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[Intensive Care Med发布指南]: ESICM/ESCMID特别工作组有关危重病患者侵袭性念珠菌病诊疗的推荐意见
2019年05月03日 指南导读, 进展交流 暂无评论

ESICM/ESCMID task force on practical management of invasive candidiasis in critically ill patients

Question 1: Can we recommend the use of risk prediction models in daily clinical practice?我们能否推荐工作中采用风险预测模型?

Recommendations 推荐意见

Risk prediction models, because of their simplicity and high negative predictive values, should be used for identifying high-risk patients (Strong recommendation, low-quality evidence).

由于风险预测模型简单且阴性预期值很高,因此可以用于鉴别高危患者(强推荐,低质量证据)

Question 2: What conventional and non-culture-based microbiological techniques are available for diagnosing IC?诊断侵袭性念珠菌病有哪些传统和非培养微生物学技术?

Consensus statements 共识说明

The panel suggests that when IC is suspected, cultures and microscopic examination should be performed on blood and other body fluids taken from all normally sterile sites (best practice statement).

小组建议,当怀疑侵袭性念珠菌病时,应当对血液和无菌部位体液标本进行培养及显微镜检查(最佳临床实践)

The panel recommends incorporating conventional and non-culture-based techniques as part of the diagnostic strategy for IC (best practice statement):

小组推荐将传统及非培养技术作为侵袭性念珠菌病诊断策略的一部分(最佳临床实践)

  • Conventional culture-based tests (best practice statement).传统培养(最佳临床实践)
  • PCR-based tests (weak recommendation, low quality of evidence).PCR检查(弱推荐,低质量证据)
  • Miniaturized-magnetic resonance-based technology (weak recommendation, low quality of evidence) 微型磁共振(弱推荐,低质量证据)

Serological tests: 血清学检查

  • BDG (weak recommendation, moderate quality of evidence) G试验(弱推荐,中等质量证据)
  • Mn-Ag and Mn-Ab (weak recommendation, low quality of evidence) 甘露聚糖抗原及甘露聚糖抗体(弱推荐,低质量证据)
  • CAGTA (weak recommendation, low quality of evidence). 念珠菌属芽管抗体(弱推荐,低质量证据)

The panel agrees that PCR-based tests and miniaturized-magnetic resonance-based technology perform well. However, the lack of standardization and of large-scale validation precludes their clinical use without ancillary testing (weak recommendation, low quality of evidence)

小组认为,PCR检查及微型磁共振技术准确性很高。然而,由于并非标准化且缺乏大规模试验验证,限制了其临床应用(弱推荐,低质量证据)

The panel agrees that the combined use of Mn-Ag and Mn-Ab, BDG quantification and CAGTA provides added value and that these tests are therefore of clinical utility (weak recommendation, low quality of evidence)

小组认为,联合甘露聚糖抗原和抗体检测,定量G试验及念珠菌属芽管抗体检测具有额外价值,这些检查有临床用途(弱推荐,低质量证据)

The panel agrees that quantification of BDG has an excellent negative predictive value, and should therefore be used to rule out IC (weak recommendation, low quality of evidence)

小组认为,定量G试验具有很高的阴性预期值,因而可用于排除侵袭性念珠菌病(弱推荐,低质量证据)

The panel recommends that the utility of quantitative detection of fungal biomarkers for identifying IC should be further assessed in large-scale clinical trials (best practice statement).

小组推荐,应通过大规模临床试验进一步评价定量检测真菌生物标志物的用途(最佳临床实践)

Question 3: Should antifungal prophylaxis be used in critically ill patients? 危重病患者是否应当进行抗真菌预防?

Consensus statements 共识说明

The panel recommends against the routine and universal administration of antifungal prophylaxis in critically ill patients (weak recommendation, moderate quality of evidence).

小组反对常规及普遍对危重病患者使用真菌预防(弱推荐,中等质量证据)

Question 4: Should pre-emptive therapy be used in critically ill patients? 抢先治疗是否应当用于危重病患者?

Consensus statements 共识说明

The panel does not recommend the use of pre-emptive antifungal therapy in critically ill patients (weak recommendation, low-quality evidence).

小组不推荐危重病患者进行抢先抗真菌治疗(弱推荐,低质量证据)

The panel agrees that more studies are needed to define the critically ill patient profile that would benefit most from pre-emptive antifungal therapy and whether the widespread use of antifungal agents influences fungal ecology (best practice statement).

小组认为,需要更多研究确定可能从抢先抗真菌治疗中获益最多的危重病患者人群,以及广泛使用抗真菌药物是否影响真菌生态(最佳临床实践)

Question 5: Which patients should receive empirical antifungal treatment? 哪些患者应当接受经验性抗真菌治疗?

Consensus statement 共识说明

The panel suggests that empirical antifungal therapy might be considered only in patients with septic shock and multi-organ failure (MOF) who have more than 1 extra-digestive site (i.e. urine, mouth, throat, upper and lower respiratory tracts, skin folds, drains, operative site) with proven Candida species colonization (strong recommendation, low quality of evidence).

小组建议,仅在感染性休克及多器官功能衰竭(MOF)且除证实胃肠道外超过一个部位(即尿,口腔,咽,上下呼吸道,皮肤皱褶,引流,手术部位)有念珠菌定植的患者,应当考虑进行经验性抗真菌治疗(强推荐,低质量证据)

The panel recommends not starting empirical antifungal therapy in patients without septic shock and MOF (strong recommendation, low quality of evidence).

小组推荐对于不伴有感染性休克和MOF的患者,不应开始经验性抗真菌治疗(强推荐,低质量证据)

Candida isolation from respiratory samples should be considered as one site of colonization among others and isolation of Candida from the respiratory tract alone should not prompt initiation of treatment. However, this suggestion does not apply to patients with a clear diagnosis of pneumonia despite the presence of fungal colonization in a non-digestive site (best practice statement).

呼吸道标本分离到念珠菌应当考虑为定植,单纯从呼吸道分离到念珠菌不应开始治疗。然而,这一推荐意见并不能用于明确诊断肺炎的患者,尽管非消化道部分有真菌定植(最佳临床实践)

The panel recommends the promotion of antifungal stewardship programs in order to limit the use of empirical therapy. The current practice of indiscriminate use of antifungals may lead to the emergence of resistant strains (best practice statement).

小组推荐,应当普及抗真菌药物监测以限制经验性治疗。目前随意使用抗真菌药物可能导致耐药菌株的产生(最佳临床实践)

Question 6: What is the preferred first-line empirical therapy in a non-neutropenic critically ill patient with invasive candidiasis? 罹患侵袭性念珠菌病的非粒缺危重病患者一线经验性治疗药物有哪些?

Consensus statement 共识说明

The panel recommends that echinocandins should be used as the first treatment option in critically ill patients with septic shock and MOF with IC (weak recommendation, low quality of evidence).

小组推荐,对于罹患侵袭性念珠菌病的感染性休克及MOF患者,棘白菌素应作为一线治疗药物(弱推荐,低质量证据)

The panel recommends that fluconazole should be considered the first treatment option for critically ill patients with low severity of disease (i.e. without septic shock and/or MOF) in settings with low fluconazole resistance (strong recommendation, low quality of evidence).

小组推荐,在氟康唑耐药率较低的情况下,对于疾病严重程度较低(即未合并感染性休克和/或MOF)的患者,氟康唑可作为一线治疗药物(强推荐,低质量证据)

The panel recommends that critically ill patients treated with fluconazole should receive a loading dose. A weight-based dosing scheme is recommended (loading dose 12 mg/kg; maintenance dose 6 mg/kg) (strong recommendation, low quality of evidence).

小组推荐,危重病患者接受氟康唑治疗时,应当使用负荷剂量。推荐使用基于体重的治疗方案(负荷剂量12 mg/kg;维持剂量6 mg/kg)(强推荐,低质量证据)

Question 7: What is the role of polyenes in critically ill patients? 多烯类抗真菌药物在危重病患者的地位如何?

Consensus statements 共识说明

The panel recommends that AmB-d should not be used as a first-line treatment in critically ill patients with documented or suspected IC due to its significant nephrotoxicity (strong recommendation, moderate quality of evidence).

小组推荐,对于确诊或疑似侵袭性念珠菌病的危重病患者,普通两性霉素B由于肾毒性明显,不能作为一线治疗药物(强推荐,中等质量证据)

The panel recommends that the use of LF-AmB (liposomal amphotericin B) should be preferred over other lipid formulations when previous treatment with echinocandins and azoles has already failed (strong recommendation, moderate quality of evidence).

小组推荐,当棘白菌素和唑类抗真菌药物失败时,脂质体两性霉素B较其他脂质制剂优先使用(强推荐,中等质量证据)

Question 8: In non-neutropenic critically ill patients, does de-escalation of antifungal therapy yield similar outcomes (in terms of clinical success and mortality) as ongoing treatment with first-line antifungal agents? 对于非粒缺危重病患者,与继续使用一线抗真菌药物相比,降阶梯抗真菌治疗能否取得相似预后(临床成功率及病死率)?

Consensus statement 共识说明

The panel recommends de-escalating from an echinocandin to fluconazole when the patient is clinically stable and the isolate is susceptible to fluconazole (Strong recommendation, moderate quality of evidence.)

小组推荐,当患者病情平稳且分离菌株对氟康唑敏感时,应当从棘白菌素降阶梯至氟康唑(强推荐,中等质量证据)

Echinocandins should not be de-escalated if central venous catheter or any other foreign material has not been removed. This recommendation is particularly pertinent to cases with an intravascular catheter that cannot be removed or if an intravascular device (e.g. pacemaker) must be left in place. (strong recommendation, moderate quality of evidence).

如果未拔除中心静脉导管或其他异物,不应对棘白菌素降阶梯。这一推荐意见尤其适用于无法拔除血管内导管或必须保留血管内装置(如起搏器)的情况(强推荐,中等质量证据)

The panel recommends that antifungal treatment should be stopped in patients with suspected (but not proven) IC with negative blood cultures and/or other negative culture specimens taken from suspected infectious foci before starting antifungal therapy (best practice statement).

小组推荐,对于疑似(未确诊)侵袭性念珠菌感染患者,若开始抗真菌治疗前留取的血培养阴性,或其他可疑感染部位标本培养结果阴性,应停止抗真菌治疗(最佳临床实践)

Question 9: What is the recommended duration of antifungal treatment in patients with candidemia and IC? 对于念珠菌血症及侵袭性念珠菌病患者,推荐的抗真菌治疗疗程如何?

Consensus statement 共识说明

The panel recommends that candidemia should be treated for at least 14 days after the first negative blood culture (strong recommendation, low quality of evidence).

小组推荐,念珠菌血症应当在首次血培养阴性后治疗至少14天(强推荐,低质量证据)

The panel suggests that IC without positive blood cultures should be treated for 10–14 days (weak recommendation, low quality of evidence).

小组推荐,侵袭性念珠菌病不伴血培养阳性时,应当治疗10-14天(弱推荐,低质量证据)

The panel recommends that adequate source control (catheter removal, appropriate drainage, surgical control) should be performed early, if clinically feasible, in every critically ill patient with IC (strong recommendation, moderate quality of evidence).

小组推荐,对于侵袭性念珠菌病的危重病患者,如果临床情况许可,应尽早进行充分的感染灶控制(拔除导管,适当引流,手术控制)(强推荐,中等质量证据)

The panel recommends that in critically ill patients with IC and inadequate source control, the treatment duration for deep-seated infection due to Candida species (including endocarditis) should be individualized and based on a multidisciplinary approach (best practice statement).

小组推荐,对于无法进行充分感染灶控制的侵袭性念珠菌病危重患者,念珠菌属导致的深部感染(包括心内膜炎)的疗程应当个体化,并基于多学科策略(最佳临床实践)

In cases where an intravascular catheter or any other foreign material cannot be removed, echinocandins should not be de-escalated to an azole because of their enhanced activity against biofilm (best practice statement).

若无法去除血管内导管或其他异物,由于棘白菌素具有较强的抗生物膜活性,不应降阶梯到唑类(最佳临床实践)

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