Jpn. J. Med. Mycol. Vol. 45, 203 208, 2004 ISSN 0916 4804 Early Presumptive Therapy EPT 1 1 1 2 3 1 1 2 3 20,,,, 4.,,.,, Early Presumptive Therapy EPT. EPT,. Early Presumptive Therapy. 10 1 12 12, 77 Early Presumptive Therapy., 38 C 3, 2, 2, 1-3- -D 10 pg/ml, PCR. Early presumptive therapy FLCZ200-400 mg/day 14, 2.,, retrospective. 62,,. 13, 10. EPT 21., CVP 14. EPT 38.7 C 0.6 C, EPT 36.7 C 0.6 C. SIRS 3 96.1 29.9. 1-3- -D 35 13 pg/ml,.. early presumptive therapy retrospective.,. early presumptive therapy. Key words: EPT, deep fungal infection, critical care medicine,,.,, 1 3., 181-8611 6-20-2,,,,.,,,, 4, 5. 8,.
204 45 4 16. Dean 6 1998 EPT. EPT,. EPT,. Dean EPT,. early presumptive therapy retrospective. 10 1 12 12,,, early presumptive therapy 77.,,.,.,.,, 7 38 C 3, Table 1 2,, 2, 1-3- -D 10 pg/ml PCR,. 77 Table 1. 11, 21, 15, 16, 8, 6. JCS III 15 14. burn index 15 21 Table 1. Patient background 19. Injury Severity Score ISS16 11 10., APACHE II 10 77 68. 59.3 18.6, 52, 23, 9, 13, 8, 8, 15., 46 59.7. EPT EPT. EPT FLCZ 77. FLCZ 200-400 mg/ 2., 400 mg/, 200 mg/. 35 400 mg/, 42 200 mg/. 400 mg/ 11.0 9.6 200 mg/ 11.9 10.3. : EPT EPT. 1 EPT,,,,. 2 EPT,,,, 4,. 3,, C-, 1-3- -D -D, :. 4. 38 C, 5, SIRS 3 4, APACHE II, SOFA Retrospective, Cohort Study, Mean 1.S.D. Man - Whitney U - test, Fischer Probability - test Unpaired- Test, - TEST. P 0.05. Table 2. 2002 2. 2
Jpn. J. Med. Mycol. Vol. 45 No. 4, 2004 205 Table 2. Risk factor of deep fungal infection Serum(1-3)- D (pg/ml). 1 EPT 100,., 97., EPT 2 21 Fig. 1., EPT 77 66 85.7, EPT 77 58 75.3., EPT., 16. Pseudomonus, Staphylococcus 30. 11% 16% 29% 25% 19% Bacteria 4% 7% 34% 36% 1 % 100% Fig. 1. Changes detected in bacteria and fungus after EPT 21% 2 EPT EPT. EPT 1 58, 62. EPT 1 17, 19. EPT 1 16, 13, EPT 1 9, 11, 8. 3 1-3- -D EPT 38.7 0.6 C Fig. 2. Changes in body temperature and 1-3-D glucan after EPT, EPT 1 37.2 0.8 C p 0.05, EPT 36.9 0.6 C p 0.05., 1-3- -D 32.3 17.6 pg/ml, EPT 1 19.4 12.6 pg/ml, 13.7 10.8 pg/ml Fig. 2.. 4 38.5 C, X, 8,000 /mm 3. EPT 30/77 39, 18. Pseudomonus, Staphylococcus, 30. 5 19,,, 1. SIRS 4 EPT 77 49 69 EPT 29.9., APACHE II EPT, 16.3 9.2, EPT 10.2 7.3., SOFA score EPT 5.6 3.2, EPT 4.4 3.1 p 0.01,. EPT WBC 18862 8237 /mm 2, EPT 9756 5354 p 0.01., CRP 18.3 3.9 mg/de 14.2 2.9 mg/de p 0.01. 6 EPT 31/77 40, 39/77 39, 49/77 65.,,
206 45 4 16 4 4.. prospective study 18 3. EPT,. EPT,,, 62.,,,,,,.,,,. ventilator associated pneumonia.,.,.,,,,,., 7.,,,,,.,., 8, 9.,,, IVH.,,.,.,.,,,. 30,,,,.,, 10, 11.,,, 1,. 2. 3,. 4 microbial translocation MBT 5 SIRS immunocompromised 12, 13.,, 97, 11.., 50 60,,,,,.,,. MRSA, 14 18 10,,,, 19,,
Jpn. J. Med. Mycol. Vol. 45 No. 4, 2004 207,,, 20, 1997 G MK,,,,, EPT, EPT pre emptive therapy, 3,,,,,,, 4 1-3- -D 20 pg/dl, 85 Candida,,, Candida albicans 72 FLCZ 1 400 mg, Candida glabrata Candida krusei FLCZ, B, FLCZ 400 mg/ 1-3- -D, MIC FLCZ, 1-3- -D, B,,,, burn index 15, ISS16 2 AIS 3 2 70, severity oriented antifungal therapy early presumptive therapy retrospective EPT,, 62 early presumptive therapy 1 Chitkara YK, Feierabend TC: Endogenous and exogenous infections with Pseudomonas aeruginosa in a bum unit. Int Surg 66: 237 240, 1981. 2 Border JR: Trauma and sepsis, in Worth MH eds : Principles and Practice of Trauma Care. Baltimore Williams & Wilkins, pp.330 387, 1982. 3 Vincent JL, Bihari DJ, Suter PM, et al.: The prevalence of nosocomial infection in intensive care units in Europe: Results of the European prevalence of infection in intensive care EPIC study. JAMA 274: 639 644, 1995. 4 :..., pp.162 168, 1998. 5,,,, :,. 40: 135 142, 1999. 6 Dean DA, Burchard KW: Fungal Infection in surgical patients. Am J Surg 171: 374 382, 1996. 7,,, :. 13: 216 222, 1999. 8 Maejima K, Deitch EA, Burg RD: Bacterial translocation from the gastrointestinal tract of rats receiving thermal injury. Infect Immun 43: 6 10, 1984. 9 Alexander JW, Boice ST, Babcock GF, et al.: The process or microbial translocation. Ann Surg 212: 496 512, 1990. 10 Solomkin JS, Flohr A, Simmons RL: Indications for therapy fungemia in postoperative patients. Arch Surg 117: 1272 1275, 1982.
208 45 4 16 11 Wey SB, Mori M, Pfaller MA, et al.: Risk factors for hospital-acquired candidemia. A matched case-control study. Arch Intern Med. 149: 2349 2353, 1989. 12 Berg RD, Garlington AW: Translocation of certain indigenous bacteria from the gastrointestinal tract to the mesenteric lymph nodes and other organs in a gnotobiotic mouse model. Infect Immun 23: 403 411, 1979. 13 Maejima K, Deitch EA, Berg R: Promotion by burn stress of the translocation of bacteria from the gastrointestinal tracts of mice. Arch Surg 119: 166 172, 1984. 14 British Society for Antimicrobial Chemotherapy Working Party: Management of deep Candida infection in surgical and intensive care unit patients. Intens Care Med 20: 522 528, 1994. 15 Demajo WA, JG Guimond F, Rotstein C, et al.: Guideline for the management of nosocomial Candida infections in non-neutropenic intensive care patients. Canadian J Inf Dis 8 Suppl. B : 3B 9B, 1997. 16 Pittet D, Monod M, Suter PM, et al.: Candida colonization and subsequent infections on critically ill surgical patients. Ann Surg 220: 751 758, 1994. 17 Wey SB, Motomi M, Pfaller MA, et al.: Hospitalacquired candidemia; The attributable mortality and excess length of stay. Arch Intern Med 148: 2642 2645, 1988. 18 Aikawa N, Sumiyama Y, Kusachi S, et al.: Use of antifungal agents in febrile patients nonresponsive to antibacterial treatment: the current status in surgical and critical care patients in Japan. J Infect Chemother 8: 237 241, 2002. 19 Dube MP, Heseltine PNR, Rinaldi MG, et al.: Fungemia and colonization with nystain-resistant Candida rugosa in a burn unit. Clin Infec Dis 18: 77 82, 1994. 20 Obayashi T, Yoshida M, Mori T, et al.: Plasma 1-3 - -D-glucan measurement in diagnosis of invasive deep mycosis and fungal febrile episords. Lancet 345: 17 20, 1995. Efficacy Study of Early Presumptive Therapy EPT for Deep Fungal Infection Hideharu Tanaka 1, Hideaki Goto 1, Seiki Sakaki 1, Kiyoshi Yoshinari 2, Mie Yoshizawa 3, Syuji Shimazaki 1 1 Department of Traumatology and Critical Care Medicine, 2 Department of Pharmacology and Toxicology, 3 Laboratory Department, Kyorin University School of Medicine 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan Abstract We retrospectively studied the efficacy of early presumptive therapy EPT. Subjects and Method: Of the critically ill patients admitted from January 1998 to the end of December 2000 to Kyorin University Trauma Burn and Intensive Care Center, 77 cases were diagnosed with suspected deep fungal infection, and EPT was administered. The diagnosis of suspected deep fungal infection was made by definition. EPT FLCZ 200 to 400 mg/day 14 days was started as soon as the diagnosis was made and continued for two weeks. Its efficacy was retrospectively studied by analyzing the clinical findings, changes in local organisms, and hematological tests. Results: After treatment, 62% of the patients showed improvement in clinical signs of infection, elimination of locally detected fungus, and improvement in the serum diagnosis test. Post-EPT detection levels of the fungus had decreased to 21%. The mean pre-ept body temperature was 38.7 C 0.6 C, but the mean post-ept temperature was 36.7 C 0.6 C. The mean level of blood 1,3- -D-glucan was 35 13 pg/ml at the time the diagnosis was made, but returned to normal levels after treatment had concluded. No patients died as a direct result of the fungal infection. Conclusion: This study of early presumptive therapy in critically ill patients in the emergency and intensive care medicine fields showed the therapy in these, and in high risk patients to be efficacious., 47.