Invasive Fungal Infections in the Critically Ill Patient

Invasive fungal infections have become an increasingly prevalent and disturbing problem in critically ill patients. The advent of broad-spectrum antibacterial therapy and immunosuppressant therapy, among other factors such as mechanical ventilation, places the intensive care patient at significant risk for infection with pathogenic fungi. Most patients who become infected with invasive fungi, especially Candida species, have been previously colonized with the offending organism, lending to the notion that colonization precedes infection inmany cases. Despite an ever-increasing array of antifungal therapy for these infections, mortality rates remain extremely high, especially when the bloodstream is the primary site of infection. In addition, a shift toward more resistant pathogens such asCandida glabrata, Candida krusei, and moldswill provide clinicianswith therapeutic challenges for many years. The wide variation in acquisition cost across antifungal agents adds an additional layer of complexity to clinical decision making. Newer antifungal agents, each with its own advantages and disadvantages, have become available in recent years. Placing each agent in its appropriate niche is a dilemma that has yet to be solved.

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Thromboelastography in clinical decision-making in the critically ill patient in a district general hospital ICU

Critical Care ◽

10.1186/cc6433 ◽

2008 ◽

Vol 12 (Suppl 2) ◽

pp. P212

Author(s):

J Louw ◽

T Veenith ◽

P Moondi

Keyword(s):

Decision Making ◽

General Hospital ◽

Critically Ill ◽

Clinical Decision Making ◽

District General Hospital ◽

Clinical Decision ◽

Critically Ill Patient

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Opinions of doctors working in South African critical care units regarding unconsented testing and empirical treatment of HIV-positive patients in ICU

Southern African Journal of Anaesthesia and Analgesia ◽

10.36303/sajaa.2020.26.1.2291 ◽

2020 ◽

pp. 38-44

Author(s):

AK Asghar ◽

AM Carpenter ◽

JN Mudali ◽

M Reade ◽

RD Wise

Keyword(s):

Critical Care ◽

Critically Ill ◽

Clinical Decision Making ◽

Severity Of Illness ◽

Clinical Decision ◽

Critically Ill Patient ◽

Routine Practice ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Practice Methods

Background: There exist a limited number of studies demonstrating the benefit of initiating anti-retroviral agents (ARVs) for the treatment of human immunodeficiency virus (HIV) in the critical care setting. However, there are physiological, practical, and ethical arguments against making HIV testing and initiation of ARVs routine practice. Methods: A self-administered, cross-sectional survey of healthcare professionals was conducted with data collected using a questionnaire distributed to delegates of the Critical Care Society of South Africa (CCSSA) 2016 Congress, and members of the society. Results: There were 101 respondents. Eight per cent would not consider testing a critically ill patient for HIV (status previously unknown), largely because they considered this unethical. Sixty-nine per cent would consider commencing ARVs in a patient newly-diagnosed with HIV during an inter-current critical illness. The factor most likely to guide them towards this was severity of illness. In general, the greatest concerns focused around biological/medical issues. However, those clinicians who would not consider initiation of ARVs were more likely than those who would, to be concerned about psychosocial issues. Conclusion: Although the majority of clinicians would consider initiation of ARVs acutely in critically ill patients, it is apparent that the clinical decision-making around this matter is complex. Advocacy is needed to further clarify relevant ethical and legal dilemmas, and in the interim consultative and collaborative care is encouraged.A

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Recent developments in the management of invasive fungal infections in patients with oncohematological diseases

Therapeutic Advances in Hematology ◽

10.1177/2040620716656381 ◽

2016 ◽

Vol 7 (6) ◽

pp. 345-359 ◽

Cited By ~ 17

Author(s):

Markus Ruhnke ◽

Stefan Schwartz

Keyword(s):

Antifungal Therapy ◽

Clinical Decision Making ◽

Fungal Infections ◽

Diagnostic Procedures ◽

Clinical Decision ◽

Invasive Fungal Infections ◽

Clinical Diagnostics ◽

Diagnostic Tools ◽

Definite Diagnosis ◽

Molecular Tests

Patients with hematological cancer have a high risk of invasive fungal diseases (IFDs). These infections are mostly life threatening and an early diagnosis and initiation of appropriate antifungal therapy are essential for the clinical outcome. Most commonly, Aspergillus and Candida species are involved. However, other non- Aspergillus molds are increasingly be identified in cases of documented IFDs. Important risk factors are long lasting granulocytopenia with neutrophil counts below 500/μl for more than 10 days or graft- versus-host disease resulting from allogeneic stem-cell transplantation. For definite diagnosis of IFD, various diagnostic tools have to be applied, including conventional mycological culture and nonconventional microbiological tests such as antibody/antigen and molecular tests, as well as histopathology and radiology. In the last few years, various laboratory methods, like the Aspergillus GM immunoassay ( Aspergillus GM EIA), 1,3-ß-D-glucan (BG) assay or polymerase chain reaction (PCR) techniques have been developed for better diagnosis. Since no single indirect test, including radiological methods, provides the definite diagnosis of an invasive fungal infection, the combination of different diagnostic procedures, which include microbiological cultures, histological, serological and molecular methods like PCR together with the pattern of clinical presentation, may currently be the best strategy for the prompt diagnosis, initiation and monitoring of IFDs. Early start of antifungal therapy is mandatory, but clinical diagnostics often do not provide clear evidence of IFD. Integrated care pathways have been proposed for management and therapy of IFDs with either the diagnostic driven strategy using the preemptive antifungal therapy as opposed to the clinical or empirical driven strategy using the ‘traditional’ empirical antifungal therapy. Antifungal agents preferentially used for systemic therapy of invasive fungal infections are amphotericin B preparations, fluconazole, voriconazole, posaconazole, caspofungin, anidulafungin, micafungin, and most recently isavuconazole. Clinical decision making must consider licensing status, local experience and availability, pharmacological and economic aspects.

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Invasive Candida Infections in the ICU: Diagnosis and Therapy

The Journal of Critical Care Medicine ◽

10.1515/jccm-2015-0025 ◽

2015 ◽

Vol 1 (4) ◽

pp. 129-139 ◽

Cited By ~ 4

Author(s):

Péter Hankovszky ◽

Domokos Társy ◽

Nándor Öveges ◽

Zsolt Molnár

Keyword(s):

Critically Ill ◽

Candida Species ◽

Antifungal Agents ◽

Fungal Infections ◽

Invasive Fungal Infections ◽

Adequate Treatment ◽

Invasive Infections ◽

Life Threatening ◽

Candida Infections ◽

Current Guidelines

AbstractInvasive fungal infections have become a serious problem in the critically ill. One of the main reasons is the development of an immunocompromised condition. The most frequently found pathogens are Candida species. In order to provide adequate treatment, understanding this potentially life-threatening infection is mandatory. The aim of this summary is to view Candida infections from a different perspective and to give an overview on epidemiology, the range of pathophysiology from colonization to the invasive infections, and its impact on mortality. New therapeutic options will also be discussed and how these relate to current guidelines. Finally, the key issue of the choice of antifungal agents will be evaluated.

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(1, 3)-β-D-glucan assay for diagnosing invasive fungal infections in critically ill patients with hematological malignancies

Oncotarget ◽

10.18632/oncotarget.7471 ◽

2016 ◽

Vol 7 (16) ◽

pp. 21484-21495 ◽

Cited By ~ 30

Author(s):

Elie Azoulay ◽

Nicolas Guigue ◽

Michael Darmon ◽

Djamel Mokart ◽

Virginie Lemiale ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Hematological Malignancies ◽

Fungal Infections ◽

Invasive Fungal Infections

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Systemic Antifungal Agents

10.2310/anes.2365 ◽

2018 ◽

Author(s):

Brett A Melnikoff ◽

René P Myers

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Antifungal Agents ◽

Fungal Infections ◽

Antifungal Prophylaxis ◽

Morbidity And Mortality ◽

Transplant Recipients ◽

Therapeutic Approaches ◽

Timely Fashion ◽

Antifungal Chemotherapy

Fungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant recipients, and sick neonates all especially vulnerable. Fungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant recipients, and sick neonates all especially vulnerable. Despite the development of a number of new and useful antifungal agents in the past decade and the noteworthy improvements in therapeutic approaches to fungal infections, physicians’ ability to diagnose these infections in a timely fashion remains limited, and patient outcomes remain poor. Antifungal prophylaxis has emerged as a potential means of reducing the occurrence of serious fungal infections. In patient populations estimated to be at high risk for acquiring a fungal infection, antifungal prophylaxis has reduced infection rates by about 50%; however, it has not been shown to significantly improve mortality. This review discusses both established and newly approved systemic antifungal agents. Tables list characteristics of currently available antifungals and antifungal chemotherapy. This review contains 2 tables and 32 references Key words: antifungal chemotherapy, antifungal prophylaxis, antifungals, Candida prophylaxis, systemic antifungal medications

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Multimodality Imaging in the Diagnostic Work-Up of Endocarditis and Cardiac Implantable Electronic Device (CIED) Infection

Journal of Clinical Medicine ◽

10.3390/jcm9072237 ◽

2020 ◽

Vol 9 (7) ◽

pp. 2237

Author(s):

Nicola Galea ◽

Francesco Bandera ◽

Chiara Lauri ◽

Camillo Autore ◽

Andrea Laghi ◽

...

Keyword(s):

Clinical Decision Making ◽

Electronic Device ◽

Multimodality Imaging ◽

Nuclear Imaging ◽

Clinical Decision ◽

Cardiac Device ◽

Systemic Complications ◽

Advantages And Disadvantages ◽

Clinical Scenarios ◽

Wide Range

Infective endocarditis (IE) is a serious cardiac condition, which includes a wide range of clinical presentations, with varying degrees of severity. The diagnosis is multifactorial and a proper characterization of disease requires the identification of the primary site of infection (usually the cardiac valve) and the search of secondary systemic complications. Early depiction of local complications or distant embolization has a great impact on patient management and prognosis, as it may induce to aggressive antibiotic treatment or, in more advanced cases, cardiac surgery. In this setting, the multimodality imaging has assumed a pivotal role in the clinical decision making and it requires the physician to be aware of the advantages and disadvantages of each imaging technique. Echocardiography is the first imaging test, but it has several limitations. Therefore, the integration with other imaging modalities (computed tomography, magnetic resonance imaging, nuclear imaging) becomes often necessary. Different strategies should be applied depending on whether the infection is suspected or already ascertained, whether located in native or prosthetic valves, in the left or right chambers, or if it involves an implanted cardiac device. In addition, detection of extracardiac IE-related lesions is crucial for a correct management and treatment. The aim of this review is to illustrate strengths and weaknesses of the various methods in the most common clinical scenarios.

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