Outcomes associated with routine systemic antifungal therapy in critically ill patients with Candida colonization

Abstract

Preemptive strategy of antifungal drug prescriptions in highly colonized ICU patients induced an increase in C. glabrata colonization without significant shift of colonization to other Candida spp. in surgical ICU patients. However, the potential detrimental impact of fluconazole on Candida ecology in ICU and/or on Candida susceptibility to antifungal drugs should be considered, and deserves further studies.

Are prophylactic antifungals in highly colonized patients safe and effective?

“…Several studies have reported the benefit of antifungal prophylactic therapy in colonized ICU patients to reduce IFI incidence, while many others failed to demonstrate any benefit in the same population [8][9][10][11]. The current study by Ferreira et al [12] casts more significant doubts whether the extensive use of prophylactic antifungals in highly colonized patients can be considered safe and effective as a routine measure. In their retrospective observational study, the authors demonstrated that Candida colonization-based pre-emptive antifungal prescription of fluconazole and caspofungin generated a significant change in acquired colonization, especially with C. glabrata and C. parapsilosis, without any impact on incidence of candidemia and on Candida-related mortality.…”

“…The use of colonization index to start a pre-emptive strategy is clearly inappropriate as a colonization index greater than 0.5 occurred in 26 % of the patients and led to an overuse of antifungal without avoiding candidemia [12].…”

Focus on infection and sepsis in intensive care patients

“…In a recent study, Ferreira et al [18] found that a pre-emptive strategy of antifungal increased C. glabrata colonization without a significant shift of colonization to other Candida spp. The results of two recent studies may help clinicians to better understand candida isolates in respiratory samples.…”

Biomarker-guided antifungal therapy in patients with suspected invasive candidiasis: Ready for prime time?

“…However, despite efforts aiming at improving AFT management, we should admit that we still fail to target the right patients. Actually, although recommended by recent guidelines, the broadly applied risk factors based approach (i.e., disease severity, previous use of antibiotics, total parenteral nutrition, recent digestive surgery and Candida colonization) leads to AFT administration to patients in whom IFI remains unproven in up to 80% of the cases [5][6][7]. In addition, such a liberal strategy was shown to be ineffective regarding patients' outcome: a recent double blinded randomized controlled trial (RCT) showed that empirical treatment of critically ill patients with ICU-acquired sepsis, Candida colonization and multiple organ failure with micafungin, compared with placebo, did not increase fungal infection-free survival at day 28 [8].…”

“…Thus, Ferreira et al showed that a policy of Candida colonization-based AFT prescriptions generated a significant change in acquired colonization patterns, especially with C. glabrata and C. parapsilosis, without any impact on candidemia incidence and on Candida-related mortality [5]. Vallabhaneni et al showed that prior echinocandin exposure is the main risk factor for C. glabrata echinocandin nonsusceptibility and presence of FKS mutations [9].…”