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1、EmpiricAntifungalTherapyintheICURamziMoufarrej,M.DChiefofCriticalCareZayedMilitaryHospital/AbuDhabiIntroductionInvasivefungalinfectionshaveincreasedsignificantlyoverthelast2decades.agingpopulationwithlifesustainingtherapieslikerenaldialysisbroadspectrumantimicrobialtherapyandinvasivemedical
2、devicesbonemarrowtransplantation(BMT)&solidorgantransplantation(SOT)intensivechemotherapyformalignanciesHIV/AIDSepidemic.NationalEpidemiologyofMycosisSurvey(NEMIS)wasaprospective,multicenterstudyconductedat6USsitesfrom1993–1995toexamineratesofriskfactorsforthedevelopmentofcandidalbloodstrea
3、minfections(CBSIs)amongpatientsinsurgicalandneonatalintensivecareunits>48hours.Among4276patients,42CBSIsoccurred.AdaptedfromBlumbergHMetal,andtheNEMISStudyGroupClinInfectDis2001;33:177–186;GarberGDrugs2001; 61(suppl1):1–12.RiskforInvasiveMycosisNon-Neutropenicrelatedtobarrierbreakdown,chang
4、eincolonization.Acuterenalfailure(RR4.2)Parenteralnutritionwithintralipid(RR3.6)PriorsurgeryspeciallyGI(RR7.3)Indwellingcentralline?Triplelumen(RR5.4)BroadspectrumantibioticsDiabetesBurnsMechanicalVentilationSteroidsNeutropenicrelatedtoaboveplusimmunecellsuppressionandunderlyingmalignancy.S
5、evereimmunosuppressive:BMTorSOTInvasiveMycosisCandidiasisAspergillosisDecreasingimmunitySOTorBMTMICUorSICUBarrierimmunityBarrierpluscellularimmunityOncologyPolyenesAmphotericinB(AmB)orLiposomalAmB(kidneytoxicity)AzolesFluconazole400-800mg/day(livertoxicity,CYP450)Voriconazole(livertoxicity,
6、visualdisturbances,CYP450)Posaconazole(livertoxicity,CYP450)EchinocandinsCaspofunginiv(livertoxicity)Combinationex.AmB/Fluconazole(liver,kidneytoxicity)Choiceofagentsdependsonwhetherthepatientonpreviousazoleprophylaxis,cultureresults,localfungalsensitivity,colonization,renalorliverdisease,p
7、resenceofdrug-druginteractions,presenceofhardware,immuno-suppresion,siteofdiseaseex.urine.TreatmentofInvasiveMycosisSiteofActionofSelectedAnti-fungalAgentsAdaptedfromAndrioleVTJAntimicrobChemother1999;44:151–162;GraybillJRetalAntimicrobAgentsChemother199
