Intensive Care Medicine

, Volume 31, Issue 11, pp 1514–1521

Invasive candidiasis: comparison of management choices by infectious disease and critical care specialists

  • Philippe Eggimann
  • Thierry Calandra
  • Ursula Fluckiger
  • Jacques Bille
  • Jorge Garbino
  • Michel-Pierre Glauser
  • Oscar Marchetti
  • Christian Ruef
  • Martin Täuber
  • Didier Pittet
  • for the Fungal Infection Network of Switzerland (FUNGINOS)



To compare the management of invasive candidiasis between infectious disease and critical care specialists.

Design and setting

Clinical case scenarios of invasive candidiasis were presented during interactive sessions at national specialty meetings. Participants responded to questions using an anonymous electronic voting system.

Patients and participants

Sixty-five infectious disease and 51 critical care physicians in Switzerland.


Critical care specialists were more likely to ask advice from a colleague with expertise in the field of fungal infections to treat Candida glabrata (19.5% vs. 3.5%) and C. krusei (36.4% vs. 3.3%) candidemia. Most participants reported that they would change or remove a central venous catheter in the presence of candidemia, but 77.1% of critical care specialists would start concomitant antifungal treatment, compared to only 50% of infectious disease specialists. Similarly, more critical care specialists would start antifungal prophylaxis when Candida spp. are isolated from the peritonal fluid at time of surgery for peritonitis resulting from bowel perforation (22.2% vs. 7.2%). The two groups equally considered Candida spp. as pathogens in tertiary peritonitis, but critical care specialists would more frequently use amphotericin B than fluconazole, caspofungin, or voriconazole. In mechanically ventilated patients the isolation of 104 Candida spp. from a bronchoalveolar lavage was considered a colonizing organism by 94.9% of infectious disease, compared to 46.8% of critical care specialists, with a marked difference in the use of antifungal agents (5.1% vs. 51%).


These data highlight differences between management approaches for candidiasis in two groups of specialists, particularly in the reported use of antifungals.


Antifungal treatment Critical care specialists Infectious disease Invasive candidiasis Switzerland Treatment survey 


  1. 1.
    Wey SB, Mori M, Pfaller MA, Woolson RF, Wenzel RP (1989) Risk factors for hospital-acquired candidemia. A matched case-control study. Arch Intern Med 149:2349–2353CrossRefPubMedGoogle Scholar
  2. 2.
    Voss A, le Noble JL, Verduyn LF, Foudraine NA, Meis JF (1997) Candidemia in intensive care unit patients: risk factors for mortality. Infection 25:8–11PubMedGoogle Scholar
  3. 3.
    Nolla-Salas J, Sitges-Serra A, Leon-Gil C, Martinez-Gonzalez J, Leon-Regidor MA, Ibanez-Lucia P, Torres-Rodriguez JM (1997) Candidemia in non-neutropenic critically ill patients: analysis of prognostic factors and assessment of systemic antifungal therapy. Study Group of Fungal Infection in the ICU. Intensive Care Med 23:23–30CrossRefPubMedGoogle Scholar
  4. 4.
    Blot SI, Vandewoude KH, Hoste EA, Colardyn FA (2002) Effects of nosocomial candidemia on outcomes of critically ill patients. Am J Med 113:480–485CrossRefPubMedGoogle Scholar
  5. 5.
    Gudlaugsson O, Gillespie S, Lee K, Vande Berg J, Hu, J, Messer S, Herwaldt L, Pfaller M, Diekema D (2003) Attributable mortality of nosocomial candidemia revisited. Clin Infect Dis 37:1172–1177CrossRefPubMedGoogle Scholar
  6. 6.
    Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, Wolff M, Spencer RC, Hemmer M (1995) The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) study. JAMA 274:639–644CrossRefPubMedGoogle Scholar
  7. 7.
    Richards MJ, Edwards JR, Culver DH, Gaynes RP (2000) Nosocomial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol 2:510–515Google Scholar
  8. 8.
    National Nosocomial Infections Surveillance (NNIS) system report (2003) Data summary from January 1992-June 2003. Am J Infect Control 31:481–498CrossRefPubMedGoogle Scholar
  9. 9.
    Voss A, Kluytmans JA, Koeleman JGM et al. (1996) Occurrence of yeast bloodstream infections between 1987 and 1995 in five Dutch university hospitals. Eur J Clin Microbiol Infect Dis 15:909–912CrossRefPubMedGoogle Scholar
  10. 10.
    Fluit AC, Jones ME, Schmitz FJ (2000) Antimicrobial susceptibility and frequency of occurrence of clinical blood isolates in Europe from the SENTRY Antimicrobial Surveillance Program, 1997 and 1998. Clin Infect Dis 30:454–460CrossRefPubMedGoogle Scholar
  11. 11.
    Swanden P, Bevanger L, Digranes A, Gaustad P, Haukland HH, Steinbakk M (1998) Constant low rate of fungemia in Norway, 1991 to 1996. Clin Infect Dis 36:455–459Google Scholar
  12. 12.
    Marchetti O, Bille J, Fluckiger U, Eggimann P, Ruef C, Garbino J, Calandra T, Glauser MP, Tauber MG, Pittet D; Fungal Infection Network of Switzerland (2004) Epidemiology of candidemia in Swiss tertiary care hospitals: secular trends 1991–2000. Clin Infect Dis 38:311–320CrossRefPubMedGoogle Scholar
  13. 13.
    Solomkin JS, Flohr AB, Simmons RL (1982) Indications for therapy for fungemia in postoperative patients. Arch Surg 117:1272–1275PubMedGoogle Scholar
  14. 14.
    Rex JH, Sobel JD (2001) Prophylactic antifungal therapy in the intensive care unit. Clin Infect Dis 32:1191–1200CrossRefPubMedGoogle Scholar
  15. 15.
    Eggimann P, Garbino J, Pittet D (2003) Management of Candida species infections in critically ill patients. Lancet Infect Dis 3:772–785CrossRefPubMedGoogle Scholar
  16. 16.
    Hughes WT, Armstrong D, Bodey GP, Bow EJ, Brown AE, Calandra T, Feld R, Pizzo PA, Rolston KV, Shenep JL, Young LS (2002) 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 34:730–751CrossRefPubMedGoogle Scholar
  17. 17.
    Gauzit R, Cohen Y, Dupont H, Hennequin C, Montravers P, Timsit JF, Veber B, Chevalier E, Blin P, Palestro B (2003) [Infections by Candida sp. in intensive care. Survey of French practices] (in French). Presse Med 32:440–449PubMedGoogle Scholar
  18. 18.
    Pittet D, Monod M, Filthuth I, Frenk E, Suter PM, Auckenthaler R (1991) Contour-clamped homogeneous electric field gel electrophoresis as a powerful epidemiologic tool in yeast infections. Am J Med 91:256S-263SCrossRefPubMedGoogle Scholar
  19. 19.
    Reagan DR, Pfaller MA, Hollis RJ, Wenzel RP (1990) Characterization of the sequence of colonization and nosocomial candidemia using DNA fingerprinting and a DNA probe. J Clin Microbiol 28:2733–2738PubMedGoogle Scholar
  20. 20.
    Luzzati R, Amalfitano G, Lazzarini L, Soldani F, Bellino S, Solbiati M, Danzi MC, Vento S, Todeschini G, Vivenza C, Concia E (2000) Nosocomial candidemia in non-neutropenic patients at an Italian tertiary care center. Eur J Clin Microbiol Infect Dis 19:602–607CrossRefPubMedGoogle Scholar
  21. 21.
    Pittet D, Monod M, Suter PM, Frenk E, Auckenthaler R (1994) Candida colonization and subsequent infections in critically ill surgical patients. Ann Surg 220:751–758PubMedGoogle Scholar
  22. 22.
    Garbino J, Lew PD, Romand JA, Hugonnet S, Auckenthaler R, Pittet D (2002) Prevention of severe Candida infections in non-neutropenic, high-risk, critically ill patients. A randomized, double-blind, placebo-controlled trial in SDD-treated patients. Intensive Care Med 28:1708–1717CrossRefPubMedGoogle Scholar
  23. 23.
    Eggimann P, Francioli P, Bille J, Schneider R, Wu MM, Chapuis G, Chiolero R, Pannatier A, Schilling J, Geroulanos S, Glauser MP, Calandra T (1999) Fluconazole prophylaxis prevents intra-abdominal candidiasis in high-risk surgical patients. Crit Care Med 27:1066–1072CrossRefPubMedGoogle Scholar
  24. 24.
    Ascioglu S, Rex JH, De Pauw B, Bennett JE, Bille J, Crokaert F, Denning DW, Donnelly JP, Edwards JE, Erjavec Z, Fiere D, Lortholary O, Maertens J, Meis JF, Patterson TF, Ritter J, Selleslag D, Shah PM, Stenvens DA, Walsh TJ; Invasive Fungal Infections Cooperative Group of the European Organization for Research, Treatment of Cancer; Mycoses Study Group of the National Institute of Allergy, Infectious Diseases (2002) Defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell transplants: an international consensus. Clin Infect Dis 34:7–14CrossRefPubMedGoogle Scholar
  25. 25.
    Edwards JE Jr, Bodey GP, Bowden RA, Buchner T, de Pauw BE, Filler SG, Ghannoum MA, Glauser M, Herbrecht R, Kauffman CA, Kohno S, Martino P, Meunier F, Mori T, Pfaller MA, Rex JH, Rogers TR, Rubin RH, Solomkin J, Viscoli C, Walsh TJ, White M (1997) International conference for the development of a consensus on the management and prevention of severe candidal infections. Clin Infect Dis 25:43–59PubMedGoogle Scholar
  26. 26.
    Vincent JL, Anaissie E, Bruining H, Demajo W, el-Ebiary M, Haber J, Hiramatsu Y, Nitenberg G, Nystrom PO, Pittet D, Rogers T, Sandven P, Sganga G, Schaller MD, Solomkin J (1998) Epidemiology, diagnosis and treatment of systemic Candida infection in surgical patients under intensive care. Intensive Care Med 24:206–216CrossRefPubMedGoogle Scholar
  27. 27.
    Rex JH, Walsh TJ, Sobel JD, Filler SG, Pappas PG, Dismukes WE, Edwards JE (2000) Practice guidelines for the treatment of candidiasis. Infectious Diseases Society of America. Clin Infect Dis 30:662–678CrossRefPubMedGoogle Scholar
  28. 28.
    Buchner T, Fegeler W, Bernhardt H, Brockmeyer N, Duswald KH, Herrmann M, Heuser D, Jehn U, Just-Nubling G, Karthaus M, Maschmeyer G, Muller FM, Muller J, Ritter J, Roos N, Ruhnke M, Schmalreck A, Schwarze R, Schwesinger G, Silling G; Panel of Interdisciplinary Investigators (2002) Treatment of severe Candida infections in high-risk patients in Germany: consensus formed by a panel of interdisciplinary investigators. Eur J Clin Microbiol Infect Dis 21:337–352CrossRefPubMedGoogle Scholar
  29. 29.
    Denning DW, Kibbler CC, Barnes RA (2003) British Society for Medical Mycology proposed standards of care for patients with invasive fungal infections. Lancet Infect Dis 3:230–240CrossRefPubMedGoogle Scholar
  30. 30.
    Mora-Duarte J, Betts R, Rotstein C, Colombo AL, Thompson-Moya L, Smietana J, Lupinacci R, Sable C, Kartsonis N, Perfect J; Caspofungin Invasive Candidiasis Study Group (2002) Comparison of caspofungin and amphotericin B for invasive candidiasis. N Engl J Med 347:2020–2029CrossRefPubMedGoogle Scholar
  31. 31.
    Kac G, Bougnoux ME, Aegerter P, Fagon JY, the CANDIREA Study Group (2003) Prospective multicenter surveillance study of ICU-acquired candidemia and candiduria: the candidemia analysis. In: 43rd ICAAC abstracts, American Society of Microbiology, September 2003, p 349, K-452gGoogle Scholar
  32. 32.
    British Society for Antimicrobial Chemotherapy (1994) Management of deep Candida infection in surgical and intensive care unit patients. Intensive Care Med 20:522–528CrossRefPubMedGoogle Scholar
  33. 33.
    Walsh TJ, Rex JH (2002) All catheter-related candidemia is not the same: assessment of the balance between the risks and benefits of removal of vascular catheters. Clin Infect Dis 34:600–602CrossRefPubMedGoogle Scholar
  34. 34.
    Nucci M, Anaissie E (2002) Should vascular catheters be removed from all patients with candidemia? An evidence-based review. Clin Infect Dis 34:591–599CrossRefPubMedGoogle Scholar
  35. 35.
    Eggimann P, Garbino J, Pittet D (2003) Epidemiology of Candida species infections in critically ill non-immunosuppressed patients. Lancet Infect Dis 3:685–702CrossRefPubMedGoogle Scholar
  36. 36.
    Calandra T, Bille J, Schneider R, Mosimann F, Francioli P (1989) Clinical significance of Candida isolated from peritoneum in surgical patients. Lancet II:1437–1440CrossRefGoogle Scholar
  37. 37.
    Rantala A, Niinikoski J, Lehtonen OP (1993) Early Candida isolations in febrile patients after abdominal surgery. Scand J Infect Dis 25:479–485PubMedGoogle Scholar
  38. 38.
    Sandven P, Qvist H, Skovlund E, Giercksky KE (2002) Significance of Candida recovered from intraoperative specimens in patients with intra-abdominal perforations. Crit Care Med 30:541–547CrossRefPubMedGoogle Scholar
  39. 39.
    Nathens AB, Rotstein OD, Marshall JC (1998) Tertiary peritonitis: clinical features of a complex nosocomial infection. World J Surg 22:158–163CrossRefPubMedGoogle Scholar
  40. 40.
    Tambyah PA, Maki DG (2000) Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med 160:678–682CrossRefPubMedGoogle Scholar
  41. 41.
    Sobel JD (1999) Management of asymptomatic candiduria. Int J Antimicrob Agents 11:285–288CrossRefPubMedGoogle Scholar
  42. 42.
    Kac G, Bougnoux ME, Aegerter P, Fagon JY, the CANDIREA Study Group (2003) Prospective multicenter surveillance study of ICU-acquired candidemia and candiduria: the candiduria analysis. In: 43rd ICAAC abstracts, American Society of Microbiology, September 2003, p 348, K-452dGoogle Scholar
  43. 43.
    Chastre J, Fagon JY (2002) Ventilator-associated pneumonia. Am J Respir Crit Care Med 165:867–903PubMedGoogle Scholar
  44. 44.
    El-Ebiary M, Torres A, Fabregas N, de la Bellacasa JP, Gonzalez J, Ramirez J, del Bano D, Hernandez C, Jimenez de Anta MT (1997) Significance of the isolation of Candida species from respiratory samples in critically ill, non-neutropenic patients. An immediate postmortem histologic study. Am J Respir Crit Care Med 156:583–590PubMedGoogle Scholar
  45. 45.
    Rello J, Esandi ME, Diaz E, Mariscal D, Gallego M, Valles J (1998) The role of Candida spp isolated from bronchoscopic samples in nonneutropenic patients. Chest 114:146–149PubMedGoogle Scholar
  46. 46.
    Haron E, Vartivarian S, Anaissie E, Dekmezian R, Bodey GP (1993) Primary Candida pneumonia. Experience at a large cancer center and review of the literature. Medicine (Baltimore) 72:137–142Google Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Philippe Eggimann
    • 1
    • 8
  • Thierry Calandra
    • 2
  • Ursula Fluckiger
    • 3
  • Jacques Bille
    • 4
  • Jorge Garbino
    • 5
  • Michel-Pierre Glauser
    • 2
  • Oscar Marchetti
    • 2
  • Christian Ruef
    • 6
  • Martin Täuber
    • 7
  • Didier Pittet
    • 1
    • 5
  • for the Fungal Infection Network of Switzerland (FUNGINOS)
  1. 1.Infection Control ProgramUniversity of Geneva HospitalsGeneva 14Switzerland
  2. 2.Infectious Diseases Service, Department of Internal MedicineCentre Hospitalier Universitaire VaudoisLausanneSwitzerland
  3. 3.Division of Infectious DiseasesUniversity HospitalBaselSwitzerland
  4. 4.Institute of MicrobiologyCentre Hospitalier Universitaire VaudoisLausanneSwitzerland
  5. 5.Division of Infectious Diseases, Department of Internal MedicineUniversity of Geneva HospitalsGenevaSwitzerland
  6. 6.Division of Infection Control and PreventionUniversitätsspitalZurichSwitzerland
  7. 7.Institute for Infectious DiseasesUniversity of BernBernSwitzerland
  8. 8.Surgical ICU and Burn UnitCentre Hospitalier Universitaire VaudoisLausanneSwitzerland

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