Significance of Candida recovered from intraoperative specimens in patients with intra-abdominal perforations

Basis for selecting optimum antibiotic regimens for secondary peritonitis

Adequate management of severely ill patients with secondary peritonitis requires supportive therapy of organ dysfunction, source control of infection and antimicrobial therapy. Since secondary peritonitis is polymicrobial, appropriate empiric therapy requires combination therapy in order to achieve the needed coverage for both common and more unusual organisms. This article reviews etiological agents, resistance mechanisms and their prevalence, how and when to cover them and guidelines for treatment in the literature. Local surveillances are the basis for the selection of compounds in antibiotic regimens, which should be further adapted to the increasing number of patients with risk factors for resistance (clinical setting, comorbidities, previous antibiotic treatments, previous colonization, severity…). Inadequate antimicrobial regimens are strongly associated with unfavorable outcomes. Awareness of resistance epidemiology and of clinical consequences of inadequate therapy against resistant bacteria is crucial for clinicians treating secondary peritonitis, with delicate balance between optimization of empirical therapy (improving outcomes) and antimicrobial overuse (increasing resistance emergence).

Epidemiology of invasive candidiasis in a surgical intensive care unit: an observational study

BACKGROUND

Invasive candidiasis (IC) is a frequent and life-threatening infection in critically ill patients. The aim of this study was to evaluate the epidemiology of IC and the antifungal susceptibility of etiological agents in patients admitted to our surgical intensive care unit (SICU) in Spain.

METHODS

We designed a prospective, observational, single center, population-based study in a SICU. We included all consecutive adult patients (≥18 years old) who had documented IC, either on admission or during their stay, between January 2012 and December 2013.

RESULTS

There were a total of 22 episodes of IC in the 1149 patients admitted during the 24-month study. The overall IC incidence was 19.1 cases per 1000 admissions. Thirteen cases of IC (59.1%) were intra-abdominal candidiasis (IAC) and 9 (40.9%) were candidemias. All cases of IAC were patients with secondary peritonitis and severe sepsis or septic shock. The overall crude mortality rate was 13.6%; while, it was 33% in patients with candidemia. All patients with IAC survived, including one patient with concomitant candidemia. The most common species causing IC was Candida albicans (13; 59.1%) followed by Candida parapsilosis (5; 22.7%), and Candida glabrata (2; 9.1%). There was also one case each (4.5%) of Candida krusei and Candida tropicalis. Thus, the ratio of non-C. albicans (9) to C. albicans (13) was 1:1.4. There was resistance to fluconazole and itraconazole in 13.6% of cases. Resistance to other antifungals was uncommon.

CONCLUSIONS

Candida parapsilosis was the second most common species after C. albicans, indicating the high prevalence of non-C. albicans species in the SICU. Resistance to azoles, particularly fluconazole, should be considered when starting an empirical treatment. Although IAC is a very frequent form of IC in critically ill surgical patients, prompt antifungal therapy and adequate source control appears to lead to a good outcome. However, our results are closely related to our ICU and any generalization must be taken with caution. Therefore, further investigations are needed.

Inadequate Source Control and Inappropriate Antibiotics are Key Determinants of Mortality in Patients with Intra-Abdominal Sepsis and Associated Bacteremia

BACKGROUND

Patients with intra-abdominal sepsis and associated bacteremia have a high mortality rate. However, outcomes studies in this population are limited, in part because of the small numbers of such patients. The objective of this study was to describe characteristics of critically ill patients with secondary blood stream infection (BSI) of intra-abdominal origin and identify predictors of mortality.

METHODS

This retrospective, single-center study evaluated patients admitted between January 2005 and January 2011 with bacteremia because of an intra-abdominal source. Patients were included if they met criteria for severe sepsis based on International Classification of Diseases, 9th Revision (ICD 9) codes for acute organ dysfunction, had a positive blood culture, had at least one ICD 9 code indicative of an intra-abdominal process, and had a confirmed or clinically suspected intra-abdominal infection (IAI) within 72 h of the blood culture. Chart review was performed to confirm the presence of these criteria and also the absence of any other potential source of bacteremia. Data were collected on patient demographics, BSI source, source control procedure details, microorganisms isolated, and antibiotics administered. Multivariable logistic regression analysis was performed to identify independent predictors of mortality.

RESULTS

Three hundred six patients with BSI were identified, of which 108 episodes were deemed to be of intra-abdominal origin. Gram-negative organisms comprised 43% of blood isolates, followed by gram-positives (33%), anaerobes (14%), and yeast (9%). Appropriate antimicrobial therapy was administered in 71% of patients. The overall mortality rate was 27.8%. As compared with survivors, non-survivors were older, more likely to have underlying COPD or asthma, and have renal or metabolic failure (p<0.05 for all). Among non-survivors, adequate source control was obtained less frequently (64% vs. 91%, p=0.002) and median time to appropriate antibiotics was longer (23 h vs. 4 h, p=0.004). Logistic regression analysis revealed inadequate source control (p=0.002) and inappropriate antibiotics (p=0.016) to be independently associated with mortality.

CONCLUSIONS

Critically ill patients with a BSI of abdominal origin are at high risk for mortality. Failure to achieve adequate source control and administration of inappropriate antibiotics were independent predictors of mortality. Thus, these represent potential opportunities to impact outcomes in patients with complicated IAI.

Fungal Culture Positivity in Patients with Perforation Peritonitis

BACKGROUND

Perforation peritonitis is the most common surgical emergency. A large number of microorganisms have been cultured from the abdominal fluid obtained from patients with gastrointestinal perforation peritonitis. The present study was undertaken to determine the frequency of positive fungal culture in perforation peritonitis as Candida co-infection is reported to be a bad prognostic factor in these patients.

MATERIALS AND METHODS

The intraoperative specimens of abdominal fluid collected during laparotomy from 140 consecutive patients of gastro-intestinal perforation were analysed by microbial culture for bacteria and fungi. Their antimicrobial susceptibility was also studied.

RESULTS

The mean presenting age of the patients was 35 years and 120 (85.7%) of them were males. Aerobic Gram Negative Bacilli (AGNB) were observed in 82 (79.6%) of the culture positive abdominal fluid specimens, of which 58 (70.7%) were Escherichia coli. Gram negative bacteria were most frequently isolated from colorectal perforation (100%) while Gram positive bacteria were from upper gastrointestinal perforation (47.2%). Candida was cultured in as many as 68 of 140 (48.6%) specimens. Its prevalence was highest in patients with gastroduodenal perforation (70.5%) and was altogether absent in patients having appendicular perforation.

CONCLUSION

High prevalence of fungal culture positivity of peritoneal fluid of patients of perforation peritonitis shows that along with the bacterial culture, fungal cultures should always be asked for in such patients. Adequate and timely antimicrobial treatment including treatment of fungal infection could help reduce mortality in this group of patients.

A multicenter multinational study of abdominal candidiasis: epidemiology, outcomes and predictors of mortality

PURPOSE

Clinical data on patients with intra-abdominal candidiasis (IAC) is still scarce.

METHODS

We collected data from 13 hospitals in Italy, Spain, Brazil, and Greece over a 3-year period (2011-2013) including patients from ICU, medical, and surgical wards.

RESULTS

A total of 481 patients were included in the study. Of these, 27% were hospitalized in ICU. Mean age was 63 years and 57% of patients were male. IAC mainly consisted of secondary peritonitis (41%) and abdominal abscesses (30%); 68 (14%) cases were also candidemic and 331 (69%) had concomitant bacterial infections. The most commonly isolated Candida species were C. albicans (n = 308 isolates, 64%) and C. glabrata (n = 76, 16%). Antifungal treatment included echinocandins (64%), azoles (32%), and amphotericin B (4%). Septic shock was documented in 40.5% of patients. Overall 30-day hospital mortality was 27% with 38.9% mortality in ICU. Multivariate logistic regression showed that age (OR 1.05, 95% CI 1.03-1.07, P < 0.001), increments in 1-point APACHE II scores (OR 1.05, 95% CI 1.01-1.08, P = 0.028), secondary peritonitis (OR 1.72, 95% CI 1.02-2.89, P = 0.019), septic shock (OR 3.29, 95% CI 1.88-5.86, P < 0.001), and absence of adequate abdominal source control (OR 3.35, 95% CI 2.01-5.63, P < 0.001) were associated with mortality. In patients with septic shock, absence of source control correlated with mortality rates above 60% irrespective of administration of an adequate antifungal therapy.

CONCLUSIONS

Low percentages of concomitant candidemia and high mortality rates are documented in IAC. In patients presenting with septic shock, source control is fundamental.

Candida peritonitis in dogs: report of 5 cases

Candida peritonitis is reported in people and is associated with significant morbidity and mortality compared with sterile or bacterial peritonitis. Recognized predisposing risk factors include peritoneal dialysis, hollow viscous organ perforation, abdominal surgery, inflamed intestinal mucosa, antimicrobial administration, and immunosuppression. In this report, we describe 5 cases of dogs with peritonitis complicated by Candida spp; 3 dogs with C albicans, one dog with C albicans and C glabrata, and one dog with C glabrata only. The 3 dogs with C albicans peritonitis presented with duodenal perforation due to NSAID therapy, intestinal resection and anastomosis following postspay-surgery dehiscence, and intestinal foreign body removal. The 2 dogs with C glabrata peritonitis had undergone cholecystectomy due to gall bladder rupture and dehiscence of intestinal biopsy removal sites following exploratory laparatomy. In all cases, initial diagnosis of fungal peritonitis was made via cytologic examination of peritoneal effusions, which revealed marked pyogranulomatous inflammation with numerous 3-8 μm oval, deeply basophilic yeast organisms with thin clear capsules noted within phagocytes and extracellularly. In addition, germ tube formation, hyphae, and pseudohyphae were rarely seen in some of the cases with pure C albicans. Identity of the organisms was determined by culture in all cases and confirmed by PCR in 3 cases. Candida spp. are commensals normally inhabiting the alimentary, the upper respiratory, and the lower urogenital tracts of mammals. They are opportunistic pathogens that can invade and colonize tissue when a patient is immune-compromised or there is disruption of the mucosal barrier. Candida peritonitis should be considered in patients with peritoneal contamination with gastrointestinal or biliary contents.

Management of invasive candidiasis in nonneutropenic ICU patients

Invasive candidiasis (IC) is a leading cause of morbidity and mortality among nonneutropenic ICU patients and these life-threatening nosocomial infections require early diagnosis and prompt treatment. However, none of the predictive tools are sufficiently accurate to identify high-risk patients and the potential interest of IC prophylactic, empirical and preemptive treatment in the nonneutropenic ICU population has not yet been demonstrated. In the case of nosocomial severe sepsis after necrotizing pancreatitis or upper digestive anastomotic leakage, early probabilistic antifungals are probably indicated. In the remaining ICU surgical and medical patients, prophylactic and empirical strategies are highly debated because they may promote antifungal selective pressure through an overuse of these molecules. In this context, non-culture-based methods such as mannan or β-D glucan or polymerase chain reaction tests are promising. However, none of these tests used alone in ICU patients is sufficiently accurate to avoid overuse of empirical/preemptive treatment. The interest of strategies associating predictive clinical scores and non-culture-based methods still needs to be demonstrated by well-conducted randomized, controlled trials. While awaiting these studies, we consider that probabilist treatment should be stopped earlier if IC is not proven.

Abdominal infections in the intensive care unit: characteristics, treatment and determinants of outcome

BACKGROUND

Abdominal infections are frequent causes of sepsis and septic shock in the intensive care unit (ICU) and are associated with adverse outcomes. We analyzed the characteristics, treatments and outcome of ICU patients with abdominal infections using data extracted from a one-day point prevalence study, the Extended Prevalence of Infection in the ICU (EPIC) II.

METHODS

EPIC II included 13,796 adult patients from 1,265 ICUs in 75 countries. Infection was defined using the International Sepsis Forum criteria. Microbiological analyses were performed locally. Participating ICUs provided patient follow-up until hospital discharge or for 60 days.

RESULTS

Of the 7,087 infected patients, 1,392 (19.6%) had an abdominal infection on the study day (60% male, mean age 62 ± 16 years, SAPS II score 39 ± 16, SOFA score 7.6 ± 4.6). Microbiological cultures were positive in 931 (67%) patients, most commonly Gram-negative bacteria (48.0%). Antibiotics were administered to 1366 (98.1%) patients. Patients who had been in the ICU for ≤ 2 days prior to the study day had more Escherichia coli, methicillin-sensitive Staphylococcus aureus and anaerobic isolates, and fewer enterococci than patients who had been in the ICU longer. ICU and hospital mortality rates were 29.4% and 36.3%, respectively. ICU mortality was higher in patients with abdominal infections than in those with other infections (29.4% vs. 24.4%, p < 0.001). In multivariable analysis, hematological malignancy, mechanical ventilation, cirrhosis, need for renal replacement therapy and SAPS II score were independently associated with increased mortality.

CONCLUSIONS

The characteristics, microbiology and antibiotic treatment of abdominal infections in critically ill patients are diverse. Mortality in patients with isolated abdominal infections was higher than in those who had other infections.

[Therapeutic strategies in intensive care units]

Severe Candida infections are frequent in intensive care units and difficult to diagnose. Various antifungal agents can be used to treat Candida severe infections, but the choice of the most adapted treatment strategy is difficult. According to different guidelines, it must be based on the efficacy and tolerance of the drug, but also on patient risk stratification and local epidemiology. A practical diagnostic approach will help to determine which patients will benefit from prophylaxis and empiric therapy.

Development and validation of a risk model for identification of non-neutropenic, critically ill adult patients at high risk of invasive Candida infection: the Fungal Infection Risk Evaluation (FIRE) Study

BACKGROUND

There is increasing evidence that invasive fungal disease (IFD) is more likely to occur in non-neutropenic patients in critical care units. A number of randomised controlled trials (RCTs) have evaluated antifungal prophylaxis in non-neutropenic, critically ill patients, demonstrating a reduction in the risk of proven IFD and suggesting a reduction in mortality. It is necessary to establish a method to identify and target antifungal prophylaxis at those patients at highest risk of IFD, who stand to benefit most from any antifungal prophylaxis strategy.

OBJECTIVES

To develop and validate risk models to identify non-neutropenic, critically ill adult patients at high risk of invasive Candida infection, who would benefit from antifungal prophylaxis, and to assess the cost-effectiveness of targeting antifungal prophylaxis to high-risk patients based on these models.

DESIGN

Systematic review, prospective data collection, statistical modelling, economic decision modelling and value of information analysis.

SETTING

Ninety-six UK adult general critical care units.

PARTICIPANTS

Consecutive admissions to participating critical care units.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Invasive fungal disease, defined as a blood culture or sample from a normally sterile site showing yeast/mould cells in a microbiological or histopathological report. For statistical and economic modelling, the primary outcome was invasive Candida infection, defined as IFD-positive for Candida species.

RESULTS

Systematic review: Thirteen articles exploring risk factors, risk models or clinical decision rules for IFD in critically ill adult patients were identified. Risk factors reported to be significantly associated with IFD were included in the final data set for the prospective data collection.

DATA COLLECTION

Data were collected on 60,778 admissions between July 2009 and March 2011. Overall, 383 patients (0.6%) were admitted with or developed IFD. The majority of IFD patients (94%) were positive for Candida species. The most common site of infection was blood (55%). The incidence of IFD identified in unit was 4.7 cases per 1000 admissions, and for unit-acquired IFD was 3.2 cases per 1000 admissions. Statistical modelling: Risk models were developed at admission to the critical care unit, 24 hours and the end of calendar day 3. The risk model at admission had fair discrimination (c-index 0.705). Discrimination improved at 24 hours (c-index 0.823) and this was maintained at the end of calendar day 3 (c-index 0.835). There was a drop in model performance in the validation sample. Economic decision model: Irrespective of risk threshold, incremental quality-adjusted life-years of prophylaxis strategies compared with current practice were positive but small compared with the incremental costs. Incremental net benefits of each prophylaxis strategy compared with current practice were all negative. Cost-effectiveness acceptability curves showed that current practice was the strategy most likely to be cost-effective. Across all parameters in the decision model, results indicated that the value of further research for the whole population of interest might be high relative to the research costs.

CONCLUSIONS

The results of the Fungal Infection Risk Evaluation (FIRE) Study, derived from a highly representative sample of adult general critical care units across the UK, indicated a low incidence of IFD among non-neutropenic, critically ill adult patients. IFD was associated with substantially higher mortality, more intensive organ support and longer length of stay. Risk modelling produced simple risk models that provided acceptable discrimination for identifying patients at 'high risk' of invasive Candida infection. Results of the economic model suggested that the current most cost-effective treatment strategy for prophylactic use of systemic antifungal agents among non-neutropenic, critically ill adult patients admitted to NHS adult general critical care units is a strategy of no risk assessment and no antifungal prophylaxis.

FUNDING

Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research.

A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts

INTRODUCTION

intra-abdominal candidiasis (IAC) may include Candida involvement of peritoneum or intra-abdominal abscess and is burdened by high morbidity and mortality rates in surgical patients. Unfortunately, international guidelines do not specifically address this particular clinical setting due to heterogeneity of definitions and scant direct evidence. In order to cover this unmet clinical need, the Italian Society of Intensive Care and the International Society of Chemotherapy endorsed a project aimed at producing practice recommendations for the management of immune-competent adult patients with IAC.

METHODS

A multidisciplinary expert panel of 22 members (surgeons, infectious disease and intensive care physicians) was convened and assisted by a methodologist between April 2012 and May 2013. Evidence supporting each statement was graded according to the European Society of Clinical Microbiology and Infection Diseases (ESCMID) grading system.

RESULTS

Only a few of the numerous recommendations can be summarized in the Abstract. Direct microscopy examination for yeast detection from purulent and necrotic intra-abdominal specimens during surgery or by percutaneous aspiration is recommended in all patients with nonappendicular abdominal infections including secondary and tertiary peritonitis. Samples obtained from drainage tubes are not valuable except for evaluation of colonization. Prophylactic usage of fluconazole should be adopted in patients with recent abdominal surgery and recurrent gastrointestinal perforation or anastomotic leakage. Empirical antifungal treatment with echinocandins or lipid formulations of amphotericin B should be strongly considered in critically ill patients or those with previous exposure to azoles and suspected intra-abdominal infection with at least one specific risk factor for Candida infection. In patients with nonspecific risk factors, a positive mannan/antimannan or (1→3)-β-D-glucan (BDG) or polymerase chain reaction (PCR) test result should be present to start empirical therapy. Fluconazole can be adopted for the empirical and targeted therapy of non-critically ill patients without previous exposure to azoles unless they are known to be colonized with a Candida strain with reduced susceptibility to azoles. Treatment can be simplified by stepping down to an azole (fluconazole or voriconazole) after at least 5-7 days of treatment with echinocandins or lipid formulations of amphotericin B, if the species is susceptible and the patient has clinically improved.

CONCLUSIONS

Specific recommendations were elaborated on IAC management based on the best direct and indirect evidence and on the expertise of a multinational panel.

Profiling of Candida albicans gene expression during intra-abdominal candidiasis identifies biologic processes involved in pathogenesis

BACKGROUND

The pathogenesis of intra-abdominal candidiasis is poorly understood.

METHODS

Mice were intraperitoneally infected with Candida albicans (1 × 10(6) colony-forming units) and sterile stool. nanoString assays were used to quantitate messenger RNA for 145 C. albicans genes within the peritoneal cavity at 48 hours.

RESULTS

Within 6 hours after infection, mice developed peritonitis, characterized by high yeast burdens, neutrophil influx, and a pH of 7.9 within peritoneal fluid. Organ invasion by hyphae and early abscess formation were evident 6 and 24 hours after infection, respectively; abscesses resolved by day 14. nanoString assays revealed adhesion and responses to alkaline pH, osmolarity, and stress as biologic processes activated in the peritoneal cavity. Disruption of the highly-expressed gene RIM101, which encodes an alkaline-regulated transcription factor, did not impact cellular morphology but reduced both C. albicans burden during early peritonitis and C. albicans persistence within abscesses. RIM101 influenced expression of 49 genes during intra-abdominal candidiasis, including previously unidentified Rim101 targets. Overexpression of the RIM101-dependent gene SAP5, which encodes a secreted protease, restored the ability of a rim101 mutant to persist within abscesses.

CONCLUSIONS

A mouse model of intra-abdominal candidiasis is valuable for studying pathogenesis and C. albicans gene expression. RIM101 contributes to persistence within intra-abdominal abscesses, at least in part through activation of SAP5.

Brazilian guidelines for the management of candidiasis - a joint meeting report of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical

Candida infections account for 80% of all fungal infections in the hospital environment, including bloodstream, urinary tract and surgical site infections. Bloodstream infections are now a major challenge for tertiary hospitals worldwide due to their high prevalence and mortality rates. The incidence of candidemia in tertiary public hospitals in Brazil is approximately 2.5 cases per 1000 hospital admissions. Due to the importance of this infection, the authors provide a review of the diversity of the genus Candida and its clinical relevance, the therapeutic options and discuss the treatment of major infections caused by Candida. Each topography is discussed with regard to epidemiological, clinical and laboratory diagnostic and therapeutic recommendations based on levels of evidence.

Occurrence, presentation and treatment of candidemia

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.

Intraabdominal Infections in the Intensive Care Unit

Intraabdominal infections are frequent and dangerous entity in intensive care units. Mortality and morbidity are high, causes are numerous, and treatment options are variable. The intensivist is challenged to recognize and treat intraabdominal infections in a timely fashion to prevent complications and death. Diagnosis of intraabdominal infection is often complicated by confounding underlying disease or masked by overall comorbidity. Current research describes a wide heterogeneity of patient populations, making it difficult to suggest a general treatment regimen and stressing the need of an individualized approach to decision making. Early focus-oriented intervention and antibiotic coverage tailored to the individual patient and hospital is warranted.

[Candida peritonitis in a haemodynamically stable patient. First choice of antifungal treatment … fluconazole?]

BACKGROUND

Candida peritonitis in postoperative patients is an independent predictor of mortality. Empirical early antifungal therapy should be started in these patients, since according to the results of studies in patients with candidemia, this has an impact on the prognosis. The treatment recommended by clinical practice guidelines in patients with haemodynamic instability are candins, but they do not make explicit recommendations for patients with dysfunction of other organs, or high lactate levels.

CASE REPORT

A case of rescue treatment with anidulafungin in a patient with candidemia and Candida glabrata peritonitis postoperative haemodynamically stable, but with an acute renal failure and elevated plasma lactate, is reported. We discuss the antifungal treatment recommendations established by clinical practice guidelines.

CONCLUSIONS

One conclusion based on this case is that the haemodynamic instability as a marker of severe sepsis must be equated with dysfunction of any organ and/or a plasma lactate level ≥ 2.5 mmol/l in order to advocate candins as an antifungal treatment. In addition, it should be emphasised that anidulafungin was effective in a clinically difficult patient with candidemia and Candida peritonitis, even when used as late rescue antifungal treatment.

Risk factors for invasive fungal disease in critically ill adult patients: a systematic review

Introduction

Over 5,000 cases of invasive Candida species infections occur in the United Kingdom each year, and around 40% of these cases occur in critical care units. Invasive fungal disease (IFD) in critically ill patients is associated with increased morbidity and mortality at a cost to both the individual and the National Health Service. In this paper, we report the results of a systematic review performed to identify and summarise the important risk factors derived from published multivariable analyses, risk prediction models and clinical decision rules for IFD in critically ill adult patients to inform the primary data collection for the Fungal Infection Risk Evaluation Study.

Methods

An internet search was performed to identify articles which investigated risk factors, risk prediction models or clinical decisions rules for IFD in critically ill adult patients. Eligible articles were identified in a staged process and were assessed by two investigators independently. The methodological quality of the reporting of the eligible articles was assessed using a set of questions addressing both general and statistical methodologies.

Results

Thirteen articles met the inclusion criteria, of which eight articles examined risk factors, four developed a risk prediction model or clinical decision rule and one evaluated a clinical decision rule. Studies varied in terms of objectives, risk factors, definitions and outcomes. The following risk factors were found in multiple studies to be significantly associated with IFD: surgery, total parenteral nutrition, fungal colonisation, renal replacement therapy, infection and/or sepsis, mechanical ventilation, diabetes, and Acute Physiology and Chronic Health Evaluation II (APACHE II) or APACHE III score. Several other risk factors were also found to be statistically significant in single studies only. Risk factor selection process and modelling strategy also varied across studies, and sample sizes were inadequate for obtaining reliable estimates.

Conclusions

This review shows a number of risk factors to be significantly associated with the development of IFD in critically ill adults. Methodological limitations were identified in the design and conduct of studies in this area, and caution should be used in their interpretation.

When and how to cover for fungal infections in patients with severe sepsis and septic shock

Candida species remain the most frequently isolated fungi in intensive care unit (ICU) patients with severe sepsis or septic shock. Delayed antifungal therapy in these patients is a recognized risk factor for mortality. However, the diagnosis of invasive candidiasis remains difficult and is frequently delayed. Clinical scores have been proposed to assess the risk of development of invasive candidiasis or candidemia. Laboratory tools for early diagnosis are disappointing or still under development. Triazoles, polyenes, and echinocandins are the key drugs used to treat invasive candidiasis in ICU patients with similar efficacy, but very variable tolerability. The increasing incidence of fluconazole-resistant and susceptible-dose dependent strains and the safety profile of antifungal agents must be taken into account when selecting empiric therapy, frequently leading to the initial use of echinocandins in ICU patients with severe sepsis or septic shock.

Diagnosis of invasive candidiasis in the ICU

Invasive candidiasis ranges from 5 to 10 cases per 1,000 ICU admissions and represents 5% to 10% of all ICU-acquired infections, with an overall mortality comparable to that of severe sepsis/septic shock. A large majority of them are due to Candida albicans, but the proportion of strains with decreased sensitivity or resistance to fluconazole is increasingly reported. A high proportion of ICU patients become colonized, but only 5% to 30% of them develop an invasive infection. Progressive colonization and major abdominal surgery are common risk factors, but invasive candidiasis is difficult to predict and early diagnosis remains a major challenge. Indeed, blood cultures are positive in a minority of cases and often late in the course of infection. New nonculture-based laboratory techniques may contribute to early diagnosis and management of invasive candidiasis. Both serologic (mannan, antimannan, and betaglucan) and molecular (Candida-specific PCR in blood and serum) have been applied as serial screening procedures in high-risk patients. However, although reasonably sensitive and specific, these techniques are largely investigational and their clinical usefulness remains to be established. Identification of patients susceptible to benefit from empirical antifungal treatment remains challenging, but it is mandatory to avoid antifungal overuse in critically ill patients. Growing evidence suggests that monitoring the dynamic of Candida colonization in surgical patients and prediction rules based on combined risk factors may be used to identify ICU patients at high risk of invasive candidiasis susceptible to benefit from prophylaxis or preemptive antifungal treatment.

[Update: invasive fungal infections: Diagnosis and treatment in surgical intensive care medicine]

Fungal infections are of great relevance in surgical intensive care and Candida species represent the predominant part of fungal pathogens. Invasive aspergillosis is also relevant especially in patients with chronic pulmonary diseases. It is crucial for therapy success to begin adequate antifungal treatment at an early stage of the disease. Risk stratification of individual patient symptoms is essential for therapy timing. In case of suspected or proven candida infection, fluconazole is the agent of choice when the patient is clinically stable and no azoles have been administrated in advance and the local epidemiology makes azol resistance unlikely. For clinically instable patients with organ dysfunction the echinocandins serve as primary therapy because of their broad spectrum and reasonable safety profile. Due to a relevant proportion of azole resistant Candida species, susceptibility testing should be done routinely. Depending on the species detected de-escalating to an azole is feasible if organ dysfunctions have resolved. An invasive aspergillosis is primarily treated with voriconazole.

Invasive candidiasis in non-hematological patients

Candida is one of the most frequent pathogens isolated in bloodstream infections, and is associated with significant morbidity and mortality. In addition to haematological patients, there are several other populations with a substantial risk of developing invasive candidiasis (IC). These include patients undergoing prolonged hospitalisation with the use of broad-spectrum antibiotics, those fitted with intravascular catheters, admitted to both adult and neonate intensive care units (ICU) or gastrointestinal surgery wards and subjects with solid tumours undergoing cytotoxic chemotherapy. As a general rule, every immunocompromised patient might be at risk of Candida infection, including, for example, diabetic patients.

The epidemiology of species responsible for IC has been changing, both at local and worldwide level, shifting from C. albicans to non-albicans species, that can be intrinsically resistant to fluconazole (C. krusei and, to some extent, C. glabrata), difficult to eradicate because of biofilm production (C. parapsilosis) or than might acquire resistance to azole during therapy.

Delaying the specific therapy has been shown to increase morbidity and mortality, but traditional microbiological diagnosis is poorly sensitive and slow. Thus, culture-based treatment may result in therapy started too late. In order to reduce the mortality in IC, several management strategies have been developed: prophylaxis, empirical and pre-emptive therapy. Compared to prophylaxis, the latter approaches allow to reduce the use of antifungals by targeting only patients at very high risk of IC. Non-invasive serological markers and scores based on clinical prediction rules such as the presence of risk factors or Candida colonisation, have been developed with the aim of allowing prompt initiation of treatment. Although the use of these diagnostic tools in pre-emptive strategies is promising, the performance and cost-effectiveness should be tested in large trials.

Agents recommended for initial treatment of candidemia in severely ill patients include echinocandins and lipid formulations of amphotericin B, while stable patients without risk factors for azole-resistance might be treated with fluconazole.

Prophylaxis, empirical and preemptive treatment of invasive candidiasis

PURPOSE OF REVIEW

Invasive candidiasis remains an important infection for ICU patients, associated with poor clinical outcomes. It has been increasingly recognized that the traditional paradigm of culture-directed antifungal treatment is unsatisfactory, and that earlier antifungal intervention strategies, such as prophylaxis, preemptive therapy, and empiric therapy, are required to improve patient outcomes. The purpose of this review is to summarize the recent supportive evidence for such strategies and to highlight the current challenges in their implementation.

RECENT FINDINGS

Despite new antifungal agents and classes, the mortality from invasive candidiasis remains high. Antifungal prophylaxis remains the best-studied early antifungal intervention strategy; however, unless targeted to patients at highest risk, is inefficient. Recent data suggests that although risk predictive models, using a combination of clinical risk factors and Candida colonization parameters, may be a relatively simple and practical approach to guide prophylaxis or preemptive therapy, further validation of these models is required. A single trial has demonstrated that empiric antifungal therapy is not of benefit when instituted to patients with antibiotic-refractory fever alone.

SUMMARY

On the basis of current knowledge, it is difficult to universally recommend antifungal prophylaxis, apart from patient groups with a known very high risk, such as those with necrotising pancreatitis or recurrent gastrointestinal perforations. Antifungal prophylaxis may also be reasonable where local incidence rates and epidemiology are compelling. Among stable patients with multifocal Candida colonization and/or a multitude of clinical-risk factors, preemptive therapy is currently not indicated, although the development of better risk predictive models may assist with such patients. Among patients with refractory fever despite broad-spectrum antibacterial therapy, empiric antifungal therapy may be reasonable where local incidence rates are high (e.g. >10%); however, a thorough search for alternate causes must be instituted.

A multicentre study of antifungal strategies and outcome of Candida spp. peritonitis in intensive-care units

Information on the species causing Candida peritonitis, their in vitro susceptibility, antifungal strategies in this setting and patient outcome is still scarce. AmarCand was a prospective, non-interventional study in 271 adult intensive-care unit (ICU) patients with proven invasive Candida infection who received systemic antifungal therapy (France, 2005-2006). Of these ICU patients, 93 (median age 65 years, simplified acute physiology score II 52) had Candida peritonitis, including 73 nosocomial peritonitis, 53 concomitant bacterial peritoneal infections and 26 candidaemias. Candida species were C. albicans (n = 63/108 isolates, 58%), C. glabrata (n = 22, 20%), C. krusei (n = 9), C. kefyr (n = 5), C. parapsilosis (n = 3), C. tropicalis (n = 3), C. ciferii (n = 2) and C. lusitaniae (n = 1). Of tested isolates, 28% were fluconazole-resistant or susceptible dose-dependent (C. albicans 3/32, C. glabrata 9/14, C. krusei 4/4). Empiric antifungal treatment was started 1 day (median) after peritonitis diagnosis, with fluconazole (n = 2 patients), caspofungin (n = 12), voriconazole (n = 3), amphotericin B (n = 2), or a combination (n = 4). Following susceptibility testing, empiric antifungal treatment was judged inadequate in 9/45 (20%) patients and modified in 30 patients (fluconazole was replaced by caspofungin (n = 14) or voriconazole (n = 4)). Mortality in ICU was 38% (35/93) and was not influenced by type of Candida species, fluconazole susceptibility, time to treatment, candidaemia, nosocomial acquisition, or concomitant bacterial infection. No specific factors for death were identified. In summary, a high proportion of fluconazole-resistant or susceptible dose-dependent strains was cultured. These results confirm the high mortality rates of Candida peritonitis and plead for additional investigation in this population. Antifungal treatment for severe cases of Candida peritonitis in ICU patients remains the standard care.

Prophylactic Fluconazole Does Not Improve Outcome in Patients with Purulent and Fecal Peritonitis due to Lower Gastrointestinal Perforation

The benefit of anticandida treatment in addition to standard antibiotic therapy in the presence of perforation/leakage of the lower gastrointestinal tract (LGIT) is still controversial. We retrospectively assessed the clinical effects of empiric anticandida treatment in patients with LGIT perforation who had undergone exploratory laparotomy due to perforated/leaking bowel or appendix between 1999 and 2004, including generalized fecal/purulent peritonitis. Two groups of patients emerged: those receiving empiric anticandida treatment (fluconazole, n = 24) and those who did not (n = 77). All the fluconazole-treated and 40/77 nonfluconazole-treated patients required intensive care unit care and were the subject of this assessment. Postoperative Candida infection and mortality rates were similar in the critically-ill fluconazole-treated and nontreated patients (4% vs 7%, 21% vs 22.5%, respectively, P = NS); resistant candidiasis rates were also similar. Hospital and intensive care unit stays were longer in the treated group, however not reaching statistical difference (26.5 ± 18 vs 21.4 ± 18.3 days, 14.8 ± 14.2 vs 9.3 ± 14.1 days, respectively). The rates of morbidity, pneumonia, and multiorgan failure were significantly higher ( P < 0.05) in the treated patients (87% vs 63%, 37% vs 7.5%, and 58% vs 35%, respectively). Empiric fluconazole in patients with peritonitis associated with LGIT perforation did not improve patients’ outcome compared with those without empiric treatment.

Clinical aspects of invasive candidiasis in critically ill patients

Invasive candidiasis has emerged as an important cause of morbidity and mortality in intensive care unit patients. This short review focuses on many aspects of Candida infection in critically ill patients including epidemiology, impact on mortality, problems related to diagnosis, strategies to identify patients at risk of developing fungal infections, role of prophylaxis and pre-emptive strategies, empiric treatment and the role of different classes of antifungal drugs. New antifungal agents, specifically new azoles and echinocandins are discussed.

Candida isolation in patients hospitalized on a surgical ward: significance and mortality-related factors

BACKGROUND

Infections caused by Candida are an emerging pathology on surgical wards. The aim of the present study was to evaluate the incidence, characteristics, and predictive factors of mortality in patients colonized and/or infected by Candida spp. in this setting.

METHODS

A consecutive series of 105 patients hospitalized on a general surgery ward between 2000 and 2004 were included, and 118 positive cultures for Candida were identified. The variables age, sex, previous medical history, current disease, anemia, ICU stay, type and localization of the microorganism, need for parenteral nutrition, and transfusions were recorded. The primary outcome was in-hospital mortality. A univariate analysis was performed to determine which of these variables were associated with mortality. With a logistic regression model, independent prognostic factors of mortality were determined.

RESULTS

The prevalence of patients colonized and/or infected by Candida on our surgical ward was 0.98% (CI 95%: 0.79-1.17), and the incidence was 49 cases per 1,000 patient-years. Of the 105 patients in this series, 56 were men (53%) and 49 women (47%); the mean age was 63.8 years (SD +/- 15.7). Twelve patients (11.4%) had candidemia. Crude mortality was 23% (24 patients), whereas the mortality attributable to candidemia was 25% (3/12 cases). Anemia (p = 0.001); transfusions (p = 0.003), and an ICU stay (p = 0.002) were associated with mortality. Candidemia was associated with neoplasms (p = 0.02) and the infection caused by Candida parapsilosis (p = 0.04). The only independent factor related to mortality was the anemia (p = 0.028; Odds Ratio: 6.43; 95% CI: 1.23-33.73).

CONCLUSIONS

Colonization and/or infection by Candida spp. in non-ICU hospitalized surgical patients implies a relative high mortality. Anemia is an independent factor for mortality.

Evolving role of early antifungals in the adult intensive care unit

BACKGROUND

Invasive candidiasis (IC) is associated with significant morbidity and mortality in critically ill patients. This, in conjunction with difficulties in diagnosis, underscores the need for novel treatment strategies based on the identification of significant risk factors for IC.

OBJECTIVE

To review the evidence surrounding the use of early antifungals in critically ill adult patients and to present concise and specific recommendations for different early treatment strategies for IC.

DATA SOURCES AND DATA EXTRACTION

Pubmed search from 1966 to July 2008 using the search terms "antifungals, critical care, prophylaxis, preemptive therapy, and empiric therapy." Examined all relevant peer-reviewed original articles, meta-analyses, guidelines, consensus statements, and review articles.

CONCLUSION

The use of early antifungal therapy should be reserved for patients with a high risk (10% to 15%) of developing IC. Despite a large number of articles published on this topic, there is no single predictive rule that can adequately forecast IC in critically ill patients. Until further prospective validation of existing data is completed, clinicians should assess patients on a case-by-case basis and determine the need for early antifungal treatment strategies based on frequent evaluations of risk factors and clinical status.

[Is the use of antifungal management advisable in critical patients with positive isolation of Candida spp. from intraabdominal clinical samples?]

The diagnostic and therapeutic approaches to IFI have changed significantly in recent years, fostered by the introduction of new diagnostic methods and new antifungal products. The diagnosis of invasive candidiasis (IC) involves both clinical and laboratory parameters, but neither of these are specific and the majority of the yeast isolated showed only colonization but not true infection. This situation occurs in critical care setting especially when surgical drainages are used. A substantial number of patients become colonized with Candida spp. after abdominal surgery, but only a minority subsequently develops invasive candidiasis. The clinical and microbiological diagnosis of Candida peritonitis remains problematic. It is still unclear which patients with may benefit from antifungal treatment. Antifungal therapy can be suggested in critically ill patients with peritonitis where Candida is diagnosed based on perioperatively sampled peritoneal fluid. Since fungal infection is also a relatively common complication of severe pancreatitis it seems reasonable that fungal prophylaxis may be an important component of management although actually there is no evidence to support this approach. However, the high mortality associated with IC is partly correlated to the difficulties of making an early diagnosis, thus, to improve earlier diagnosis and survival of IC, new nonculture-based microbiological tools such as Candida albicans germ tube antibodies (CAGTA) and/or polymerase chain reaction (PCR) techniques for the detection of fungal-specific DNA should be used in conjunction with recent published "Candida score" prediction rule. An algorithm based on this approach has been provided to assess early treatment in surgical patients with yeasts isolated from intra-abdominal samples.

Caspofungin for prevention of intra-abdominal candidiasis in high-risk surgical patients

PURPOSE

Thirty to forty percent of patients with recurrent gastrointestinal perforation/anastomotic leakage or acute necrotizing pancreatitis develop intra-abdominal invasive candidiasis (IC). A corrected Candida colonization index (CCI) > or =0.4 is a powerful predictor of IC. Fluconazole prevents intra-abdominal IC in this setting, but azole-resistant Candida species are emerging. The aim of this study was to explore the efficacy and safety of caspofungin for prevention of intra-abdominal IC in high-risk surgical patients.

METHODS

Prospective non-comparative single-center study in consecutive adult surgical patients with recurrent gastrointestinal perforation/anastomotic leakage or acute necrotizing pancreatitis. Preventive caspofungin therapy (70 mg, then 50 mg/day) was given until resolution of the surgical condition. Candida colonization index and CCI, occurrence of intra-abdominal IC and adverse events were monitored.

RESULTS

Nineteen patients were studied: 16 (84%) had recurrent gastrointestinal perforation/anastomotic leakage and 3 (16%) acute necrotizing pancreatitis. The median duration of preventive caspofungin therapy was 16 days (range 4-46). The colonization index decreased significantly during study therapy, and the CCI remained <0.4 in all patients. Caspofungin was successful for prevention of intra-abdominal IC in 18/19 patients (95%, 1 breakthrough IC 5 days after inclusion). No drug-related adverse event requiring caspofungin discontinuation occurred.

CONCLUSION

Caspofungin may be efficacious and safe for prevention of intra-abdominal candidiasis in high-risk surgical patients. This needs to be further investigated in randomized trials.

Detection of (1-->3)-beta-D-glucan as an adjunct to diagnosis in a mixed population with uncommon proven invasive fungal diseases or with an unusual clinical presentation

This single-center observational prospective study evaluated the performance of (1-->3)-beta-D-glucan as an adjunct diagnostic tool in 12 patients with proven invasive fungal disease with different risk factors. The infections were due to either uncommon fungal pathogens such as dematiaceous molds (Scedosporium apiospermum, Alternaria infectoria, and Cladosporium macrocarpum) and hyaline septate molds (Fusarium solani and Blastoschizomyces capitatus) or Aspergillus spp. with unusual clinical presentations.