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Bruyère R, Quenot JP, Prin S, Dalle F, Vigneron C, Aho S, Leon C, Charles PE. Empirical antifungal therapy with an echinocandin in critically-ill patients: prospective evaluation of a pragmatic Candida score-based strategy in one medical ICU. BMC Infect Dis 2014; 14:385. [PMID: 25015848 PMCID: PMC4227296 DOI: 10.1186/1471-2334-14-385] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 07/04/2014] [Indexed: 12/26/2022] Open
Abstract
Background Invasive candidiasis (IC) is a life-threatening ICU-acquired infection. A strong correlation between time to antifungal therapy (AFT) administration and outcome has been established. Empirical therapy benefit should be balanced with the risk of echinocandin overuse. We assessed therefore a decision rule that aimed at guiding empirical therapy. Methods A 45-month prospective cohort study in a teaching medical ICU. All of the patients with suspected IC (uncontrolled sepsis despite broad spectrum antibiotics without any bacterial proven infection in patients with Candida score ≥ 3 points including multifocal Candida sp. colonization) were eligible. The primary endpoint was proven IC diagnosis (i.e., candidemia) following treatment onset. Timing of AFT administration was also investigated in those latter patients. Antifungal therapy step-down and discontinuation was done according to international guidelines in patients with candidemia. Otherwise, echinocandin discontinuation was encouraged in patients without proven IC, excepting when a clinical improvement was achieved without any other explanation that antifungals initiation (i.e., probable IC). In addition, a survival multivariate analysis using a Cox model was conducted. Results Fifty-one patients were given an echinocandin with respect to our decision rule. Among them, candidemia was diagnosed thereafter in 9 patients. Over the same period, antifungal therapy was triggered by candidemia announcement (i.e., definite therapy) in 12 patients who did not fulfill criteria for empirical therapy before. Time elapsed from candidemia onset to echinocandin therapy initiation was shortened (0.4 [0.5] vs. 2.4 [2.8] hours; p = 0.04) when it was given empirically. In addition, 18 patients clinically improved under empirical antifungal therapy without any obvious other explanation, despite IC remained unproven. Moreover, echinocandin exposure duration was independently related to survival in those patients. Over the same period, our predefined criteria for empirical therapy were overruled in 55 cases. None of them develop IC thereafter. Finally, Our decision rule allowed IC early recognition of proven/probable IC with sensitivity, specificity, positive and negative predictive value of 69.2%, 82.1%, 69.2% and 82.1%, respectively. Conclusion Implementation of pragmatic guidelines for empirical AFT based on CS and fungal colonization assessment could be useful in selecting patients who really benefit from an echinocandin.
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Affiliation(s)
| | | | | | | | | | | | | | - Pierre-Emmanuel Charles
- Service de Réanimation Médicale, Hôpital Bocage Central, CHU Dijon, 14 rue Gaffarel, BP 77908-21079, Dijon, Cedex, France.
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Qu’apportent les recommandations 2012 de l’European Society of Clinical Microbiology and Infectious Diseases sur la prise en charge des candidoses invasives chez les patients non neutropéniques ? MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0854-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zein M, Parmentier-Decrucq E, Kalaoun A, Bouton O, Wallyn F, Baranzelli A, Elmanser D, Sendid B, Nseir S. Factors predicting prolonged empirical antifungal treatment in critically ill patients. Ann Clin Microbiol Antimicrob 2014; 13:11. [PMID: 24621182 PMCID: PMC3984712 DOI: 10.1186/1476-0711-13-11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 02/23/2014] [Indexed: 02/02/2023] Open
Abstract
Objective To determine the incidence, risk factors, and impact on outcome of prolonged empirical antifungal treatment in ICU patients. Methods Retrospective observational study performed during a one-year period. Patients who stayed in the ICU >48 h, and received empirical antifungal treatment were included. Patients with confirmed invasive fungal disease were excluded. Prolonged antifungal treatment was defined as percentage of days in the ICU with antifungals > median percentage in the whole cohort of patients. Results Among the 560 patients hospitalized for >48 h, 153 (27%) patients received empirical antifungal treatment and were included in this study. Fluconazole was the most frequently used antifungal (46% of study patients). Median length of ICU stay was 19 days (IQR 8, 34), median duration of antifungal treatment was 8 days (IQR 3, 16), and median percentage of days in the ICU with antifungals was 48% (IQR 25, 80). Seventy-seven patients (50%) received prolonged empirical antifungal treatment. Chemotherapy (OR [95% CI] 2.6 [1.07-6.69], p = 0.034), and suspected infection at ICU admission (3.1 [1.05-9.48], p = 0.041) were independently associated with prolonged empirical antifungal treatment. Duration of mechanical ventilation and ICU stay were significantly shorter in patients with prolonged empirical antifungal treatment compared with those with no prolonged empirical antifungal treatment. However, ICU mortality was similar in the two groups (46 versus 52%, p = 0.62). Conclusion Empirical antifungal treatment was prescribed in a large proportion of study patients. Chemotherapy, and suspicion of infection at ICU admission are independently associated with prolonged empirical antifungal treatment.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Saad Nseir
- Pôle de Réanimation Médicale, CHRU de Lille, Hôpital Salengro, Lille, France.
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Czaika V, Nenoff P, Glöckner A, Fegeler W, Becker K, Schmalreck AF. Epidemiology and changes in patient-related factors from 1997 to 2009 in clinical yeast isolates related to dermatology, gynaecology, and paediatrics. Int J Microbiol 2013; 2013:703905. [PMID: 24391669 PMCID: PMC3874336 DOI: 10.1155/2013/703905] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 06/30/2013] [Accepted: 07/01/2013] [Indexed: 12/20/2022] Open
Abstract
From 1997 to 2009, 1,862 dermatology, gynaecology, and paediatrics (DGP) associated clinical yeast isolates were analysed for species occurrence, specimen origin and type, (multi-) resistance pattern, and testing period. The top seven of the isolated DGP-associated species remained the same as compared to total medical wards, with Candida albicans (45%) as most frequent pathogen. However, the DGP wards and DGP ICUs showed species-specific profiles; that is, the species distribution is clinic-specific similar and however differs in their percentage from ward to ward. By applying the "one fungus one name" principle, respectively, the appropriate current taxonomic species denominations, it has been shown that no trend to emerging species from 1998 to 2008 could be detected. In particular the frequently isolated non-Candida albicans species isolated in the DGP departments have already been detected in or before 1997. As yeasts are part of the cutaneous microbiota and play an important role as opportunistic pathogens for superficial infections, proper identification of the isolates according to the new nomenclature deems to be essential for specific and calculated antifungal therapy for yeast-like DGP-related infectious agents.
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Affiliation(s)
- Viktor Czaika
- Klinik für Dermatologie, Venerologie und Allergologie, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Pietro Nenoff
- Laboratorium für medizinische Mikrobiologie, Straße des Friedens 8, 04579 Mölbis, Germany
| | - Andreas Glöckner
- BDH-Klinik Greifswald GmbH, Karl-Liebknecht-Ring 26a, 17491 Greifswald, Germany
| | - Wolfgang Fegeler
- Institute of Medical Microbiology, Domagkstraße 10, 48149 Münster, Germany
| | - Karsten Becker
- Institute of Medical Microbiology, Domagkstraße 10, 48149 Münster, Germany
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Timsit JF, Azoulay E, Cornet M, Gangneux JP, Jullien V, Vésin A, Schir E, Wolff M. EMPIRICUS micafungin versus placebo during nosocomial sepsis in Candida multi-colonized ICU patients with multiple organ failures: study protocol for a randomized controlled trial. Trials 2013; 14:399. [PMID: 24261608 PMCID: PMC4222830 DOI: 10.1186/1745-6215-14-399] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 11/08/2013] [Indexed: 12/16/2022] Open
Abstract
Background The potential interest of antifungal treatment of non-immunocompromized patients with sepsis, extra-digestive Candida colonization and multiple organ failure is unknown. It represents three-quarters of antifungals prescribed in Intensive Care Units. It may allow early treatment of invasive fungal infection in the incubation phase but expose patients to unnecessary antifungal treatments with subsequent cost and fungal selection pressure. As early diagnostic tests for invasive candidiasis are still considered to be insufficient, the potential interest in this strategy needs to be demonstrated. Methods This prospective multicenter, double blind, randomized-controlled trial is conducted in 23 French Intensive Care Units. All adult patients, mechanically ventilated for more than four days with sepsis of unknown origin and with at least one extradigestive fungal colonization site and multiple organ failure are eligible for randomization. Patients with proven invasive candidiasis are not included. After a complete mycological screening, patients are allocated to receive micafungin 100 mg intravenously once a day or placebo for 14 days. We plan to enroll 260 patients. The main objective is to demonstrate that micafungin increases survival of patients without invasive candidiasis at day 28 as compared to placebo. Other outcomes include day 28 and 90 survival and organ failure evolution. Additionally, pharmacokinetics of micafungin in enrolled patients will be measured and evolution of fungal biomarkers and susceptibility profiles of infecting fungi will also be followed. Discussion This study will help to provide guidelines for treating non-immunocompromized patients with fungal colonization multiple organ failure and sepsis of unknown origin. Trial registration Clinicaltrials.gov number NCT01773876
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Affiliation(s)
- Jean-François Timsit
- University Grenoble 1, Intensive Care Unit, Albert Michallon Hospital, BP 217, 38043 Grenoble, Cedex 9, France.
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Carradori S, Secci D, Bolasco A, Rivanera D, Mari E, Zicari A, Lotti LV, Bizzarri B. Synthesis and cytotoxicity of novel (thiazol-2-yl)hydrazine derivatives as promising anti-Candida agents. Eur J Med Chem 2013; 65:102-11. [DOI: 10.1016/j.ejmech.2013.04.042] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 04/24/2013] [Accepted: 04/25/2013] [Indexed: 02/07/2023]
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Mikulska M, Del Bono V, Ratto S, Viscoli C. Occurrence, presentation and treatment of candidemia. Expert Rev Clin Immunol 2013; 8:755-65. [PMID: 23167687 DOI: 10.1586/eci.12.52] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Candida is one of the most common causes of nosocomial bloodstream infections. Candidemia is not confined to hematological patients, intensive care units or abdominal surgery wards, but it is remarkably frequent in the internal medicine setting. High mortality associated with candidemia can be reduced by prompt, appropriate antifungal therapy. The epidemiology of species has been shifting toward non-albicans strains. Significant improvements in nonculture-based diagnostic methods, such as serological markers, have been made in recent years, and novel diagnostic techniques should be further studied to enable early pre-emptive therapy. Treatment guidelines indicate that echinocandins are at present the best choice for patients who are severely ill or possibly infected with fluconazole-resistant strains.
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Affiliation(s)
- Małgorzata Mikulska
- Division of Infectious Diseases, Department of Health Science, University of Genoa, Genoa, Italy
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Ullmann AJ, Akova M, Herbrecht R, Viscoli C, Arendrup MC, Arikan-Akdagli S, Bassetti M, Bille J, Calandra T, Castagnola E, Cornely OA, Donnelly JP, Garbino J, Groll AH, Hope WW, Jensen HE, Kullberg BJ, Lass-Flörl C, Lortholary O, Meersseman W, Petrikkos G, Richardson MD, Roilides E, Verweij PE, Cuenca-Estrella M. ESCMID* guideline for the diagnosis and management of Candida diseases 2012: adults with haematological malignancies and after haematopoietic stem cell transplantation (HCT). Clin Microbiol Infect 2013; 18 Suppl 7:53-67. [PMID: 23137137 DOI: 10.1111/1469-0691.12041] [Citation(s) in RCA: 233] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Fungal diseases still play a major role in morbidity and mortality in patients with haematological malignancies, including those undergoing haematopoietic stem cell transplantation. Although Aspergillus and other filamentous fungal diseases remain a major concern, Candida infections are still a major cause of mortality. This part of the ESCMID guidelines focuses on this patient population and reviews pertaining to prophylaxis, empirical/pre-emptive and targeted therapy of Candida diseases. Anti-Candida prophylaxis is only recommended for patients receiving allogeneic stem cell transplantation. The authors recognize that the recommendations would have most likely been different if the purpose would have been prevention of all fungal infections (e.g. aspergillosis). In targeted treatment of candidaemia, recommendations for treatment are available for all echinocandins, that is anidulafungin (AI), caspofungin (AI) and micafungin (AI), although a warning for resistance is expressed. Liposomal amphotericin B received a BI recommendation due to higher number of reported adverse events in the trials. Amphotericin B deoxycholate should not be used (DII); and fluconazole was rated CI because of a change in epidemiology in some areas in Europe. Removal of central venous catheters is recommended during candidaemia but if catheter retention is a clinical necessity, treatment with an echinocandin is an option (CII(t) ). In chronic disseminated candidiasis therapy, recommendations are liposomal amphotericin B for 8 weeks (AIII), fluconazole for >3 months or other azoles (BIII). Granulocyte transfusions are only an option in desperate cases of patients with Candida disease and neutropenia (CIII).
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Affiliation(s)
- A J Ullmann
- Department of Internal Medicine II, Julius-Maximilians-University, Würzburg, Germany.
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Murat JB, Lebeau B, Chumpitazi B, Cornet M, Maubon D, Faure O, Quesada JL, Thiebaut-Bertrand A, Timsit JF, Pelloux H. Minimum inhibitory concentrations of amphotericin B against Candida kruseiisolates from a French teaching hospital laboratory: a retrospective study over 8 years. Mycoses 2013; 56:56-60. [DOI: 10.1111/j.1439-0507.2012.02200.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Buschart A, Burakowska A, Bilitewski U. The fungicide fludioxonil antagonizes fluconazole activity in the human fungal pathogen Candida albicans. J Med Microbiol 2012; 61:1696-1703. [DOI: 10.1099/jmm.0.050963-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Anna Buschart
- Biological Systems Analysis, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Anna Burakowska
- Biological Systems Analysis, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Ursula Bilitewski
- Biological Systems Analysis, Helmholtz Centre for Infection Research, Braunschweig, Germany
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Epidemiology and outcomes of candidemia in 3648 patients: data from the Prospective Antifungal Therapy (PATH Alliance®) registry, 2004–2008. Diagn Microbiol Infect Dis 2012; 74:323-31. [DOI: 10.1016/j.diagmicrobio.2012.10.003] [Citation(s) in RCA: 287] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 10/05/2012] [Indexed: 12/29/2022]
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Candida glabrata: Multidrug Resistance and Increased Virulence in a Major Opportunistic Fungal Pathogen. CURRENT FUNGAL INFECTION REPORTS 2012. [DOI: 10.1007/s12281-012-0091-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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