真菌--胡亮钉讲稿精品.ppt

* * Thank you Dr. Baildon and thank all of you for the opportunity to discuss the management and medical needs for invasive mycoses. This slide outlines the mortality due to invasive mycoses over the last 2 decades. In data published last month from the CDC, you can see significant increases in mortality due to invasive mycoses. Mortality due to Candida has recently declined, perhaps due to better recognition of these infections and earlier antifungal therapy. However, mortality due to Aspergillus has steadily increased, rising more than 4-fold over that period. Although not as common, other mycoses, particularly moulds, like Fusarium and Pseudallescheria—for which limited therapeutic options exist—are associated with even higher mortality rates. * * * * * * * * * 抗真菌药物(1) 二性霉素B CAmB AmBisome Amphotec Abelcet 二性霉素B 对粒缺患者疗效减低 避免与盐水输注 低钾 造血抑制 AmBisome 治疗严重的真菌感染 可作为经验性治疗粒缺伴发热的患者 在二性霉素中副作用最少 3-5mg/kg/d 累积剂量2-3g (3-4W) Amphotec和 Abelcet Amphotec 3-4mg/kg 最大6mg/kg 最大累积剂量 30g Abelcet 5mg/kg 最少2W 文献报告对毛霉菌有效 AmBisomeAbelcetAmphotecCAmB 抗真菌药物(2) Caspofungin Micafungin Echinocandins Characteristics Rapidly fungicidal for yeast Intravenous administration Minimal renal toxicity Activity Yeasts (C. albicans; non-albicans) Moulds (Aspergillus; not Zygomycetes) Others (Endemic mycoses; not Cryptococcus) Cyclic lipopeptide antifungals that inhibit ?-1,3-glucan synthase Caspofungin Micafungin Anidulafungin Caspofungin C krusei 和 C Parapsilosis 不敏感 新生隐球菌、分支菌属、镰刀菌和接合菌无效 播散性念珠菌和侵袭性曲霉菌有效 卡肺有效 不作为治疗曲霉菌一线药物 可与其他类抗真菌药联合应用(二性霉素B 或唑类) 抗真菌药物(3) Fluconazole Itraconazole Voriconazole Posaconazole Fluconazole 治疗非粒缺患者侵袭性真菌感染 光滑念珠菌敏感性低和克柔念珠菌无效 预防念珠菌病在高危人群粒细胞恢复前或粒细胞恢复后1W Itraconazole 治疗组织胞浆菌一线药物 镰刀菌疗效差, 接合菌无效 偶有白念和烟曲霉菌耐药 治疗曲霉菌、念珠菌二线药物 曲霉菌或念珠菌的预防 心功能不全者慎用 Voriconazole 广谱抗真菌药物 侵袭性曲霉菌治疗一线药物 (US approved) 有效率53% 对Flu 75%(C Krusei), Itra 63%耐药的念珠菌 对Itra 和二性霉素B耐药的 曲霉菌 治疗严重的真菌感染(免疫功能低下的患者) 对镰刀菌 43%和丝状真菌(US for salvage), 接合菌无效 抗真菌治疗 真菌感染预防 经验性治疗 联合治疗