Publication: Evaluación de biomarcadores serológicos de candidiasis invasiva para su aplicación clínica
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2017-02-16
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Universidad Complutense de Madrid
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Abstract
INTRODUCCIÓN. El retraso diagnóstico de la candidiasis invasiva es un problema por la alta mortalidad de esta infección. Los ”scores” predictivos utilizados habitualmente para identificar a aquellos pacientes que desarrollarán candidiasis invasive selecciona una gran cohorte de pacientes de alto riesgo, de los cuales muchos de ellos jamás desarrollarán la infección. La aplicación de estos ”scores” clínicos implica un sobreuso de antifúngicos, lo cual tiene consecuencias para el paciente, para el gasto hospitalario, y para la epidemiología de la candidiasis invasive. Estas consecuencias pueden ser modificadas mediante la aplicación de programas de Antifungal Stewardship en el hospital. En una primera generación de antifungal stewardship se ha reducido entre 250.000 € y 370.000 € por año en un hospital terciario a través de recomendaciones y auditorías sobre el uso de antifúngicos, sin menoscabar la calidad asistencial del pacientes ni aumentar la mortalidad. Sin embargo, la solución al sobreuso de antifúngicos solo es parcial, y los clínicos no tienen la suficiente confianza para retirar tratamientos antifúngicos en pacientes de alto riesgo. El desarrollo de las técnicas diagnósticas independientes de cultivo ha emergido como herramientas prometedoras para el diagnóstico precoz de la candidiasis invasiva. Sin embargo, en este contexto hay muchas limitaciones, principalmente relacionadas con su baja rentabilidad cuando se usan de manera. individual y por el gran número de falso positivos que presentan contribuyendo también, por su parte, al sobreuso de antifúngicos Sin embargo, los biomarcadores de candidiasis invasive todavía no han sido evaluados adecuadamente como herramientas de exclusión de candidiasis invasive ni como complementarias en los programas de antifungal stewardship...
INTRODUCTION. Delayed diagnosis of invasive candidiasis has been demonstrated to have a significant impact on the mortality and cost of this infection. Several clinical predictive “scores” have been proposed in order to facilitate the indication of empirical antifungal therapy in high-risk patients. Unfortunately, the positive predictive value of these “scores” is very low and its widespread application has led to a significant overuse of antifungal drugs. The consequences of this practice include unnecesary toxicity, drug interactions, changes in the epidemiology and resistance pattern of Candida infection and a huge increase in the cost. This strategy can be modified by the application of Antifungal Stewardship Programs (ASP). An ASP based on a bundle of measures and on the bedside advice of experts with wide clinical expertise has been able to reduce 250,000- 370,000 € per year in antifungals in our hospital,without impairing the quality of patient care, nor increasing mortality [1-3]. However, this experience showed us that better microbiological diagnostic tools were needed in order to be able of stopping empirical therapy with enough confidence in many of our high-risk patients. Culture-independent diagnostic techniques emerged as very promising tools for the early diagnosis of invasive candidiasis. However, available data showed that when used alone, most of these biomarkers had too low sensitivity to be useful in an AFS program. Besides, the large number of false positives could also contribute to even enlarge the overuse of antifungal drugs. We noticed that the combination of different biomarkers had not been adequately evaluated for the exclusion of invasive candidiasis as complementary tools in ASP...
INTRODUCTION. Delayed diagnosis of invasive candidiasis has been demonstrated to have a significant impact on the mortality and cost of this infection. Several clinical predictive “scores” have been proposed in order to facilitate the indication of empirical antifungal therapy in high-risk patients. Unfortunately, the positive predictive value of these “scores” is very low and its widespread application has led to a significant overuse of antifungal drugs. The consequences of this practice include unnecesary toxicity, drug interactions, changes in the epidemiology and resistance pattern of Candida infection and a huge increase in the cost. This strategy can be modified by the application of Antifungal Stewardship Programs (ASP). An ASP based on a bundle of measures and on the bedside advice of experts with wide clinical expertise has been able to reduce 250,000- 370,000 € per year in antifungals in our hospital,without impairing the quality of patient care, nor increasing mortality [1-3]. However, this experience showed us that better microbiological diagnostic tools were needed in order to be able of stopping empirical therapy with enough confidence in many of our high-risk patients. Culture-independent diagnostic techniques emerged as very promising tools for the early diagnosis of invasive candidiasis. However, available data showed that when used alone, most of these biomarkers had too low sensitivity to be useful in an AFS program. Besides, the large number of false positives could also contribute to even enlarge the overuse of antifungal drugs. We noticed that the combination of different biomarkers had not been adequately evaluated for the exclusion of invasive candidiasis as complementary tools in ASP...
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Microbiología, leída el 30/11/2015. Tesis formato europeo (compendio de artículos)