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首页> 外文期刊>The Internet Journal of Emergency and Intensive Care Medicine >A Protocol For The Use Of Antifungals In An ICU: Funguria And Fungal Urinary Infection
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A Protocol For The Use Of Antifungals In An ICU: Funguria And Fungal Urinary Infection

机译：在ICU中使用抗真菌药物的协议：真菌和真菌性尿路感染

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Fungal infections are one of the most serious problems in hospitals today. Among them, funguria and urinary infections account for 40% of all the nosocomial infections and over one million new infections in the United States each year. The increase incidence of funguria is associated with risk factors including urinary catheters, treatment with broad-spectrum antibiotics, age, gender, diabetes mellitus, and chronic renal failure. Currently the majority of fungal urinary tract infections involve Candia albicans, however, non-albicans Candida and non-Candida yeasts are increasing as the etiological cause. A protocol for the treatment of funguria and urinary infections based on current medical evidence and cost effective therapy for use in the ICU is discussed. Introduction Since the clinical introduction of penicillin, infections with rare or resistant organisms have become more frequent until today when they are considered the norm in infectious diseases.1,2,3,4 One complication observed in modern medicine is an increase rate of fungal infections, and most notably funguria.5,6 Urinary tract infections (UTI) are now among the most frequent nosocomial infections, and catheter associated urinary infections (CAUTI) account for up to 40% of all nosocomial infections in the United States.7 The incidence of all CAUTI caused by fungi in two recent studies has been reported to be 24.8% and 26.5%, respectively. 8-9 Additionally, Candida is now reported to be the most frequently isolated organism from the urine of patients in surgical intensive care units.10 The rise in fungal infections is such that, candiduria essentially unknown before 1940 has become a nosocomial problem. 5The increase incidence of funguria is associated with the use of urinary catheters, treatment with broad-spectrum antibiotics, corticosteroids, immunosuppressive agents, and antineoplastics. Other risk factors include advanced age, female gender, diabetes mellitus, chronic renal failure and hemodialysis.11,12,13 The majority of fungal UTI involve Candida species. The most frequent organism is Candida albicans followed by Candida glabrata, Candida tropicalis, and Candida krusei.12-13 However, non-albicans Candida and non-Candida yeasts are increasing as the etiological cause of fungal UTI. 14-15Despite an increase in the frequency of funguria, there is not a consensus in the literature as to the diagnosis and management of fungal UTI. There is still much discussion as to colonization versus infection along with the need and efficacy of treatment. Practice guidelines for the treatment of candidiasis by the Infectious Diseases Society of America (IDSA) as recent as April 2000 fail to clearly define funguria and fungal UTI.10 Additionally, the IDSA does not adequately address recent prospective randomized studies comparing amphotericin B bladder irrigation versus intravenous amphotericin B therapy or oral fluconazole therapy. Several therapeutic options have been discussed but no regimen appears superior. Presented below is a protocol for the management of funguria and fungal UTI in an intensive care unit. Treatment of ascending pyelonephritis and renal candidiasis is beyond the scope of this review and is discussed elsewhere.13 Definition Of Funguria And Urinary Tract Infection The findings of fungus in the urine may represent contamination, colonization of the catheter, or infection.16 As of now, there is no reliable method for differentiating colonization from infection.13,17 It is not known whether quantitative urinalysis, presence of pyuria, or symptoms correlate with fungal infection. However, Tambyah and Maki found recently that there is a significant difference in the urine white blood cell count between patients with and without bacterial CAUTI (p=0.009).18An asymptomatic bacteriuria is defined by the Centers for Disease Control (CDC) according to one of the following criteria: patient has an indwelling urinary catheter within seven days before the culture, and
机译：真菌感染是当今医院中最严重的问题之一。其中，真菌感染和泌尿道感染占美国所有医院感染的40％，每年新增百万以上。真菌病发病率增加与危险因素有关，包括导尿管，广谱抗生素治疗，年龄，性别，糖尿病和慢性肾功能衰竭。当前，大多数真菌泌尿道感染涉及白色念珠菌，但是，非白色念珠菌念珠菌和非念珠菌酵母菌的病因越来越多。讨论了一种基于当前医学证据和在ICU中使用的经济有效的治疗真菌和尿路感染的方案。引言自从青霉素临床引入以来，稀有或耐药性细菌的感染变得越来越普遍，直到今天，它们才被认为是传染病的常态。1,2,3,4现代医学中观察到的一种并发症是真菌感染的发生率增加。 5,6尿路感染（UTI）现在是最常见的医院感染之一，在美国，与导管相关的尿路感染（CAUTI）占所有医院感染的40％。7两项最新研究表明，由真菌引起的所有CAUTI分别为24.8％和26.5％。 8-9此外，据报道，念珠菌是外科重症监护病房中从患者尿液中分离出的最频繁的有机体。10真菌感染的增加使得念珠菌在1940年之前基本上是未知的，成为医院的问题。 5真菌感染的增加与导尿管的使用，广谱抗生素，皮质类固醇，免疫抑制剂和抗肿瘤药的治疗有关。其他危险因素包括高龄，女性，糖尿病，慢性肾功能衰竭和血液透析。11,12,13大多数真菌性尿路感染涉及念珠菌。最常见的生物是白色念珠菌，其次是光滑念珠菌，热带念珠菌和克鲁斯念珠菌。12-13然而，非白色念珠菌和非念珠菌是真菌UTI的病因。 14-15尽管真菌的发生频率增加，但文献中关于真菌性尿路感染的诊断和处理尚无共识。关于定植与感染以及治疗的必要性和有效性，仍有许多讨论。美国传染病学会（IDSA）于2000年4月发布的治疗念珠菌病的实践指南未能明确定义真菌和真菌性尿道感染。10此外，IDSA未能充分处理近期的前瞻性随机研究，将两性霉素B膀胱冲洗与静脉使用两性霉素B治疗或口服氟康唑治疗。已经讨论了几种治疗选择，但是没有一种方案看起来更好。下面介绍的是重症监护病房中真菌和真菌尿路感染的治疗方案。上升型肾盂肾炎和肾念珠菌病的治疗不在本评价的范围内，在其他地方进行讨论。13真菌和尿路感染的定义尿液中真菌的发现可能代表污染，导管定植或感染。16截至目前，尚无可靠的方法来区分定植和感染。13,17尚不确定定量尿液分析，脓尿的存在或症状是否与真菌感染有关。但是，Tambyah和Maki最近发现，有和没有细菌性CAUTI的患者之间的尿白细胞计数存在显着差异（p = 0.009）。18疾病控制中心（CDC）定义一种无症状菌尿。符合以下条件：培养前7天内患者有导尿管，以及

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