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EVIDENCE BASED DATA
Year : 2008  |  Volume : 52  |  Issue : 2  |  Page : 221-222 Table of Contents     

Fungal Infection in the ICU


Senior Prof. & Head, Department of Anaesthesiology, R.N.T.Medical College, Udaipur (Raj.), India

Date of Web Publication19-Mar-2010

Correspondence Address:
Pramila Bajaj
25, Polo Ground, Udaipur (Raj.)
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Bajaj P. Fungal Infection in the ICU. Indian J Anaesth 2008;52:221-2

How to cite this URL:
Bajaj P. Fungal Infection in the ICU. Indian J Anaesth [serial online] 2008 [cited 2019 Dec 13];52:221-2. Available from: http://www.ijaweb.org/text.asp?2008/52/2/221/60629

Data collected over the past 10-20 years clearly show that invasive fungal infections, far from being ob­served in immunocompromised hosts only, are increas­ingly recognized as a growing problem in critically ill nonimmunocompromised patients and in subjects under­going major surgical procedures [1],[2],[3] . While Candida spp. are the most common cause of severe fungal infections in the ICU, mould infections are so far rare, but the prob­lem is rapidly rising due to the increased spectrum of patients at risk for aspergillar infections [4] . According to Vaderwoude [5] , this particular group of patients has re­cently been categorized into different risk classes : high risk (allogeneic bone marrow-transplanted patients, neu­tropenic and haematological patients); intermediate risk (autologous bone marrow-transplanted patients, subjects suffering from malnutrition, under corticosteroid therapy, with diabetes or underlying pulmonary diseases) and low risk (patients suffering for cystic fibrosis and connec­tive tissue disease). Cases of invasive pulmonary as­pergillosis have been reported in apparently nonimmunocompromised COPD patients [5] .


   Risk factors Top


A comprehensive list of risk factors predispos­ing to severe candidiasis are recent abdominal surgery, gastrointestinal tract perforation, dialysis, broad-spectrum antibiotic therapy, and candida colonization are consid­ered to be conditions that increase the risk [3] .

Among the factors that can predict fatal out­come are extremes of age, severity of the underlying morbidities, duration of positivity of blood cultures, ab­sence of antifungal treatment and presence of infected catheters: since these two latter variables are potentially under clinical control, they should be implemented in the form of strategies able to influence the outcome[1] . In fact, exogenous acquisition of Candida has been pro­posed in cases of patients bearing intravascular devices and receiving TPN : catheter-related candidaemia was particulary common in the case of C. parapsilosis infec­tions.


   Therapeutic strategies : from prophylaxis to pre-emptive therapy Top


Among the many strategies implemented to pre­vent severe candidiasis, pre-emptive therapy and tar­geted prophylaxis could play a relevant role. According to the definition given by Eggimann [6] , pre-emptive therapy is the early administration of antifungal treatment to pa­tients with evidence of substantial colonization in the pres­ence of multiple risk factors : the number of factors con­sidered (usually two to four, but in some cases even one) differs in the various studies. Pre-emptive therapy should be given to patients with well-established risk factors, including a known degree of Candida colonization [6] . Ac­cording to Eggimann, in critically ill patients, in the case of worsening general conditions and multiple organ dys­function, if invasive candidiasis(IC) is suspected (pres­ence of known risk factor, fever in spite of broad-spec­trum antibiotics, organ dysfunction), empirical antifungal therapy may be justified while the results of blood cul­tures are awaited [6] . A more problematic scenario could be the presence of risk factors but the absence of known colonisation : assessment of the degree of colonisation should allow earlier identification of subjects who might benefit from the treatment (pre-emptive in this case). The time needed for assessment of the degree of colon­isation could be a limiting step.

Prophylaxis means the administration of antifun­gals to groups of patients known to be at high risk of candidal infection[6] : organ-transplanted patients (today with some limitation according to the type of organ trans­planted, severity of illness, complexity of surgery) , immuno compromised patients with expected long-term neutropenia; "nonimmunocompromised patients in whom prophylaxis is known to be effective" [7] . However it must be stressed that concerns have been raised about this latter definition, particularly in the case of complicated postsurgical patients, a category still deserving of fur­ther large and well-conducted clinical trials. Then, in criti­cally ill, nonimmunocompromised, nonneutropenic surgi­cal or medical patients, prophylaxis should be considered for selected groups of patients in whom the risk of IC is sufficiently high to justify the intervention : a figure considered in the literature is frequency of candidiasis higher than 10% in spite of aggressive use of infection control measures [6],[7] . In the recent IDSA guidelines for the treatment of candidiasis [7] , expected long ICU stay (more than 3 days) and prolonged mechanical ventila­tion are inductions for prophylaxis, because of a docu­mented tendency towards a decreased rate of candidi­asis [6],[7],[8] .


   Conclusions Top


Several risk factors for IC are recorded in a large number of critically ill patients admitted to medical and surgical ICUs : a consistent proportion of them (rang­ing from 20% to 60%) become colonised during their hospital stay, but unlike immunocompromised neutropenic individuals, only a minority (1-5%) will develop IC. The strategy proposed for the critically ill at risk of or sus­pected of having IC, unlike that implemented for the immunosuppressed, neutropenic host, relies upon a quan­titative definition of colonisation and implementation of pre-emptive therapy or targeted prophylaxis, as indi­cated [6] . Even though not yet validated by prospective clini­cal studies, the proposed strategy differentiates between prophylaxis and pre-emptive therapy. Prophylaxis is con­sidered for a selected group of patients in whom the frequency of candidaemia is high enough to make such treatment beneficial. Pre-emptive antifungal therapy, on the other hand, should be given to individuals with well­known risk factors and a known degree of candida colonisation, clinical markers which expose to such a high risk of IC that "the benefit of immediate antifungal treatment outweighs potentially negative side effects in­cluding emergence of resistant strains" [6] .

 
   References Top

1.Eggimann P, Garbino J, Pittet D. Epidemiology of Candida species infections in critically ill nonimmunosuppressed pa­tients. Lancet Infect Dis 2003;3:685-702.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Svoboda P, Kantarova I. Systemic Candida infection in the ICU. In: Vincent JL (ed) :Yearbook of intensive care and emer­gency medicine. Springer, New York Berlin Heidelberg, pp 2006:595-603.  Back to cited text no. 2      
3.Playford GE, Webster AC, Sorrell TC, Craig JC. Antifungal agents of preventing fungal infections in the non-neutropenic critically ill and surgical patients : systematic review and meta­analysis of randomized clinical trials. J Antimicrob Chemioter 2006; 57:628-638.  Back to cited text no. 3      
4.Meersseman W, Wilmer A, Peetersman WE. The spectrum of invasive aspergillosis in the ICU : not just for haematology patients. In : Vincent JL (ed) Yearbook of intensive care and emergency medicine. Springer, New York Berlin Heidelberg 2004: pp 258-264.  Back to cited text no. 4      
5.Vandewoude KH, Blot SI, Depuydt P, et al. Clinical relevance of Aspergillus isolation from respiratory tract sample in criti­cally ill patients. Crit Care 2006:10:R31 (doi:10.1186/cc4823).  Back to cited text no. 5      
6.Eggimann P, Garbino J, Pittet D. Management of Candida spe­cies infections in critically ill nonimmunosuppressed patients. Lancet Infect Dis 2003;3:772-785.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004; 38:161-189.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Rex JH, Sobel JD. Prophylactic antifungal Therapy in ICU. Clin Infect Dis 2001; 32:1191-1200.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  




 

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