Objective
The global burden of invasive fungal disease is increasing. Candida albicans remains the leading cause of fungal bloodstream infections, although non-albicans candidal infections are emerging. Areas of controversy regarding diagnosis and management are hampering our ability to respond effectively to this evolving threat. The purpose of this narrative review is to address current controversies and provide recommendations to supplement guidelines.
Diagnosis of invasive candidiasis
- Invasive candidiasis in a patient in the ICU setting usually leads to an increased white blood cell (WBC) count and increased neutrophils.
- Diagnosis of invasive candidiasis requires a combination of diagnostic tests and patient risk factors.
- Beta-D glucan and Candida albicans germ tube antibody are used as biomarkers and as adjuncts to diagnosis, although direct culture remains the gold standard.
- Scoring systems are available to help distinguish between colonization and invasive disease.
Treatment of invasive candidiasis
The specific type and dose of antifungal medication used to treat invasive candidiasis usually depends on the patient’s age, immune status, and location and severity of the infection. For most adults, the initial recommended antifungal treatment is an echinocandin (caspofungin, micafungin, or anidulafungin) given through the vein (intravenous or IV) with de-escalation to fluconazole when clinical stability is achieved. Empirical therapy is highly recommended in high-risk patients, but a more targeted pre-emptive approach is now being favoured. The evidence for prophylactic therapy remains weak.
Summary
Many critically ill patients are heavily colonised with Candida species, especially when receiving broad-spectrum antibacterials. In the ICU, the treatment of IC remains a challenge. Mortality attributable to invasive candidiasis may be as high as 70%. Prompt diagnosis and treatment are the key to improving outcomes. The less toxic therapeutic options have opened doors towards prevention and optimizing therapy in invasive candidiasis.
Source:
O’Leary RA, Einav S, Leone M, Madách K, Martin C, Martin-Loeches I. Management of invasive candidiasis and candidaemia in critically ill adults: expert opinion of the European Society of Anaesthesia Intensive Care Scientific Subcommittee. J Hosp Infect. 2018 Apr;98(4):382-390. doi: 10.1016/j.jhin.2017.11.020. Epub 2017 Dec 6. PMID: 29222034.
