Discontinuation of empirical antifungal therapy in ICU patients using 1,3-β-D-glucan
Discontinuation of empirical antifungal therapy in ICU patients using 1,3-β-D-glucan
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DOI：
10.1093/jac/dkw188
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发表时间：
2016-09-01
影响因子：
5.2
通讯作者：
Colombo, Arnaldo L.
中科院分区：
文献类型：
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作者：
Nucci, Marcio;Nouer, Simone A.;Colombo, Arnaldo L.
经验性抗真菌治疗高危ICU患者是一个有吸引力的策略，但是过度使用抗真菌药物是一个潜在的问题。我们评估了根据预测规则确定的发生念珠菌血症的高危ICU患者是否可以在1-3-β-D-葡聚糖（BDG）反复阴性的基础上停止经验性抗真菌治疗我们对85名接受抗生素或中心静脉导管加两个额外因素的ICU患者进行了多中心队列研究。（透析、肠外营养、手术、胰腺炎或接受皮质类固醇或其他免疫抑制剂）加上发热、体温过低、低血压、酸中毒、C反应蛋白升高或白细胞增多。进行血培养（第1天和第2天）和BDG（第1-3天，基线期），并给予阿尼芬净。第4天，血培养阴性和BDG的患者停止抗真菌治疗。在ClinicalTrials.gov上注册（NCT 01734525）。入选患者的念珠菌血症发生率为8.2%，而无入选标准的患者为0.5%（高出16.9倍）。64例患者（75.3%）基线BDG阳性，包括7例念珠菌血症患者。所有21例基线BDG阴性的患者均在第4天停用阿尼芬净。直到第30天，没有人出现念珠菌血症。根据连续阴性的BDG检测，提前停止高危ICU患者的经验性棘白菌素治疗可能是一种合理的策略，具有减少ICU患者过度使用棘白菌素的巨大潜力。需要更多患者的前瞻性研究。
Empirical antifungal therapy in high-risk ICU patients is an attractive strategy, but overuse of antifungal agents is a potential problem.We evaluated if ICU patients at high risk to develop candidaemia identified by a prediction rule could discontinue empirical antifungal therapy on the basis of repeatedly negative 1-3-beta-d-glucan (BDG) tests.We conducted a multicentre cohort study in 85 ICU patients receiving antibiotics or with central venous catheter plus two additional factors (dialysis, parenteral nutrition, surgery, pancreatitis or receipt of corticosteroids or other immunosuppressive agents) plus either fever, hypothermia, hypotension, acidosis, elevated C-reactive protein or leucocytosis. Blood cultures (days 1 and 2) and BDG (days 1-3, baseline period) were performed and anidulafungin was given. On day 4, patients with negative blood cultures and BDG discontinued antifungal therapy. Registered in ClinicalTrials.gov (NCT01734525).The incidence of candidaemia was 8.2% in patients selected versus 0.5% in patients without entry criteria (16.9 times higher). Sixty-four patients (75.3%) had baseline positive BDG, including 7 with candidaemia. All 21 patients with baseline negative BDG discontinued anidulafungin on day 4. None developed candidaemia until day 30.Early discontinuation of empirical echinocandin therapy in high-risk ICU patients based on consecutive negative BDG tests may be a reasonable strategy, with great potential to reduce the overuse of echinocandins in ICU patients. Prospective studies with a higher number of patients are needed.