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

Intensive Care Medicine (Impact Factor: 7.21). 11/2008; 35(1):55-62. DOI: 10.1007/s00134-008-1338-7


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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Available from: Gabriele Sganga
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    • "Recent IDSA guidelines suggest that "empirical antifungal therapy should be considered in critically ill patients with risk factors for invasive candidiasis and no other known cause of fever" [14]. Risk factors for invasive candidiasis are well identified [15]. However, these are so numerous that most ICU patients could be considered as exhibiting risk factors for invasive candidiasis. "
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    ABSTRACT: Although prompt initiation of appropriate antifungal therapy is essential for the control of invasive Candida infections and an improvement of prognosis, early diagnosis of invasive candidiasis remains a challenge and criteria for starting empirical antifungal therapy in ICU patients are poorly defined. Some scoring systems, such as the "Candida score" could help physicians to differentiate patients who could benefit from early antifungal treatment from those for whom invasive candidiasis is highly improbable. This study evaluated the performance of this score in a cohort of critically ill patients. A prospective, observational, multicenter, cohort study was conducted from January 2010 to March 2011 in five intensive care units in Nord-Pas de Calais, an area from North of France. All patients exhibiting, on ICU admission or during their ICU stay, a hospital-acquired severe sepsis or septic shock could be included in this study. The data collected included patient characteristics on ICU admission and at the onset of severe sepsis or septic shock. The "Candida score" was calculated at the onset of sepsis or shock. The incidence of invasive candidiasis was determined and its relationship with the value of the "Candida score" was studied. Ninety-four patients were studied. When severe sepsis or shock occurred, 44 patients had a score = 2, 29 patients had a score = 3, 17 patients had a score = 4, and 4 patients had a score = 5. Invasive candidiasis was observed in five (5.3%) patients. One patient had candidemia, three patients had peritonitis, and one patient had pleural infection. The rates of invasive candidiasis was 0% in patients with score = 2 or 3, 17.6% in patients with score = 4, and 50% in patients with score = 5 (p < 0.0001). Our results confirm that the "Candida score" is an interesting tool to differentiate among ICU patients who exhibit hospital-acquired severe sepsis or septic shock those would benefit from early antifungal treatment (score > 3) from those for whom invasive candidiasis is highly improbable (score ≤ 3).
    Full-text · Article · Nov 2011 · Annals of Intensive Care
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    • "This distribution reflects the predisposing factors identified by several authors [12], including neutropenia, cancer chemotherapy, colonization with Candida spp., exposure to broad spectrum antibiotics, indwelling central venous catheters, hemodialysis or renal failure, high APACHE score, mechanical ventilation, prior surgery, particularly gastro-abdominal surgery [13], gastrointestinal perforation and higher age. Another important risk group are solid organ transplant recipients receiving immunosuppressants [14]. "
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    ABSTRACT: Working by a distinct cell wall-specific mechanism of action, the echinocandin class of antifungals has substantially expanded the range of available treatments for invasive Candida infections. Anidulafungin, caspofungin and micafungin were investigated versus drugs from earlier antifungal classes in large clinical trials that demonstrated their excellent clinical and microbiological efficacy in the primary treatment of invasive candidiasis. Therefore, and supported by a number of favourable pharmacological characteristics, the echinocandins rapidly became established in guidelines and clinical practice as primary treatment options for moderately to severely ill patients with invasive candidiasis. This article reviews the relevant clinical evidence that forms the basis for the use of echinocandins in the management of invasive candidiasis, and discusses their current role in the context of recent guideline recommendations and treatment optimization strategies.
    No preview · Article · Apr 2011
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    • "Traditional culture from sterile sites other than the bloodstream (for example, the peritoneum) are useful for diagnosis of invasive candidiasis. For specific details on the diagnosis of invasive candidiasis in the ICU, a recent review is available [46]. "
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    ABSTRACT: Candida is one of the most frequent pathogens in bloodstream infections, and is associated with significant morbidity and mortality. The epidemiology of species responsible for invasive candidiasis, both at local and worldwide levels, has been changing - shifting from Candida albicans to non-albicans species, which can be resistant to fluconazole (Candida krusei and Candida glabrata) or difficult to eradicate because of biofilm production (Candida parapsilosis). Numerous intensive care unit patients have multiple risk factors for developing this infection, which include prolonged hospitalisation, use of broad-spectrum antibiotics, presence of intravascular catheters, parenteral nutrition, high Acute Physiology and Chronic Health Evaluation score, and so forth. Moreover, delaying the specific therapy was shown to further increase morbidity and mortality. To minimise the impact of this infection, several management strategies have been developed - prophylaxis, empirical therapy, pre-emptive therapy and culture-based treatment. Compared with prophylaxis, empirical and pre-emptive approaches allow one to reduce the exposure to antifungals by targeting only the patients at high risk of candidemia, without delaying therapy until the moment blood Candida is identified in blood cultures. The agents recommended for initial treatment of candidemia in critically ill patients include echinocandins and lipid formulation of amphotericin B.
    Preview · Article · Dec 2010 · Critical care (London, England)
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