及第一次探索真菌的效用 支持较短疗程的生物标记物。结果可能会影响许多国家和国际准则。

Invasive candidiasis is the most common invasive fungal disease, and uncomplicated candidemia is the most common presentation. Randomized controlled trials in adults and a prospective observational study in children demonstrated primary treatment with an echinocandin antifungal improved outcomes. While these data inform initial therapy choice, there remains a paucity of data regarding appropriate duration of therapy. Current guidelines recommend 14 total days of antifungal therapy for candidemia regardless of clinical presentation and initial response, yet this is based on opinion and not comparative data. Several studies have proven that shorter durations of antibacterial therapy are safe and effective for the treatment of numerous serious bacterial infections. However, there has been no comparative study to assess shorter versus standard duration therapy for any invasive fungal disease. A large proportion of pediatric invasive candidiasis is uncomplicated candidemia with relatively rapid clinical improvement on primary echinocandin therapy. It is hypothesized that these patients do not require 14 days of therapy and instead would be effectively treated with a shorter duration. The primary objective of this randomized controlled trial is to determine whether 7 more days of therapy is necessary after completing an initial 7days of echinocandin therapy for pediatric candidemia. Subjects initially treated with an echinocandin showing clinical improvement with blood culture clearance will be randomized at 7 days into one of two arms: 1) cessation of therapy, or 2) continuation of therapy for 14 total days. This primary aim will include a novel outcome measure, the desirability of outcome ranking (DOOR), which simultaneously captures benefits and negative consequences of treatment. We will compare the DOOR outcome in children randomized to receive 7 days of an echinocandin only (short-course) versus 7 days of echinocandin therapy followed by 7 more days of antifungal therapy (standard-course). We hypothesize that subjects randomized to short-course therapy will on average have a higher DOOR measure than subjects randomized to standard-course therapy. The secondary objective will assess utility of a novel biomarker, the T2Candida® assay, to provide supporting evidence for effectiveness of short course therapy. We previously demonstrated the T2Candida® assay can rapidly diagnose invasive candidiasis in children. However, there are no data on the utility of a negative biomarker to support cessation of therapy. Aim 2 will compare the 14-day DOOR measure for subjects with a negative or positive T2Candida® biomarker at day 7 of therapy within each study group. We hypothesize that a negative T2Candida® biomarker at day 7 will be associated with a higher DOOR measure at day 14. This study will leverage the Pediatric Fungal Network (PFN), a multidisciplinary group composed of 37 sites across the US and the only such group dedicated to pediatric invasive fungal disease. This will be the first randomized controlled trial to define the optimal duration of therapy for any invasive fungal disease, and the first to explore the utility of a fungal biomarker to support a shorter course. Results could impact numerous national and international guidelines.