1. Pre-emptive therapy. colonization, colonization, pre-emptive therapy. , ICU colonization. colonization. 2, C. albicans

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1 Jpn. J. Med. Mycol. Vol. 45, , 2004 ISSN ,.,, colonization, pre-emptive therapy. 2, non-albicans Candida., fluconazole.,. Key words: postoperative infection, non-albicans Candida, pre-emptive therapy, fluconazole, 1 1.,. Wey 2 Table 1,,. 50 3,,,,.,, colonization,. 2, C. albicans (non-albicans Candida. Nonalbicans Candida, fluconazole FLCZ, 4, ,, non-albicans Candida,,. I. 1. Pre-emptive therapy Pittet 5, colonization,, 1/3.,,,, colonization, 5. pre-emptive therapy, 6,., colonization,, empiric therapy targeted therapy., ICU colonization 50, 23 7, pre-emptive therapy, colonization. Solomkin 3 3 5

2 Table 1. High risk group Factor Odds ratio 95 CI No. of antibiotics Antibiotic 7 days ICU 7 days Central venous nutrition Arterial line 7 days Artificial ventilatory assistance Steroid Hemodyalysis adjusted Odds 18.1, Multiple blood transfusion Candida site two or more colonization, transient inoculation, colonization 2 Pittet 5 Candida colonization index colonization, colonization 0.5, positive predictive value,, colonization corrected colonization index,. 1 2 pre-emptive therapy., Phillips 8 49, 43. Walsh,. Obayashi 9 -D ,, D,, -D positive predictive value 59.,,.,,., -D glucan PCR., pre-emptive therapy, species,. 3 pre-emptive therapy, preemptive therapy,,,, transient inoculation, colonization. -D glucan,,. colonization,,,., 3 -D glucan, FLCZ.. 1 3, ICU,,,,, colonization. -D glucan 47 9, colonization 3, 1., clinical value, efficiency, -D glucan colonization 2. -D glucan colonization 1, colonization 3 20,. 4 ICU,,.,. Eggimann 10 FLCZ,. FLCZ 4,

3 Jpn. J. Med. Mycol. Vol. 45 No. 4, P=0.02, relative risk 0.12,. Pelz 11 ICU 3, 260 FLCZ 400 mg,. Kaplan-Meier, FLCZ, FLCZ 55., endpoint FLCZ 10.6, 12.3,,,. II. Non-albicans NNIS National Nosocomial Infection Surveillance system, 1980,, FLCZ, C. glabrata , C. albicans, 50, non-albicans Candida. C. glabrata FLCZ albicans tropicalis parapsilosis glabrata krusei, C. glbarata, C. krusei 12. FLCZ C. glabrata, C. krusei, C. albicans 13, 14. Abi-Said 15 C. glabrata C. krusei FLCZ,, C. albicans C. tropicalis. C. parapsilosis,. C. glabrata,,,., 16, 17. C. glabrata FLCZ 12 mg/kg/, 800 mg, AMPH 18. FLCZ 800 mg, AMPH. C. glabrata. III. liposomal amphotericin B amphotericin B 19., fluconazole, itraconazole,., voriconazole 12, 20., micafungin 1,3- -D glucan, 21. amphotericin B,. fluconazole, Candida non-albicans, 12., non-albicans FLCZ 22, Candida FLCZ, FLCZ. AMPH, voriconazole,, liposomal AMPH,. Micafungin,., targeted therapy, glabrata krusei, FLCZ, empiric therapy. IV., 5.,. 23, a, b, c 24, d, e, f,,., microbial translocation.,

4 CT. Microbial translocation, regimen AMPH 24. V., C. glabrata FLCZ FLCZ, 18 Candida, 3,.,,,,, X, CT,., Candida, 7, empiric therapy.,,,, 17. Candida,, 72, colonization., , 15 20, Aspergillus Fusarium, Trichosporon. AMPH,. Voriconazole, micafungin AMPH.,,. 1 Fridkin S, Jarvis WR: Epidemiology of nosocomial fungal infections. Clin Microbiol Rev 9: , Wey SB, Mori M, Pfaller MA, et al.: Risk factors for hospital-acquired candidemia. A matched case-control study. Arch Intern Med 149: , Solomkin JS, Flohr AM, Simmons RC, et al.: Indication for therapy for fungemia in postoperative patients. Arch Surg 117: , Pfaller AM, Jones RN, Messer SA, et al.: National surneillance of nosocomial blood stream infection due to species of Candida other than Candida albicans: frequency of occurrence and antifungal susceptibility in the SCOPE program. Diagn Microbiol Infect Dis 30: , Pittet D, Monod M, Suter PM, et al.: Candida colonization and subsequent infections in critically ill surgical patients. Ann Surg 220: , British Society for Antimicrobial Chemotherapy Working Party: Management of deep Candida infection in surgical and intensive care unit patients. Intensive Care Med 20: , Burchard KW, Minor LB, Slotman GJ, et al.: Fungal sepsis in surgical patients. Arch Surg 118: , Phillips P, Dowd A, Jewesson P, et al.: Nonvalue of antigen detection immunoassays for diagnosis of candidemia. J Clin Microbiol 28: , Obayashi T, Yoshida M, Mori T, et al.: Plasma 1,3 -D-glucan measurement in diagnosis of invasive deep mycosis and fungal febrile episodes. Lancet 345: 17 20, Eggiman P, Francioli P, Bille J, et al.: Fluconazole prophylaxis prevents intra-abdominal candidiasis in high-risk surgical patients. Crit Care Med 27: , Pelz RK, Hendix CW, Swoboda SM, et al.: Doubleblinded placebo-controlled trial of fluconazole to prevent candidal infections in critically ill surgical patients. Ann Surg 233: , Patterson TF: Role of newer azoles in surgical patients. J Chemother 11: , Wingard JR, Merz WG, Rinaldi MG, et al.: Association of Torulopsis glabrata infections with fluconazole prophylaxis in neutropenic bone marrow transplant patients. Antimicrob Agents Chemother 37: , ,,,. 53: , Abi-Said D, Anaissie E, Uzun O, et al.: The epidemiology of hematogenous candidiasis caused by different Candida species. Clin Infect Dis 24: , Gumbo T, Isada CM, Hall G, et al.: Candida glabrata fungemia Clinical features of 139 patients. Medicine 78: , Nguyen MH, Peacock JE, Morris AJ, et al.: The changing face of candidemia: emergence of non- Candida albicans species and antifungal resistance. Am J Med 100: , Rex JH, Walsh TJ, Sobel JD, et al.: Practice guideline for the treatment of candidiasis. Clin Infect Dis 30: , Wong-Beringer A, Jacobs RA, Guglielmo BJ: Lipid formation of amphotericin B: Clinical efficacy and toxicities. Clin Infect Dis 27: , Ruhnke M, Schmidt-Westhausaen A, Trautmann M:

5 Jpn. J. Med. Mycol. Vol. 45 No. 4, In vitro activities of voriconazole UK-109,496 against fluconazole-susceptible and -resistant Candida albicans isolates from oral cavities of patients with human immunodeficiency virus infection. Antimicrob Agent Chemother 41; , : , Rex JH, Bennett JE, Sugar AM, et al.: A randomized trial comparing fluconazole with amphotericin B for the treatment of candidemia in patient without neutropenia. N Engl J Med 331: , Edwards JE Jr: International Conference for the development of a consensus on the management and prevention of severe candidal infections. CID 25: 43 59, Luiten EJT, Hop WCJ, Lange JF, et al.: Controlled clinical trial selective decontamination for the treatment of severe acute pancreatitis. Ann Surg 222: 57 65, Strategy for the Treatment of Fungal Infections in Critically Ill Surgical Patients Yoshio Takesue Department of Surgery, Division of clinical Medical Science, programs for Applied Biomedicine, Graduate School of Biomedical Sciences, Hiroshima University, Kasumi, Miami-ku, Hiroshima , Japan To improve the outcome of invasive Candida infections, earlier empirical therapy before the establishment of the definitive diagnosis is considered to be necessary. However, appropriate use of empirical therapy for suspected candidiasis in febrile non-neutropenic surgical patients has not been defined. According to the guidelines from the Infectious Diseases Society of America, empirical therapy of suspected candidiasis in this setting should be limited to patients with Candida colonization of multiple sites, multiple other risk factors, and absence of any other causes of fever. A corrected colonization index which takes into account both the density and the degree of colonization of Candida spp. was shown to be the independent factors that predict subsequent candidal infection. It may also be appropriate to commence empirical therapy on the basis of a positive serodiagnostic test. -D glucan is a cell-wall constituent of fungi, which is assumed to be a marker of fungal sepsis. However, it has been shown that -D-glucan can also be detected in patients without fungal infections, such as those on haemodialysis, and its positive predictive value is relatively low. The monoutilization of -D-glucan for the assessment of fungal infection should therefore be avoided. The combined assessment of -D-glucan and extent of colonization with Candida spp. is believed to have the advantage of lessening the likelihood of a false positive reaction of -D-glucan., 47 3.