| Objective Establish a risk stratification of hematological malignancies(HM)with invasive fungal disease(IFD)based on the existing guideline to provide clinical basis for optimizing antifungal therapy strategy.Methods A clinical dates of 458 patients diagnosed with hematological malignancies complicated with invasive fungal disease in the Hematology Department,Fujian Medical University Union Hospital from January 2016 to June 2018,were analyzed retrospectively.Analyze the difference of diagnostic accuracy rate,effective rate and adverse reaction rate between empirical therapy and diagnose-driven therapy.Explore the risk stratification of IFD and antifungal strategy.Results 1.Among the 458 patients,285 were male and 173 were female.The mean age was 50.5 ±15.5 years old.The mean time of grain deficiency was 10(2 / 18)days.AML 233 cases(50.9%),ALL 61 cases(13.3%),HAL 2 cases(0.4%),MDS 29 cases(6.3%),MM 32 cases(7.0%),HD/NHL 91 cases(19.9%),CML 3 cases(0.7%),CLL 7 cases(1.5%).Among them,209 cases(45.6%)were initially treated,56 cases(12.2%)were CR,80 cases(17.5%)were relapse/refractory /NR.A total of 187 fungal strains were detected,of which 96.8% were Candida.The samples were collected from sputum,feces,oral cavity,pharynx,blood,perianal and urine.Pulmonary infection occurred in 444 cases(96.9%),intestinal infection in 91 cases(19.9%),oral infection in 69 cases(15.1%),bloodstream infection in 8 cases(1.7%)and urinary tract infection in 3 cases(0.7%).2.According to The Chinese guidelines for the diagnosis and treatment of invasive fungal disease in patients with hematological disorders and cancers(the fifth revision),239 cases were empirical therapy group and 219 cases were diagnosed as diagnose-driven therapy group.The rates of clinical diagnosis / diagnosis were 7.9% and 16.4% respectively.The diagnostic accuracy rate was significantly different(P=0.005).The effective rate of empirical therapy and diagnose-driven therapy was 87.9% and 81.7% respectively(P≥0.05).The incidence of adverse reactions was 18.4% and 16.9% respectively(P≥0.05).3.Based on the guidelines and clinical practice at home and abroad,the PICSN risk stratification was established according to the risk factors including time of neutropenia,status of disease,primary disease,IFD history and complication.All patients were divided into high risk group(n = 264)、middle risk group(n=118,14d≥neutropenia>7d,acute leukemia,diabetes)and low risk group(n=76,not meeting the above-mentioned conditions).The effective rate of antifungal therapy in high,middle and low risk groups was 80.8%、87.9% and 94.5%.In high risk group,the effective rates of empirical therapy and diagnose-driven therapy were 89.2% and 71.1% respectively,the difference was statistically significant(P=0.000).The effective rates of empirical therapy and diagnose-driven therapy was 83.6% and 92.7% in middle risk group and was 90.3% and 97.6% respectively in low risk group.There was no significant difference in effective rate between empirical therapy and diagnose-driven therapy in the middle and low risk group(P > 0.05).Conclusion Candida infection is most in HMs with IFD and lungs are the most common infection site.Acute leukemia is the main type of HMs with invasive fungal disease.There is no significant difference in efficacy and safety between empirical therapy and diagnose-driven therapy,but diagnose-driven therapy has more advantages in treatment accuracy.The PICSN risk stratification established in this study will be helpful to guide clinical empirical antifungal therapy according to the condition of disease,especially for patients with more than 14 days of neutropenia、a relapse / refractory disease、IFD history and pulmonary disfunction,while middle risk and low risk patients can choose diagnose-driven therapy as appropriate. |
PDF Full Text Request