您是否在不知不覺中幫助了超級真菌的崛起？

馬庫斯·A·班克斯 / 2024 年 1 月 12 日 / Medscape 醫學新聞

根據《發病率和死亡率週報》1 月 11 日發表的一項研究，不必要或不正確地使用外用抗真菌藥物正在推動癬等真菌感染的傳播，這些感染變得越來越難以治療。

如果患者的病情不是由真菌引起的，但按真菌治療，治療將是無效的。

作者強烈建議初級保健臨床醫生在開立克黴唑 (clotrimazole) 或抗真菌藥物和皮質類固醇組合等治療藥物之前，透過實驗室測試確認癬的診斷。 而且由於許多局部治療藥物也可以透過非處方藥物獲得，因此醫生應該建議患者如何正確使用它們。

該研究的作者，紐約威爾康奈爾醫學院的皮膚科醫生、醫學博士莎莉·利普納(Shari Lipner) 表示，「在過去的幾年裡，報告了許多體癬和甲真菌病的抗真菌藥物抗藥性病例」，或分別是癬和手指或腳趾甲感染。

其中許多病例起源於南亞，歐洲和加拿大也有通報。 2023年，美國報告了第一例新的抗真菌藥物抗藥性癬菌病例。 這種毛癬菌對局部藥物沒有反應，需要口服治療。

利普納說：「這確實是一個嚴重的問題，也是一個巨大的公共衛生問題」。

在這項新研究中，Lipner 及其同事檢查了 2021 年 Medicare D 部分外用抗真菌藥物索賠的處方模式。 他們報告稱，當年有 650 萬份外用抗真菌處方，其中一些配方中含有類固醇。 其中 40% 是初級保健臨床醫生開出的處方，是所有臨床醫生群體中最多的。 該估計幾乎肯定低估了局部抗真菌藥物的使用，因為該資料庫不包括非處方藥購買或來自其他保險付款人的數據。

研究人員報告稱，處方數量相當於每 8 名 Medicare D 部分受益人中就有 1 人接受抗真菌藥物治療。

「如果我想到來到我辦公室的患者，我肯定不會給其中八分之一的患者服用抗真菌藥物，而且我看到很多真菌感染，」利普納說。 利普納的研究結果顯示，一些臨床醫生僅透過視力來診斷癬，而不是透過顯微鏡、真菌培養測試或聚合酶鏈反應測試等技術來確認診斷。

紐約大學朗格健康中心的皮膚科醫生阿夫羅姆·卡普蘭醫學博士表示，有時看起來像癬的東西實際上可能是濕疹，在這種情況下，局部抗真菌藥物並不合適。

「如果你給某人開出他們不需要的藥物，那麼你基本上就是讓他們遭受副作用而沒有獲益，」卡普蘭說，他沒有參與這項研究。

卡普蘭在美國報告了第一例僅對口服藥物有反應的癬病例，他強調，局部治療對當今的許多癬病例效果良好。 但卡普蘭說，如果不加區別地開藥刺激了更有彈性的真菌的發展，那麼未來可能會出現更多只有口服藥物起作用的情況。 此外，卡普蘭補充說，口服藥物本質上對患者的要求比擦在皮膚上的藥物更高。

利普納說：「我們希望醫生能夠認真思考這項研究，並在沒有確診的情況下改變他們的做法」。

利普納和卡普蘭報告沒有相關的財務關係。

馬庫斯·A·班克斯 (Marcus A. Banks)，麻薩諸塞州，是一位駐紐約市的記者，主要報導健康新聞，重點關注新的癌症研究。 他的作品發表在 Medscape、Cancer Today、The Scientist、Gastroenterology & Endoscopy News、Slate、TCTMD 和 Spectrum 等雜誌上。

引用本文：你是否在不知不覺中幫助了超級真菌的崛起？ – Medscape – 2024 年 1 月 12 日。

Are You Unwittingly Aiding the Rise of Superfungi?

Marcus A. Banks / January 12, 2024 / Medscape Medical News

Unnecessary or incorrect use of topical antifungal medications is driving the spread of fungal infections like ringworm, which are becoming more difficult to treat, according to a January 11 study published in Morbidity and Mortality Weekly Report. 

If a patient’s condition is not caused by a fungus but is treated as such, treatment will be ineffective.

The authors strongly advise primary care clinicians to confirm ringworm diagnoses through lab testing before prescribing treatments such as clotrimazole or combinations of antifungals and corticosteroids. And because many topical treatments are also available over-the-counter, doctors should advise patients about how to use them correctly.

“In the last few years, there have been many antifungal resistant cases of tinea corporisand onychomycosis reported,” or ringworm and finger or toenail infections, respectively, said Shari Lipner, MD, PhD, a dermatologist at Weill Cornell Medicine in New York, and an author of the study.

Many of these cases originated in South Asia and have also been reported in Europe and Canada. In 2023, the first cases of a new strain of antifungal-resistant ringworm were reported in the United States. This species, Trichophyton indotineae, does not respond to topical medications, requiring oral treatment instead.

“It’s really a serious problem and a huge public health concern,” Lipner said. 

For the new study, Lipner and colleagues examined prescription patterns from 2021 Medicare Part D claims of topical antifungals. They report that 6.5 million topical antifungal prescriptions were filled that year, some of which included steroids in the formulation. Primary care clinicians wrote 40% of these prescriptions, the most for any clinician group. The estimate is almost certainly an undercount of topical antifungal use because the database did not include over-the-counter purchases or data from other insurance payers.

The number of prescriptions equate to 1 in every 8 Medicare Part D beneficiary receiving an antifungal, the researchers reported. 

“If I think about the patients that come into my office, I’m certainly not giving an antifungal to 1 in 8 of them, and I see a lot of fungal infections,” Lipner said. The findings suggest to Lipner that some clinicians are diagnosing ringworm by eyesight alone rather than confirming the diagnosis with techniques such as microscopy, fungal culture testing, or polymerase chain reaction testing. 

Sometimes what looks like ringworm may actually be eczema, in which case, the topical antifungal would not be appropriate, according to Avrom Caplan, MD, a dermatologist at NYU Langone Health in New York.

“If you’re prescribing something to somebody that they don’t need, you’re basically exposing them to the side effects without the benefit,” Caplan, who was not part of the study, said. 

Caplan, who reported the first cases of ringworm that only responded to oral medications in the United States, stressed that topical treatments work fine for many ringworm cases today. But if indiscriminate prescribing spurs the development of more resilient fungi, more situations may arise in which only oral medications work in the future, Caplan said. In addition, oral medications are inherently more demanding on a patient than something they can rub on their skin, Caplan added.

“We hope that physicians will really think hard about this study and change their practices if they’re not confirming the diagnosis,” Lipner said.

Lipner and Caplan report no relevant financial relationships.

Marcus A. Banks, MA, is a journalist based in New York City who covers health news with a focus on new cancer research. His work appears in Medscape, Cancer Today, The Scientist, Gastroenterology & Endoscopy News, Slate, TCTMD, and Spectrum.

Cite this: Are You Unwittingly Aiding the Rise of Superfungi? – Medscape – January 12, 2024.