血液肿瘤患者抗真菌经验治疗与抢先治疗首选药物的现况调查研究

Cross-sectional investigation of first-choice of antifungal agents in empirical and preemptive antifungal therapy for patients with hematological malignancies

目的根据我国多中心血液肿瘤化疗与造血干细胞移植（HSCT）患者抗真菌治疗的病例资料，描述治疗策略和首选药物情况。方法调查全国15个血液病中心共367例血液肿瘤接受化疗或HSCT的患者，在2008年1月至2009年12月间抗真菌经验与抢先治疗的首选用药情况，分析抗真菌药物的构成比及影响首选用药的因素。结果367例患者中282例（76．8％）接受抗真菌经验治疗，85例（23．2％）接受抢先治疗。抗真菌治疗的首选药物分别为氟康唑55例（15．0％），伊曲康唑174例（47．4％），伏立康唑39例（10．6％），普通和（或）脂质体两性霉素B57例（15．5％），卡泊芬净26例（7．1％），米卡芬净7例（1．9％），联合治疗9例（2．5％）。根据患者的不同特点进行分析，抢先治疗首选伏立康唑和联合治疗的比例高于经验治疗，但伊曲康唑在两种治疗策略中均为首选比例最多的药物；接受HSCT的患者中，首选伊曲康唑和卡泊芬净的比例高于非移植患者，而非移植患者中则首选两性霉素B、氟康唑和伏立康唑高于移植患者；在进行抗真菌二级预防的患者中，首选卡泊芬净和联合治疗的比例较多，而未预防和一级预防的患者中首选伊曲康唑治疗的患者多于二级预防的患者。结论目前我国血液肿瘤接受化疗和HSCT患者中，抗真菌治疗仍以经验治疗为主，首选最多的药物为伊曲康唑，其次分别为两性霉素B、氟康唑、伏立康唑和棘白菌素类药物。

Objective To describe the constituent ratio of different kinds of antifungal agents as first choice in empirical or preemptive antifungal therapy for patients with hematological malignancies received chemotherapy or hematopoietic stem cell transplantation （HSCT）. Methods Between 2008 January and 2009 December, 367 patients received chemotherapy or HSCT from 15 medical centers in China were collected. The strategies of antifungal therapy and the first-choice antifungal agents were analyzed. Results Of them, 282（76.8% ） patients received empirical antifungal therapy, 85 （23.2%） preemptive therapy. The number of first choice antifungal agents were 55 （ 15.0% ） of fluconazole, 174（47.4% ） of itraconazole, 39 （ 10.6% ） of voriconazole, 57 （ 15.5% ） of traditional/lipid formulation amphotericin B, 26 （ 7. 1% ） of caspofungin, 7 （ 1.9% ） of micafungin, and 9 （2.5 % ） of combination antifungal therapy respectively. Moreover, voriconazole and combination antifungal agents were more often selected for preemptive antifungal therapy, while the probabilities of itraconazole were the highest in both empirical and preemptive strategies. More patients undergoing HSCT were first given itraconazole or caspofungin for antifungal therapy, while amphoteri- cin B, fluconazole and voriconazole were more administered in patients received chemotherapy. Caspofungin and combined antifungal agents were more often used for patients with secondary antifungal prophylaxis, while itraconazole was usually used for patients with no prophylaxis or primary antifungal prophylaxis. Conclusion Empirical antifungal therapy was more administered in hematological malignancies patients received chemo- therapy or HSCT. Itraeonazole was the most commonly used agent for antifungal therapy followed by amphoter- icin, fluconazole, voriconazole and echinocandin agents.