BS Nguyễn Nghiêm Tuấn�Bệnh viện ĐKQT Nam Sài Gòn
ĐIỀU TRỊ NHIỄM CANDIDA XÂM LẤN
TẠI KHOA HỒI SỨC TÍCH CỰC
NỘI DUNG
Tỷ lệ nhiễm khuẩn huyết do Candida
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The SCOPE study
Hilmar Wisplinghoff et al. Clin Infect Dis. 2004;39:309-317
The SCOPE study
| | % BSI | % Crude Mortality | |||||
Rank | Pathogen | BSI per 10,000 admissions | Total (n=20,978) | ICU (n=10,515) | Non-ICU (n=10,515) | Total | ICU | Non-ICU |
1. | CoNS | 15.8 | 31.3 | 35.9 | 26.6 | 20.7 | 25.7 | 13.8 |
2. | S aureus | 10.3 | 20.2 | 16.8 | 23.7 | 25.4 | 34.4 | 18.9 |
3. | Enterococcus spp | 4.8 | 9.4 | 9.8 | 9.0 | 33.9 | 43.0 | 24.0 |
4. | Candida spp | 4.6 | 9.0 | 10.1 | 7.9 | 39.2 | 47.1 | 29.0 |
5. | E coli | 2.8 | 5.6 | 3.7 | 7.6 | 22.4 | 33.9 | 16.9 |
6. | Klebsiella spp | 2.4 | 4.8 | 4.0 | 5.5 | 27.6 | 37.4 | 20.3 |
7. | P aeruginosa | 2.1 | 4.3 | 4.7 | 3.8 | 38.7 | 47.9 | 27.6 |
8. | Enterobacter spp | 1.9 | 3.9 | 4.7 | 3.1 | 26.7 | 32.5 | 18.0 |
9. | Serratia spp | 0.9 | 1.7 | 2.1 | 1.3 | 27.4 | 33.9 | 17.1 |
10. | A baumannii | 0.6 | 1.3 | 1.6 | 0.9 | 34.0 | 43.4 | 16.3 |
Phân bố �các chủng Candida
Tình hình kháng thuốc một số chủng Candida tại châu Á
Nhiễm khuẩn huyết do Candida tại�ICU – BV Chợ Rẫy
Tử vong do nhiễm Candida xâm lấn
*
Tử vong do nhiễm Candida xâm lấn
FIGURE 2. ALL-CAUSE MORTALITY RATES IN IC RANDOMIZED TRIALS�J Antimicrob Chemother, Volume 78, Issue 7, July 2023, Pages 1569–1585
Một số vấn đề trong thực hành điều trị nhiễm Candida xâm lấn
Thời điểm bắt đầu điều trị?�
Critically Ill Patients.
Đặc hiệu
Targeted
Theo KN
Empiric
Định hướng
Pre-emptive
Phòng ngừa
Prophylaxis
Ít khả năng
Chưa mắc bệnh
Chắc chắn
Nhiều khả năng
Bằng chứng vi sinh học
Figure 3. Hospital mortality according to whether or not patients received antifungal therapy and adequate source control within 24h of septic shock onset
Clin Infect Dis, Volume 54, Issue 12, 15 June 2012, Pages 1739–1746, https://doi.org/10.1093/cid/cis305
The content of this slide may be subject to copyright: please see the slide notes for details.
Figure 1. Kaplan-Meier curves comparing patients who received antifungal therapy within 24 hours of the onset of septic shock
Clin Infect Dis, Volume 54, Issue 12, 15 June 2012, Pages 1739–1746, https://doi.org/10.1093/cid/cis305
The content of this slide may be subject to copyright: please see the slide notes for details.
Intensive Care Med (2022) 48:865–875
Intensive Care Med (2022) 48:865–875
Critically Ill Patients.
Đặc hiệu
Targeted
Theo KN
Empiric
Định hướng
Pre-emptive
Phòng ngừa
Prophylaxis
Ít khả năng
Chưa mắc bệnh
Chắc chắn
Nhiều khả năng
Bằng chứng vi sinh học
Lựa chọn thuốc trúng đích�
Điều chỉnh liều kháng nấm� theo hướng cá thể hóa
TABLE 1 CAUSES OF ANTIFUNGAL THERAPY FAILURE.�
Clin Infect Dis, Volume 46, Issue 9, 1 May 2008, Pages 1426–1433, https://doi.org/10.1086/587101
CAUSES OF ANTIFUNGAL THERAPY FAILURE |
Host factor |
Severity of illness |
Persistence of immunodeficiency (e.g., neutropenia or use |
of corticosteroids) |
Primary (intrinsic) drug resistance |
Wrong diagnosis |
Mixed infection |
Low concentration of the drug at the site of infection |
Pharmacokinetic and pharmacodynamic |
Drug interactions |
Biofilms |
Poor vascular supply (e.g., abscess and necrotic tissue) |
Development of resistance (secondary) |
Misdiagnosis of failure—immune reconstitution inflammatory syndrome |
Drug | Standard dose | Hepatic impairment | Renal impairment | CRRT | Obesity |
Fluconazole | LD 800 mg 12 mg/kg day 1�MD 400 mg (6 mg/kg/day) | Limited data, no specific �recommendations | 100-20 mg q24h if CLCR �<50 mL/min; supplemental �dose of 50-100 mg after IHD | 300-400 mg q12 | No dosage adjustment; �dose on total body weight |
Voriconazole | LD 6 mg/kg q12h day 1�MD 4 mg/kg 12h | Mild to moderate hepatic insufficiency �(Child-Pugh Class A and B): 6 mg/kg �q12h X 2 doses (load), then 2 mg/kg iv q12h �Monitor serum concentrations | No dosage adjustment | No dosage adjustment | Dose based on adjusted �body weight |
Anidulafungin | LD 200 mg day 1�MD 100 mg q24h | For Child-Pugh class A, B, or C: usual dose | No dosage adjustment | No dosage adjustment | Increase the daily echinocandin dose by at least 25%-50% of the usual dose in patients weighing >75 kg |
Caspofungin | LD 70 mg day 1 MD 50 mg q24h | For Child-Pugh score of 7-9, after �initial 70 mg load on day 1, �decrease daily dose to 35 mg q24h� | No dosage adjustment | No dosage adjustment | |
Micafungin | 100 mg q24h | No dose adjustment needed �for Child-Pugh score of 7-9. | No dosage adjustment | No data. �Usual dose likely. | |
Lipid formulation �of amphotericin B | 3-5 mg/kg q24h | No data. Usual dose likely. | No dosage adjustment | No dosage adjustment | Dose based on lean body weight |
Flucytosine | 25 mg/kg q6h | No data. Usual dose likely. | 25 mg/kg q 24-48 h; �supplementary dose� of 20-50mg/kg after IHD | NA | Dose based on ideal body weight |
J Antimicrob Chemother 2018; 73 Suppl 1: i33–i43
Table 1 Summary guidance for antifungal dosing in different critically ill patient subpopulations
From:
| ARC | AKI | RRT | ALF |
Amphotericin | Unchanged | Unchanged | Unchanged | Unchanged |
Fluconazole | Increase | Decrease | Increase | Unchanged |
Voriconazole | TDM | TDM | TDM | TDM |
Itraconazole | TDM | TDM | TDM | TDM |
Posaconazole | TDM | TDM | TDM | TDM |
Caspofungin | Unchanged | Unchanged | Unchanged | Decrease |
Micafungin | Unchanged | Unchanged | Unchanged | Unchanged |
Anidulafungin | Unchanged | Unchanged | Unchanged | Unchanged |
Flucytosine | TDM | TDM | TDM | TDM |
TDM: therapeutic drug monitoring ARC: augmented renal clearance
AKI: acute kidney injury RRT: renal replacement therapy
ALF: acute liver failure
Đặc tính PK/PD một số thuốc kháng nấm
Cold Spring Harb Perspect Med 2015;5:a019653
Đặc tính PK/PD một số thuốc kháng nấm
Một số thuốc kháng nấm mới
Thuốc kháng nấm mới: phổ tác dụng
Thuốc kháng nấm mới: một số chỉ định
Công cụ quản lý �điều trị nhiễm Candida xâm lấn
Fig. 3
Clinical Microbiology and Infection 2020 261501-1506DOI: (10.1016/j.cmi.2020.01.029)
Clinical Microbiology and Infection Volume 26, Issue 11, November 2020, Pages 1501-1506
Clinical Microbiology and Infection Volume 26, Issue 11, November 2020, Pages 1501-1506
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