Invasive fungal infections in patients with cancer in the Intensive Care Unit.
ABSTRACT Invasive fungal infections (IFIs) have emerged as a major cause of morbidity and mortality amongst critically ill patients. Cancer patients admitted to the Intensive Care Unit (ICU) have multiple risk factors for IFIs. The vast majority of IFIs in the ICU are due to Candida spp. The incidence of invasive candidiasis (IC) has increased over recent decades, especially in the ICU. A shift in the distribution of Candida spp. from Candida albicans to non-albicans Candida spp. has been observed both in ICUs and oncology units in the last two decades. Timely diagnosis of IC remains a challenge despite the introduction of new microbiology techniques. Delayed initiation of antifungal therapy is associated with increased mortality. Therefore, prediction rules have been developed and validated prospectively in order to identify those ICU patients at high risk for IC and likely to benefit from early treatment. These rules, however, have not been validated in cancer patients. Similarly, major clinical studies on the efficacy of newer antifungals typically do not include cancer patients. Despite the introduction of more potent and less toxic antifungals, mortality from IFIs amongst cancer patients remains high. In recent years, aspergillosis and mucormycosis have also emerged as significant causes of morbidity and mortality amongst ICU patients with haematological cancer.
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ABSTRACT: To determine whether our practice of requesting an autopsy for patients who die in the medical intensive care unit (MICU) continues to be a valid approach to obtain clinically and educationally relevant findings. In this retrospective study conducted in an adult MICU population of a university hospital, the clinical diagnoses and postmortem major diagnoses of 100 patients who died in 1996 (autopsy rate of 93%) were compared. Eighty-one percent of the clinical diagnoses were confirmed at autopsy. In 16%, autopsy findings revealed a major diagnosis that, if known before death, might have led to a change in therapy and prolonged survival (class I missed major diagnoses). The most frequent class I missed major diagnoses were fungal infection, cardiac tamponade, abdominal hemorrhage, and myocardial infarction. Another 10% of autopsies revealed a diagnosis that, if known before death, would probably not have led to a change in therapy (class II error). Autopsy remains an important tool for education and quality control. In contrast with historical series of 1 to 2 decades ago, there is a clear shift in the type of class I missed major diagnoses toward opportunistic infections. Bedside-applicable techniques such as electrocardiography with supplemental posterior leads, echocardiography, and meticulous abdominal ultrasonography might improve the outcome in selected MICU patients.Mayo Clinic Proceedings 07/2000; 75(6):562-7. · 5.79 Impact Factor
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ABSTRACT: To describe the evolving epidemiology, management, and risk factors for death of invasive Candida infections in intensive care units (ICUs). Prospective, observational, national, multicenter study. One hundred eighty ICUs in France. Between October 2005 and May 2006, 300 adult patients with proven invasive Candida infection who received systemic antifungal therapy were included. None. One hundred seven patients (39.5%) with isolated candidemia, 87 (32.1%) with invasive candidiasis without documented candidemia, and 77 (28.4%) with invasive candidiasis and candidemia were eligible. In 37% of the cases, candidemia occurred within the first 5 days after ICU admission. C. albicans accounted for 57.0% of the isolates, followed by C. glabrata (16.7%), C. parapsilosis (7.5%), C. krusei (5.2%), and C. tropicalis (4.9%). In 17.1% of the isolates, the causative Candida was less susceptible or resistant to fluconazole. Fluconazole was the empirical treatment most commonly introduced (65.7%), followed by caspofungin (18.1%), voriconazole (5.5%), and amphotericin B (3.7%). After identification of the causative species and susceptibility testing results, treatment was modified in 86 patients (31.7%). The case fatality ratio in ICU was 45.9% and did not differ significantly according to the type of episode. Multivariate analysis showed that factors independently associated with death in ICU were type 1 diabetes mellitus (odds ratio [OR] 4.51; 95% confidence interval [CI] 1.72-11.79; p = 0.002), immunosuppression (OR 2.63; 95% CI 1.35-5.11; p = 0.0045), mechanical ventilation (OR 2.54; 95% CI 1.33-4.82; p = 0.0045), and body temperature >38.2 degrees C (reference, 36.5-38.2 degrees C; OR 0.36; 95% CI 0.17-0.77; p = 0.008). More than two thirds of patients with invasive candidiasis in ICU present with candidemia. Non-albicans Candida species reach almost half of the Candida isolates. Reduced susceptibility to fluconazole is observed in 17.1% of Candida isolates. Mortality of invasive candidiasis in ICU remains high.Critical care medicine 04/2009; 37(5):1612-8. · 6.37 Impact Factor
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ABSTRACT: To describe a nosocomial outbreak of gastric mucormycosis caused by Rhizopus microsporus var. rhizopodiformis in five adult patients admitted to an intensive care unit (ICU). Epidemiological surveillance study. A 12-bed polyvalent ICU of an acute care teaching hospital in Pamplona, Spain. Five patients admitted to the ICU requiring artificial ventilation, diagnosis on admission severe pneumonia in four patients and one polytrauma patient, within a 14-week period, were diagnosed with gastric mucormycosis based on microbiological and/or histopathological characteristics. Upper gastrointestinal bleeding was the presenting manifestation in 80% of patients. Filamentous fungi isolated at the microbiology laboratory of the hospital were examined at the national Mycology Reference Laboratory in Madrid. Rhizopus microsporus var. rhizopodiformis growth was detected in gastric aspiration samples, environmental samples, wooden tongue depressors used to prepare oral medications (and given to patients through a nasogastric catheter), and in some tongue depressors stored in unopened boxes unexposed to the ICU environment. All depressors were purchased from the same supplier. R. microsporus was not isolated from batches purchased at different times from the same supplier and from another supplier. The outbreak terminated when contaminated tongue depressors were withdrawn from use. Wooden tongue depressors contaminated by R. microsporus var. rhizopodiformis used to prepare oral medications caused an outbreak of fungal gastritis with an attributable mortality of 40%. Wooden material should not be used in the hospital setting.Intensive Care Medicine 05/2004; 30(4):724-8. · 5.26 Impact Factor