#17
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Цитата:
Complicated VVC Recurrent Vulvovaginal Candidiasis (RVVC) RVVC, usually defined as four or more episodes of symptomatic VVC in 1 year, affects a small percentage of women (<5%). The pathogenesis of RVVC is poorly understood, and the majority of women with RVVC have no apparent predisposing or underlying conditions. Vaginal cultures should be obtained from patients with RVVC to confirm the clinical diagnosis and to identify unusual species, including nonalbicans species, particularly Candida glabrata (C. glabrata does not form pseudohyphae or hyphae and is not easily recognized on microscopy). C. glabrata and other nonalbicans Candidia species are observed in 10%–20% of patients with RVVC. Conventional antimycotic therapies are not as effective against these species as against C. albicans. Treatment Each individual episode of RVVC caused by C. albicans responds well to short duration oral or topical azole therapy. However, to maintain clinical and mycologic control, some specialists recommend a longer duration of initial therapy (e.g., 7–14 days of topical therapy or a 100 mg, 150 mg, or 200 mg oral dose of fluconazole every third day for a total of 3 doses (day 1, 4, and 7) to attempt mycologic remission before initiating a maintenance antifungal regimen. Maintenance Regimens Oral fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose) weekly for 6 months is the first line of treatment. If this regimen is not feasible, some specialists recommend topical clotrimazole 200 mg twice a week, clotrimazole (500-mg dose vaginal suppositories once weekly), or other topical treatments used intermittently. Suppressive maintenance antifungal therapies are effective in reducing RVVC. However, 30%–50% of women will have recurrent disease after maintenance therapy is discontinued. Routine treatment of sex partners is controversial. C. albicans azole resistance is rare in vaginal isolates, and susceptibility testing is usually not warranted for individual treatment guidance. Severe VVC Severe vulvovaginitis (i.e., extensive vulvar erythema, edema, excoriation, and fissure formation) is associated with lower clinical response rates in patients treated with short courses of topical or oral therapy. Either 7–14 days of topical azole or 150 mg of fluconazole in two sequential doses (second dose 72 hours after initial dose) is recommended. Nonalbicans VVC The optimal treatment of nonalbicans VVC remains unknown. Options include longer duration of therapy (7–14 days) with a nonfluconazole azole drug (oral or topical) as first-line therapy. If recurrence occurs, 600 mg of boric acid in a gelatin capsule is recommended, administered vaginally once daily for 2 weeks. This regimen has clinical and myco-logic eradication rates of approximately 70% (175). If symptoms recur, referral to a specialist is advised. Compromised Host Women with underlying debilitating medical conditions (e.g., those with uncontrolled diabetes or those receiving cor-ticosteroid treatment) do not respond as well to short-term therapies. Efforts to correct modifiable conditions should be made, and more prolonged (i.e., 7–14 days) conventional antimycotic treatment is necessary. [Ссылки доступны только зарегистрированным пользователям ] |
#18
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Цитата:
Где написано, что надо сеять кандиду и определять ее чувствительность к противогрибковым препаратам? ----- И второй вопрос. Кандида у женщин, не получающих химиотерапию и не имунокомпрометированных, от чего бывает? |
#19
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Так, я кажется догадалась в чем дело - у нас если говорится культуральное исследование, то подразумевается и посев и одновременное определение чувствительности...сейчас вот еще почитала гайд, да там только посев...и потом, в соответствие с найденным возбудителем - лечение. У нас это будет посев и определение чувствительности. Поэтому для меня посев обозначает автоматом и определение чувствительности.
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#20
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Цитата:
Цитата:
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#21
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Цитата:
Посев на чувствительность не нужен в качестве рутинного исследования. То, что его делают в вашей лаборатории, не говорит о том, что это правильно. Ан. на дисбактериоз тоже везде делают. Это же не значит, что так надо. |
#22
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Яна, ваши цитаты как раз и говорят о том, что посев у нас идет автоматом с определением чувствительности. Мы поэтому так и пишем. И именно поэтому, говоря посев, я подразумевала сразу и определение чувствительности.
Да, я согласна с тем, что если опираться на гайды, достаточно сделать посев на возбудителя. |
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#23
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Цитата:
А что вас заставляет опираться на что-то другое? |
#24
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Цитата:
[Ссылки доступны только зарегистрированным пользователям ] Лично я посевом не пользуюсь - микроскопия на цитолиз и мицелий + ПЦР на C.albicans и C.glabrata -далее в зависмости от результатов исследования. Если C.albicans - флуконазол 1,4,7 день по 150 мг Если C.glabrata - итраконазол 200 мг ежедневно 10 дней. Если рецидив в течении 2 мес при C.albicans флуконазол (150) 1 раз в неделю на 6 мес,если рецидив при C.glabrata борная кислота 1% раствор на тампон 2 раза в день 2 раза в неделю на полгода. |
#25
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Да, Really
Меня ничто не заставляет, но если я пишу направление на посев, ко мне автоматом вернется посев с чувствительностью, независимо от того, есть там запрос или нет. Поэтому вот у меня в голове клин - читаю посев в гайдах - значит автоматом с чувствительностью. Ну сорри. Наша Раша. |
#26
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#28
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#29
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Ну, если уж на то пошло, про настоятельную необходимость посева не так давно и BMJ писал :-)
[Ссылки доступны только зарегистрированным пользователям ] RECOMMENDED TESTS Except in research settings samples are almost universally taken with a cotton tipped swab from the vaginal wall. Possible uncomplicated VVC In the context of specialist services offering a comprehensive sexual health service routine microscopy and culture is the standard of care for symptomatic women4–9 (evidence level III, recommendation grade B). A vaginal swab taken from the anterior fornix12 (evidence level III, recommendation grade B). Gram or wet film examination4–9 (evidence level III, recommendation grade B) Directly plated to solid fungal media. Speciation to albicans/non-albicans is strongly preferred3,13–15 (evidence level III, recommendation grade B). Vaginal pH is not useful in the diagnosis of VVC which can coincide with bacterial vaginitis11 (evidence level IV, recommendation grade C). Blind16 (evidence level III, recommendation grade B) or self taken swabs (evidence level IV, recommendation grade C) may be useful if directly taken swabs are not easily taken and if examination is not deemed necessary. Complicated disease Tests for individual episodes as above. Speciation to albicans/non-albicans is essential and should be performed to species level if a non-albicans species is isolated on more than one occasion3,13–15 (evidence level III, recommendation grade B). Self taken swabs are useful in obtaining culture evidence of recurrent/persistent VVC. These can taken when the patient is symptomatic before treatment and can be combined with a symptom diary as part of the assessment process (evidence level IV, recommendation grade C). Microscopy should be of either a Gram stained or wet mount preparation4–9 (evidence level III, recommendation grade B). Culture should be from a directly plated solid fungal media (evidence level III, recommendation grade B). Chromogenic agar if available enables easy identification of species and mixed species infection and is preferred for investigation for complicated VVC17 (evidence level III, recommendation grade B). Liquid culture media are not recommended as they do not allow semi-quantitation. Other methods of testing for candida such as latex agglutination have not made their way into routine clinical practice.18–20 Polymerase chain reaction is currently of use only as a research tool.21–23 Antifungal sensitivities There is no proved utility of antifungal sensitivity testing for complicated VVC24 (evidence level III, recommendation grade B). It is possibly indicated for women with a chronic immunological abnormality25 (evidence level III, recommendation grade B); or repeated isolation of a non-albicans yeast26,27 (evidence level IV, recommendation grade C). Про чувствительность Юля уже объяснила :-) |