Candida is the most common cause of invasive fungal infections (IFI) and is associated with significant mortality, especially with delays in initiating appropriate therapy for candidemia.1-4 Clinical prediction rules have been developed to identify patients in the intensive care unit (ICU) at high risk of candidiasis, but are limited by their low sensitivity.1
Prophylactic, pre-emptive and empirical systemic antifungal therapy (SAT) have been used in an attempt to reduce candida-related mortality, but the criteria for SAT use in critically ill patients remains poorly defined.1
The French Society for Critical Care (SRLF) in collaboration with the French Society for Infectious Diseases (SPILF) and the French Society for Anesthesia and Intensive Care (SFAR) conducted a 1-day cross-sectional cohort study of 169 ICUs in France and Belgium to determine the prevalence, indications, administration, and potential benefits of systemic antifungal therapy in critically ill patients.5 On December 8, 2008, 2047 patients were hospitalized in these ICUs and 154 (7.5%) received systemic antifungal therapy (SAT). A total of 54 (35%) patients had documented IFI while the other 100 with unproven IFI received SAT for either multiple Candida colonization, pre-emptively in unstable patients with undocumented sepsis, or for prophylaxis. Compared to patients who did not receive SAT, patients with SAT were significantly more likely to have severe illness requiring life-saving therapies, be immunocompromised, undergone emergency surgery, colonized with candida, and have Candida score >2. A survey on prescribing habits revealed 126 (74.5%) physicians routinely prescribed SAT in patients with nonresolving sepsis who tested negative for bacteria.
Candida colonization was assessed routinely in 152 (89.9%) ICUs, although 35% did not make decisions based on the colonization index and 64% did not base decisions on the Candida score. The Candida species recovered were 48% C.albicans, 7% C.glabrata, 5% C.tropicalis, 3% C.parapsilosis, 1% C.krusei, and 20% were other or undetermined.
On the study day, the duration of SAT use had been 11.7 days (range 5-16 days). In the 38 patients with proven Candida IFI, fluconazole (71%) and echinocandins (27%) were the SATs most frequently used, while in the 16 patients with proven non-Candida IFI, voriconazole (56%) and echinocandins (31%) were the most common. In the 100 patients without definite IFI, 66% received fluconazole, 23% echinocandins, 8% liposomal amphotericin B and 3% received voriconazole.
Although patients receiving SAT had significantly greater severity of acute illness and were more likely to be still in the ICU or hospital at day 28, there was no significant difference in mortality on day 28 between those who did and did not receive SAT. Since it would be expected that mortality would be higher in patients with more severe illness, this suggests the current pattern of SAT prescribing may be effective at reducing IFI-associated mortality, but costs, adverse events, and emergence of resistant strains were not investigated. The optimal prescribing of SAT in severely ill patients without documented IFI but risk factors for IFI remains undefined and the impact ...