Antifungal stewardshipの実践とカンジダ血症の予後に関与する要因
カンジダ血症は入院患者の主要な侵襲性真菌感染症であり，高い死亡率をもたらす．Antifungal stewardship（AFS）によりカンジダ血症の予後の改善や抗真菌薬の副作用，耐性化抑制などが期待される．カンジダ血症に対して行うべき事項はバンドルとして示され，遵守により予後改善の効果が期待される．AFSの実際としてACTIONsバンドルを用いたカンジダ血症のマネジメントを行い，カンジダ血症における予後に関与する要因の検討を行った．血液培養の陰性化後2週間の抗真菌薬投与は予後の改善の要因となった．一方，肝硬変を含む肝機能障害，低い予後栄養指数，高Acute Physiology and Ch...
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| Published in | 日本医真菌学会雑誌 Vol. 63; no. 4; pp. 93 - 98 |
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| Main Authors | , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
一般社団法人 日本医真菌学会
31.10.2022
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| Subjects | |
| Online Access | Get full text |
| ISSN | 2434-5229 2434-5237 |
| DOI | 10.11534/ishinkin.22.011 |
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| Abstract | カンジダ血症は入院患者の主要な侵襲性真菌感染症であり，高い死亡率をもたらす．Antifungal stewardship（AFS）によりカンジダ血症の予後の改善や抗真菌薬の副作用，耐性化抑制などが期待される．カンジダ血症に対して行うべき事項はバンドルとして示され，遵守により予後改善の効果が期待される．AFSの実際としてACTIONsバンドルを用いたカンジダ血症のマネジメントを行い，カンジダ血症における予後に関与する要因の検討を行った．血液培養の陰性化後2週間の抗真菌薬投与は予後の改善の要因となった．一方，肝硬変を含む肝機能障害，低い予後栄養指数，高Acute Physiology and Chronic Health EvaluationⅡスコアは予後の不良の要因であった．適切な抗真菌薬の選択と用法用量，治療期間は予後の改善する重要な項目である．一方，高齢，腎機能障害，肝機能障害，ステロイドを含む免疫抑制薬の使用などの患者背景もカンジダ血症の発生や予後不良のリスクとなることが知られており，コントロールが困難であることも多い．患者の栄養指標やリンパ球数も予後の予測因子となり，栄養状態の改善はカンジダ血症の予後向上のために行うべき対策である．この総説ではAFS活動とリスク要因となる患者の疾患背景をおもに取り上げ概説する． |
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| AbstractList | カンジダ血症は入院患者の主要な侵襲性真菌感染症であり，高い死亡率をもたらす．Antifungal stewardship（AFS）によりカンジダ血症の予後の改善や抗真菌薬の副作用，耐性化抑制などが期待される．カンジダ血症に対して行うべき事項はバンドルとして示され，遵守により予後改善の効果が期待される．AFSの実際としてACTIONsバンドルを用いたカンジダ血症のマネジメントを行い，カンジダ血症における予後に関与する要因の検討を行った．血液培養の陰性化後2週間の抗真菌薬投与は予後の改善の要因となった．一方，肝硬変を含む肝機能障害，低い予後栄養指数，高Acute Physiology and Chronic Health EvaluationⅡスコアは予後の不良の要因であった．適切な抗真菌薬の選択と用法用量，治療期間は予後の改善する重要な項目である．一方，高齢，腎機能障害，肝機能障害，ステロイドを含む免疫抑制薬の使用などの患者背景もカンジダ血症の発生や予後不良のリスクとなることが知られており，コントロールが困難であることも多い．患者の栄養指標やリンパ球数も予後の予測因子となり，栄養状態の改善はカンジダ血症の予後向上のために行うべき対策である．この総説ではAFS活動とリスク要因となる患者の疾患背景をおもに取り上げ概説する． |
| Author | 竹末, 芳生 中嶋, 一彦 一木, 薫 石川, かおり 山田, 久美子 植田, 貴史 |
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| Copyright | 2022 一般社団法人日本医真菌学会 |
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| References_xml | – reference: 24) Hassan EA, Abd El-Rehim AS, Hassany SM, Ahmed AO, Elsherbiny NM, Mohammed MH: Fungal infection in patients with end-stage liver disease: low frequency or low index of suspicion. Int J Infect Dis 23: 69–74, 2014. – reference: 25) Hwang SY, Yu SJ, Lee JH, Kim JS, Yoon JW, Kim YJ, Yoon JH, Kim EC, Lee HS: Spontaneous fungal peritonitis: a severe complication in patients with advanced liver cirrhosis. Eur J Clin Microbiol Infect Dis 33: 259–264, 2014. – reference: 19) Alves PGV, Melo SGO, Bessa MAS, Brito MO, Menezes RP, Araújo LB, Penatti MPA, Pedroso RDS, Röder DVDB: Risk factors associated with mortality among patients who had candidemia in a university hospital. Rev Soc Bras Med Trop 53: e20190206, 2020. – reference: 23) Guimarães T, Nucci M, Mendonça JS, Martinez R, Brito LR, Silva N, Moretti ML, Salomão R, Colombo AL: Epidemiology and predictors of a poor outcome in elderly patients with candidemia. Int J Infect Dis 16: e442–e447, 2012. – reference: 13) Huang HY, Lu PL, Wang YL, Chen TC, Chang K, Lin SY: Usefulness of EQUAL Candida Score for predicting outcomes in patients with candidaemia: a retrospective cohort study. Clin Microbiol Infect 26: 1501–1506, 2020. – reference: 36) Lee JY, Kim HI, Kim YN, Hong JH, Alshomimi S, An JY, Cheong JH, Hyung WJ, Noh SH, Kim CB: Clinical significance of the prognostic nutritional index for predicting short- and long-term surgical outcomes after gastrectomy: a retrospective analysis of 7781 gastric cancer patients. Medicine (Baltimore) 95: e3539, 2016. – reference: 35) Buzby GP, Mullen JL, Matthews DC, Hobbs CL, Rosato EF: Prognostic nutritional index in gastrointestinal surgery. Am J Surg 139: 160–167, 1980. – reference: 11) Takesue Y, Ueda T, Mikamo H, Oda S, Takakura S, Kitagawa Y, Kohno S; ACTIONs Project: Management bundles for candidaemia: the impact of compliance on clinical outcomes. J Antimicrob Chemother 70: 587–593, 2015. – reference: 12) Mellinghoff SC, Hoenigl M, Koehler P, Kumar A, Lagrou K, Lass-Flörl C, Meis JF, Menon V, Rautemaa-Richardson R, Cornely OA: EQUAL Candida Score: an ECMM score derived from current guidelines to measure QUAlity of Clinical Candidaemia Management. Mycoses 61: 326–330, 2018. – reference: 32) Scalas D, Banche G, Merlino C, Giacchino F, Allizond V, Garneri G, Patti R, Roana J, Mandras N, Tullio V, Cuffini AM: Role of caspofungin in restoring the impaired phagocyte-dependent innate immunity towards Candida albicans in chronic haemodialysis patients. Int J Antimicrob Agents 39: 73–76, 2012. – reference: 6) Garbino J, Kolarova L, Rohner P, Lew D, Pichna P, Pittet D: Secular trends of candidemia over 12 years in adult patients at a tertiary care hospital. Medicine (Baltimore) 81: 425–433, 2002. – reference: 38) Hayıroğlu Mİ, Keskin M, Keskin T, Uzun AO, Altay S, Kaya A, Öz A, Çinier G, Güvenç TS, Kozan Ö: A novel independent survival predictor in pulmonary embolism: prognostic nutritional index. Clin Appl Thromb Hemost 24: 633–639, 2018. – reference: 46) Kaito S, Sekiya N, Najima Y, et al: Nutritional risk index as a risk factor for breakthrough candidemia in allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 55: 661–664, 2020. – reference: 39) Adrie C, Lugosi M, Sonneville R, Souweine B, Ruckly S, Cartier JC, Garrouste-Orgeas M, Schwebel C, Timsit JF; OUTCOMEREA study group: Persistent lymphopenia is a risk factor for ICU-acquired infections and for death in ICU patients with sustained hypotension at admission. Ann Intensive Care 7: 30, 2017. – reference: 9) 二木芳人，賀来満夫，青木洋介，他：抗菌薬適正使用支援プログラム実践のためのガイダンス．日化療会誌 65: 650–687, 2017. – reference: 33) van Asbeck EC, Hoepelman AI, Scharringa J, Verhoef J: The echinocandin caspofungin impairs the innate immune mechanism against Candida parapsilosis. Int J Antimicrob Agents 33: 21–26, 2009. – reference: 37) Tokunaga R, Sakamoto Y, Nakagawa S, Miyamoto Y, Yoshida N, Oki E, Watanabe M, Baba H: Prognostic nutritional index predicts severe complications, recurrence, and poor prognosis in patients with colorectal cancer undergoing primary tumor resection. Dis Colon Rectum 58: 1048–1057, 2015. – reference: 31) Mahajan S, Kalra OP, Asit KT, Ahuja G, Kalra V: Phagocytic polymorphonuclear function in patients with progressive uremia and the effect of acute hemodialysis. 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| Title | Antifungal stewardshipの実践とカンジダ血症の予後に関与する要因 |
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