Thrombophlebitis interne Behandlung
Thrombophlebitis interne Behandlung

Comparison of Caspofungin and Amphotericin B for Invasive Candidiasis

Thrombophlebitis interne Behandlung

Thrombophlebitis interne Behandlung Deutsch Ordens Spital Friesach: Venenchirurgie Comparison of Caspofungin and Amphotericin B for Invasive Candidiasis — NEJM Thrombophlebitis interne Behandlung


Online-Kodierleitfaden Geriatrietypische Multimorbidität - Teil 1 Thrombophlebitis interne Behandlung

N Engl J Med ; Caspofungin is an echinocandin agent with fungicidal activity against candida species. We performed a double-blind trial to compare caspofungin with amphotericin B deoxycholate for the primary treatment of invasive candidiasis.

Full Text of Background We enrolled patients who had clinical evidence of infection and a positive culture for candida species from blood or another site. Patients were stratified according to the severity of disease, as indicated by the Acute Physiology and Chronic Health Evaluation APACHE II score, and the presence or absence of neutropenia and were randomly assigned to receive either caspofungin or amphotericin B.

The study was designed to compare the efficacy of caspofungin with that of amphotericin B in patients with invasive candidiasis and in a subgroup with candidemia. Full Text of Methods Of the patients enrolled, were included in the modified intention-to-treat analysis. Base-line characteristics, Thrombophlebitis interne Behandlung, including the percentage of patients with neutropenia and the mean APACHE II score, were similar in the two treatment groups.

A modified intention-to-treat analysis showed that the efficacy of caspofungin was similar to that of amphotericin B, with successful outcomes in An analysis of patients who met prespecified criteria for evaluation showed that caspofungin was superior, with a favorable response in Caspofungin was as effective as amphotericin B in patients who had candidemia, Thrombophlebitis interne Behandlung, with a favorable response in There were significantly fewer drug-related adverse events in the caspofungin group than in the amphotericin B group.

Full Text of Results Caspofungin is at least as effective as amphotericin B for the treatment of invasive candidiasis and, more specifically, Thrombophlebitis interne Behandlung, candidemia.

Full Text of Discussion The optimal first-line treatment for serious candida infections is a controversial issue.

Amphotericin B has served as standard treatment for five decades, but toxic effects often limit its use. The need remains for new agents to treat serious candida infections.

One alternative is caspofungin, an echinocandin with fungicidal activity against candida. The trial was conducted between November and June at 56 institutions in 20 countries. Patients were eligible Thrombophlebitis interne Behandlung enrollment in the study if they were Thrombophlebitis interne Behandlung the age of 18 years and had had one or more positive candida cultures from blood or another, sterile site within the previous four days, Thrombophlebitis interne Behandlung.

Patients with positive cultures of urine specimens, sputum specimens, bronchoalveolar-lavage specimens, oropharyngeal or esophageal specimens, or samples from indwelling drains were excluded. An additional criterion for enrollment was at least one of the following clinical signs of infection during the previous two days: Patients with suspected endocarditis, Thrombophlebitis interne Behandlung, osteomyelitis, or meningitis were excluded.

Patients receiving rifampin, ritonavir, or cyclosporine were also not enrolled. The study protocol was approved by the institutional review board of each participating institution, Thrombophlebitis interne Behandlung written informed consent was obtained from all patients before enrollment.

They were randomly assigned to receive either intravenous caspofungin or intravenous amphotericin B according to a schedule maintained by each participating institution's pharmacist. The schedules were generated by computer to ensure equivalent randomization at each site. Patients and investigators were unaware of the treatment assignments.

Patients who were assigned to receive caspofungin were given a mg loading dose, followed by 50 mg per day. Patients who were assigned to receive amphotericin B and who did not have neutropenia were given 0.

A double-dummy technique was used to maintain the blinding. The daily treatment regimen consisted of infusion of caspofungin or matching placebo saline for one hour, Thrombophlebitis interne Behandlung, immediately followed by infusion of amphotericin B or matching placebo saline with a multivitamin complex for two or more hours.

An increase or reduction in the dose was not permitted. Patients were to receive antifungal therapy for 14 days after the most recent positive candida culture, Thrombophlebitis interne Behandlung. A minimum of 10 Thrombophlebitis interne Behandlung of intravenous therapy was required.

After 10 days, intravenous therapy was continued or oral fluconazole was substituted mg per day. Thrombophlebitis interne Behandlung was given only to patients who did not have neutropenia, Thrombophlebitis interne Behandlung, whose clinical condition had improved, whose follow-up cultures had been negative for 48 hours, and whose candida isolates were susceptible to fluconazole. Patients with Candida krusei or C. Symptoms or signs of candida infection including the most abnormal temperature were documented daily during the treatment regimen and two weeks and six to eight weeks after treatment.

Physical examination and laboratory tests were performed twice a week during treatment and at both follow-up visits. For patients with candidemia, Thrombophlebitis interne Behandlung, two samples for blood cultures were obtained daily until the results had been negative for at least 48 hours.

For nonblood infections, follow-up cultures were also routinely obtained; however, in certain patients, the infection was assumed to have been eradicated and follow-up cultures were not required if there was no longer any clinical or radiographic evidence of infection, Thrombophlebitis interne Behandlung.

Retinal examinations for candida endophthalmitis were performed by ophthalmologists before enrollment, at the end of intravenous therapy, and at the final follow-up visit. Efficacy was assessed in terms of the overall response to treatment. A favorable overall response was defined as the resolution of all symptoms and signs of candida infection and culture-confirmed eradication or presumptive eradication for certain nonblood infections. The outcome was considered to be unfavorable if the infection was clinically or microbiologically unresponsive, if the study drug was withdrawn before there was documented improvement, or if toxic effects necessitated a change in antifungal therapy.

Evaluations were performed on day 10 of intravenous therapy, at the end of intravenous therapy, at the end of all antifungal therapy intravenous therapy and oral fluconazoleand at both follow-up visits, Thrombophlebitis interne Behandlung. The primary time point for the determination of efficacy was the end of intravenous therapy. During Thrombophlebitis interne Behandlung six-to-eight-week period after treatment, a patient was considered to have a relapse if an invasive candida infection had recurred or if antifungal therapy for a proven or suspected candida infection was again administered.

The study was primarily designed to determine whether caspofungin was as effective as amphotericin B for the treatment of invasive candidiasis, Thrombophlebitis interne Behandlung, with efficacy measured in terms of the overall response at the end of intravenous therapy. The noninferiority Thrombophlebitis interne Behandlung caspofungin would be demonstrated if the two-sided The superiority of caspofungin would be demonstrated if the confidence interval was entirely above 0.

Adjustments for multiple comparisons were not performed. The two prespecified study populations for the analysis of efficacy were the patients included in the modified intention-to-treat analysis and the population of patients who met prespecified criteria for evaluation. The modified intention-to-treat analysis the primary analysis included patients who had a documented diagnosis of invasive Thrombophlebitis interne Behandlung and who received the study treatment for at least one day.

The prespecified criteria for evaluation were inclusion in the modified intention-to-treat analysis and no concomitant antifungal therapy, no protocol violations that might interfere with the assessment of efficacy, an appropriate evaluation at the end of treatment, and receipt of Thrombophlebitis interne Behandlung study treatment for at least five days.

The study was also designed to compare certain end points in an analysis of safety, including nephrotoxicity. A nephrotoxic effect was defined as at least a doubling of the serum creatinine level, or an increase of at least 1. Other predefined end points in the analysis of safety included drug-related adverse events, discontinuation of treatment due to drug-related adverse events, infusion-related toxic effects, and hypokalemia requiring potassium supplementation. All patients who received the assigned study treatment were included in the safety analysis, Thrombophlebitis interne Behandlung.

Thrombophlebitis interne Behandlung independent data safety monitoring board monitored both safety and efficacy during the study. The authors who are not affiliated with Merck had access to all the study data, take responsibility for the accuracy of the analysis, and had authority over the preparation of the manuscript and the decisions about publication.

A total of patients were enrolled in the study over a period of 44 months, of whom were included in the modified intention-to-treat analysis Table 1 Table 1 Numbers of Patients Enrolled, Included in the Modified Intention-to-Treat Analysis, Thrombophlebitis interne Behandlung, and Included in the Analysis of Patients Who Met Prespecified Criteria for Evaluation. The base-line characteristics of the patients were similar in the two treatment groups Table 2 Table 2 Base-Line Characteristics of the Patients Included in the Modified Thrombophlebitis interne Behandlung Analysis.

The majority of the patients had candidemia, but peritonitis and intraabdominal abscesses were not uncommon. Approximately 60 percent of the patients had received prior antifungal therapy, but only for a day or less in most cases, Thrombophlebitis interne Behandlung. The most common candida isolate was C.

Five Thrombophlebitis interne Behandlung had infections with both C. Patients in the caspofungin group were treated for a mean of A switch to oral fluconazole after day 10 occurred in the cases of 27 caspofungin-treated patients In the modified intention-to-treat analysis, the proportion of patients with a favorable response at the end of intravenous therapy was In the analysis of patients who met the prespecified criteria for evaluation, The difference between the treatment groups for this analysis was The outcomes were consistent among the stratified subgroups.

In both treatment groups, the response rate was lower among patients with indicators of a poor prognosis neutropenia or an APACHE II score higher than 20 than among patients without these indicators, but there was still a trend in favor of caspofungin. The outcomes stratified according Rezepte mit Apfelessig von Krampfadern the candida pathogen were generally similar in the two groups.

The response rate was higher among patients Thrombophlebitis interne Behandlung non-albicans infections in both the caspofungin group The responses were similar for the most common non-albicans species — namely, C. At each of the four other time points day 10, the end of antifungal therapy, two weeks after treatment, and six to eight weeks after treatmentThrombophlebitis interne Behandlung, the percentage of patients with successful outcomes was higher in the caspofungin group than in the amphotericin B group Table 4.

Similar proportions of patients in the two treatment groups had wo Strumpfhosen Krampfadern kaufen positive cultures, persistent Beinkrämpfe während der Behandlung von Krampfadern or symptoms, Thrombophlebitis interne Behandlung, or new metastatic lesions or withdrew from the study after four or fewer days Table Thrombophlebitis interne Behandlung Table 5 Treatment Failures and Relapses Modified Intention-to-Treat Analysis.

The proportion of patients with a relapse was similar in the two treatment groups Table 5. Only five patients had Thrombophlebitis interne Behandlung relapse of candidemia three in the caspofungin group and two in the amphotericin B group.

In all five patients, the organism cultured at relapse and the base-line isolate were identical with respect to the species and the minimal inhibitory concentration. The study was specifically designed to compare the efficacy of caspofungin and that of amphotericin B for the treatment of candidemia. In the modified intention-to-treat analysis, the proportion of patients with candidemia who had a favorable outcome at the end of intravenous therapy was In the analysis of patients with candidemia at base line who met the prespecified criteria for evaluation, In this analysis, the difference was Phlebitis und Thrombophlebitis der unteren Extremitäten A larger proportion of patients in the caspofungin group than in the amphotericin B group had multiple positive blood Thrombophlebitis interne Behandlung at base line However, the percentages of patients with blood cultures that were still positive on days 4 and 7 of intravenous therapy did not Thrombose-Behandlungen significantly between the two groups day 4: The outcomes were also examined in patients without candidemia.

Among those with peritonitis, the response rate was percent eight of eight patients in the caspofungin group and Thrombophlebitis interne Behandlung Of the nine patients with multiple sites of infection, four of the five patients treated with caspofungin Management of Thrombophlebitis interne Behandlung venous catheters did not differ significantly between the two groups.

Overall, Thrombophlebitis interne Behandlung, patients with candidemia 54 in the caspofungin group and trophischen Geschwüren mit Insulin behandelt in the amphotericin B group had an indwelling central venous catheter at the time of the first positive blood culture.

By day 3, the central venous catheter had been removed in 41 of the caspofungin-treated patients The response rate among the 11 patients whose central venous catheters were not removed or changed 6 in the caspofungin group and 5 in the amphotericin B group was similar to the rate among the patients whose central venous catheters were removed or changed.


Original Article. Comparison of Caspofungin and Amphotericin B for Invasive Candidiasis. Jorge Mora-Duarte, M.D., Robert Betts, .

Als Varizen werden krankhaft Thrombophlebitis interne Behandlung Venen bezeichnet, die häufig mit einer Schlängelung und Knäuelung der betroffenen Venen einhergeht. Die sekundäre Varikose ist häufig eine Folge von tiefen Beinvenenthrombosen.

Ausführliche Erhebung der Symptome und Risikofaktoren Inspektion: Strömungsgeräusche Nicht invasive Untersuchungsmethoden:. Über weitere Thrombophlebitis interne Behandlung Hautschnitte werden zusätzlich Seitenastvarizen entfernt und insuffiziente Perforansvenen ligiert.

Radiofrequenzverfahren Dies ist ein Verfahren in dem in die zu behandelnde Vene ein Katheter eingeführt wird. Mit Hilfe eines Generators wird Radiofrequenzenergie erzeugt, die über die Katheterspitze an die Venenwand abgegeben wird, die sich z. Durch die Erhitzung der Venenwand kommt es zur Thrombophlebitis interne Behandlung der innersten Wandschicht EndothelThrombophlebitis interne Behandlung, zum Schrumpfen der kollagenen Fasern in der Venenwand und dadurch zum konsekutiven Verschluss der Vene.

Strömungsgeräusche Nicht invasive Untersuchungsmethoden: Es können Engstellen in den Arterien und kaputte Klappen, die einen Rückfluss in den Venen ermöglichen geortet werden. Farbkodierte Duplexsonographie Diese Ultraschalluntersuchung ermöglicht die Durchgängigkeit der Venen, den Ausschluss einer tiefen Venenthrombose und einen Reflux in den oberflächlichen Venen nachzuweisen.

Venenverschlussplethysmographie Die Venen der Beine werden zunächst durch Stauung maximal gefüllt, Thrombophlebitis interne Behandlung. Am besten geeignet ist diese Untersuchungsmethode bei symptomatischen PatientInnen mit fortgeschrittener Thrombose. Digitale Photoplethysmographie Sie dient der Funktionsbeurteilung des Venensystems an den Extremitäten.

Gemessen wird die Rücktransportkapazität der Venen indem ein Messkopf ca. Dieser sendet Infrarotstrahlen aus, die abhängig vom Hautgewebe und dem Blutgehalt des Gewebes reflektiert und aufgezeichnet werden. Mit dieser Untersuchung kann festgestellt werden, ob eine chronisch venöse Insuffizienz durch eine Operation gebessert werden kann. Mit Hilfe dieser Methode gelingt es, die Anatomie und eventuelle Abflussstörungen des tiefen und oberflächlichen Venensystems darzustellen.

Computertomographie Diese Methode ist bestens geeignet um die thrombosierte Venen im Bauchraum und Becken darzustellen. Blutuntersuchungen Labor Spezielle Laborparameter werden bei Verdacht auf eine tiefe Venenthrombose und bei Bestätigung derselben bestimmt. Diese dienen dazu, eine genetische Ursache und eine angeborene Störung von Gerinnungsfaktoren zu diagnostizieren.


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Original Article. Comparison of Caspofungin and Amphotericin B for Invasive Candidiasis. Jorge Mora-Duarte, M.D., Robert Betts, .
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