抗侵袭性念珠菌药物管理指标与治疗方案一致性对重症患者预后的影响

Consistency of treatment strategies and antifungal stewardship indicators in intensive care units’patients with invasive candidiasis:the clinical outcomes

目的评估侵袭性念珠菌病重症患者的治疗方案与抗真菌药物管理指标的一致性,并探讨该种一致性与患者临床结局的相关性。方法回顾性收集2018年1月到2021年4月使用抗真菌药物的侵袭性念珠菌病重症患者。以抗真菌药物治疗方案中首选药物、药物剂量、疗程以及病原微生物培养频率等作为抗真菌药物管理指标,应用多因素Logistic回归分析患者治疗方案和管理指标的一致性与患者临床结局的关系。结果本研究共纳入158例侵袭性念珠菌病重症患者。发现治疗方案与管理指标的一致性较低。一致性最高的指标为首选药物合理(一致性为77%);只有20例患者(12.7%;20/158)的所有初始用药方案与管理指标一致(即药物、剂量及疗程均一致)。多因素分析发现,每天或者每隔1 d的念珠菌培养直至念珠菌培养阴性这一管理指标与临床治疗成功显著相关(校正OR=5.57,95%CI:1.20~25.80,P=0.028)。首选药物疗程合理这一管理指标可以显著降低患者14 d全因死亡(校正OR=0.09,95%CI:0.01~0.71,P=0.022)。结论重症真菌感染应重点关注患者的病原学持续监测以及进行足量的抗真菌治疗疗程。

Objective To evaluate the consistency between the treatment strategies and the antifungal stewardship(AFS)indicators of intensive care units(ICU)patients with invasive candidiasis,and to explore the correlation of the consistency and the clinical outcome.Methods Severe patients with invasive candidiasis who used antifungal drugs from January 2018 to April2021 were collected retrospectively.Preferred drugs,drug dose,course of treatment and pathogenic microorganism culture frequency in the antifungal drug treatment scheme etc.were used as AFS indicators.Multivariate logistic regression was performed to analyze the correlation between the consistency of the indicators and treatment strategies and the clinical outcomes of ICU patients.Results A total of 158 patients in ICU with invasive candidiasis were included.It was found that the consistency between the treatment plan and the management index was low.The index with the highest consistency was reasonable drug of choice(compliance rate was 77%),while only 20 patients(12.7%;20/158)achieved consistent of initial drug and the management index(i.e.,appropriate selection of antifungals,dose and duration of the treatment).In multivariate analysis,the Follow-up cultures were conducted daily or every day until clearance of candidiasis was significantly associated with clinical success(adjusted odds ratio=5.57,95%confidence interval=1.20 to 25.80,P=0.028).The management index of reasonable course of preferred drugs can significantly reduce all-cause death in 14 days(adjusted odds ratio=0.09,95%confidence interval=0.01 to 0.71,P=0.022).Conclusion Patients with severe fungal infection should focus on the continuous monitoring of etiology and sufficient antifungal treatment.