|EVIDENCE BASED DATA
|Year : 2008 | Volume
| Issue : 2 | Page : 221-222
Fungal Infection in the ICU
Senior Prof. & Head, Department of Anaesthesiology, R.N.T.Medical College, Udaipur (Raj.), India
|Date of Web Publication||19-Mar-2010|
25, Polo Ground, Udaipur (Raj.)
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bajaj P. Fungal Infection in the ICU. Indian J Anaesth 2008;52:221-2
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 ,, . 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  . According to Vaderwoude  , 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  .
| Risk factors|| |
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  .
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 . 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|| |
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  , 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  . 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  . 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 : 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"  . 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 , . In the recent IDSA guidelines for the treatment of candidiasis  , 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 ,, .
| Conclusions|| |
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  . 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"  .
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