救急·集中治療領域における深在性真菌症の診断·治療ガイドラインの影響 ガイドライン準拠,非準拠と転帰への影響

摘要

Purpose:This study was designed to investigate the influence of "The diagnosis and treatment guidelines for deep mycosis" (hereinafter referred to as "the Guidelines") in Japan on the diagnosis and treatment of deep mycosis in the field of emergency and critical care medicine and their influences on patient outcomes.Methods:In patients (administered antimycotics or who had pyrexia showing no response to any antimicrobial drug) medically examined and suspected of having had a fungal infection at 15 medical institutions throughout Japan,participating in the Japanese Society for the Study of Critical Care for Mycosis during the period from May 2003 through August 2004 and with facilities for emergency and critical care medicine, patient background, risk factors, awareness of the Guidelines,diagnosis,contents of treatment, and 'outcomes were investigated.On the basis of the data pertaining to these items, whether or not the course of diagnosis and treatment for each patient conformed to the diagnosis and treatment recommended in the Guidelines was retrospectively evaluated.Whether or not the treatment had been conducted with antimycotics and the doses recommended in the Guidelines,was also investigated, and outcomes were assessed according to conformity and non-conformity to the Guidelines.Results:Of the 125 subjects assessed, 55.2% responded that they were conscious of the Guidelines.The subjects who had indications for the Guidelines included 10 (8.0%),who were definitely diagnosed as having had mycosis,3 (2.4%) who were diagnosed as having had clinical mycosis,and 35 (28.0%) who were suspected of having had mycosis. In the remaining 77 (61.6%),whether their conditions were non-mycosis or mycosis could not be determined. The treatment conformed to the Guidelines in 25 subjects (20.0%),but did not in 23 (18.4%).In 77 subjects (61.6%), whether or not the condition had been mycosis could not be determined.The number of the patients in whom whether or not the treatment had conformed to the Guidelines could be determined was decreased and there was a marked influence of administration of antimycotics, which was based on the assumption that "pyrexia with no response to broad-spectrum antimicrobial drugs persists for at least 3 days" in the Guidelines,was given as the reason. There was no significant difference in outcomes (survival or death) at the end of the study based on whether or not the subject had been conscious of the Guidelines or whether or not the contents of treatment conformed to the Guidelines.The number of days that treatment was administered in the ICU was greater in the treatment conforming to the Guidelines than in that not conforming to the Guidelines, but the difference did not reach statistical significance.Conclusion:The Guidelines were recognized at the time of treatment by more than half of the patients registered,but there were actually only a few patients in whom the diagnosis and treatment conformed to the Guidelines. One possible reason is considered to be that there was a marked influence of one item of the Guidelines,i.e. "pyrexia without response to broad-spectrum antimicrobial drugs persists for at least 3 days",in patients with suspected mycosis,who receive empirical treatment,in terms of the reason.Future examination is considered to be needed regarding the validity of this item.