Management of invasive candidiasis and candidemia in adult non-neutropenic intensive care unit patients: Part I. Epidemiology and diagnosis

Intensive Care Medicine (Impact Factor: 5.54). 01/2008; 35(1):55-62. DOI: 10.1007/s00134-008-1338-7

ABSTRACT BackgroundInvasive candidiasis and candidemia are frequently encountered in the nosocomial setting, particularly in the intensive care
unit (ICU).

Objectives and methodsTo review the current management of invasive candidiasis and candidemia in non-neutropenic adult ICU patients based on a review
of the literature and a European expert panel discussion.

Results and conclusions
Candida albicans remains the most frequently isolated fungal species followed by C. glabrata. The diagnosis of invasive candidiasis involves both clinical and laboratory parameters, but neither of these are specific.
One of the main features in diagnosis is the evaluation of risk factor for infection which will identify patients in need
of pre-emptive or empiric treatment. Clinical scores were built from those risk factors. Among laboratory diagnosis, a positive
blood culture from a normally sterile site provides positive evidence. Surrogate markers have also been proposed like 1,3
β-d glucan level, mannans, or PCR testing. Invasive candidiasis and candidemia is a growing concern in the ICU, apart from cases
with positive blood cultures or fluid/tissue biopsy, diagnosis is neither sensitive nor specific. The diagnosis remains difficult
and is usually based on the evaluation of risk factors.

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    ABSTRACT: Direct treatment costs caused by candidemia in German intensive care unit (ICU) patients are currently unknown. We analyzed treatment costs and the impact of antifungal drug choice. Comprehensive data of patients who had at least one episode of candidemia while staying in the ICU between 01/2005 and 12/2010 were documented in a database using the technology of the Cologne Cohort of Neutropenic Patients (CoCoNut). A detailed analysis of all disease-associated treatment costs was performed. Patients treated with echinocandins (i.e., anidulafungin, caspofungin, micafungin) or fluconazole were analyzed separately and compared. Forty-one and 64 patients received echinocandins and fluconazole, respectively. The mean Acute Physiology and Chronic Health Evaluation (APACHE) IV score was 114 (95 % confidence interval [CI]: 106-122) vs. 95 (95 % CI: 90-101, p = <0.001). Twenty-three (56 %) and 33 (52 %, p = 0.448) patients survived hospitalization, while 17 (41 %) and 22 (34 %, p = 0.574) survived one year after diagnosis. In the echinocandin and fluconazole groups, the mean costs per patient of ICU treatment were 20,338 (95 % CI: 12,893-27,883) vs. 11,932 (95 % CI: 8,016-15,849, p = 0.110), and the total direct treatment costs per patient were 37,995 (95 % CI: 26,614- 49,376) vs. 22,305 (95 % CI: 16,817- 27,793, p = 0.012), resulting in daily costs per patient of 1,158 (95 % CI: 1,036- 1,280) vs. 927 (95 % CI: 828- 1,026, p = 0.001). Our health economic analysis shows the high treatment costs of patients with candidemia in the ICU. Sicker patients had a prolonged hospitalization and were more likely to receive echinocandins, leading to higher treatment costs. Outcomes were comparable to those achieved in less sick patients with fluconazole.
    European Journal of Clinical Microbiology 09/2014; 34(2). DOI:10.1007/s10096-014-2230-8 · 2.54 Impact Factor
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    ABSTRACT: Background The elderly patients affected by candidemia are growing in proportion to inpatients, but available data are limited. We aimed to determine the epidemiology, antifungal management and clinical risk factors of death in the elderly population with candidemia in China.Methods This retrospective study included 63 elderly (¿65 years) and 84 younger patients (16¿60 years) at 4 tertiary hospitals. Multivariable logistic regression model was used to identify independent risk factors of death in elderly patients.ResultsThe distribution of Candida species did not differ between elderly and younger patients (p >0.05). Resistance to fluconazole and voriconazole for non-Candida albicans species in elderly patients was approximately double that in younger patients. Host-related risk factors (e.g., underlying solid tumour, diabetes mellitus and chronic renal failure) and hospital-related factors (e.g., prior stay in an intensive care unit, mechanical ventilation, central vascular and urethral catheters placement) were identified more common in elderly patients. Elderly patients less often received triazoles and were less likely to receive antifungal therapies mostly because elderly or their guardians quit antifungal therapies. APACHE II scores and 30-day mortality were higher for elderly than younger patients (31.7% vs. 16.7%, p =0.032). For elderly patients, antifungal therapy administered before microbiological documentation was the only protective factor for death, whereas absence of antifungal therapies, receipt of mechanical ventilation and APACHE II score ¿20 were independent predictors of death.Conclusions Elderly patients with candidemia had poor prognoses characterized by certain host and hospital-related risk factors and special pathogen resistance features. More awareness of the burden of this disease is required, and the absence of antifungal therapies should be avoided to improve the prognoses of elderly patients with this severe infection.
    BMC Infectious Diseases 11/2014; 14(1):609. DOI:10.1186/s12879-014-0609-x · 2.56 Impact Factor
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    ABSTRACT: Purpose of reviewInvasive and mucosal candidiasis are associated with major morbidity in patients with inappropriate host defence mechanisms. This review focuses on recent studies elucidating the immune response against candidiasis and possible immunotherapeutic approaches.Recent findingsThe last year has seen substantial advances in understanding antifungal immunity. The role of pattern recognition receptors and the Th1 and Th17 immune pathways has been further elucidated. The first genome-wide studies have identified new risk factors for candidaemia. Trials of adjuvant immunotherapy for fungal infections have provided directions for the future.SummaryUnderstanding the fungal pathogenesis and the induction of protective antifungal adaptive immunity has advanced the development of immunotherapeutic strategies and vaccines against invasive and mucosal candidiasis.
    Current Opinion in Infectious Diseases 10/2014; 27(6). DOI:10.1097/QCO.0000000000000105 · 5.03 Impact Factor

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