Use of antifungal agents in febrile patients nonresponsive to antibacterial treatment: the current status in surgical and critical care patients in Japan

Abstract

Disseminated candidiasis is difficult to diagnose and treat, and often becomes life-threatening in critically ill patients. However, guidelines or consensus views regarding the management of disseminated candidiasis do not exist in Japan. To develop feasible guidelines in Japan, we studied the current status of antifungal treatment in critically ill patients in Japan. From April 1999 to January 2000, critically ill patients from either surgical wards or critical care/intensive care units of 26 teaching hospitals were studied, using a prospective enrollment protocol. Patient enrollment criteria included persistent fever(≧38°C) for 3 days or more despite antibacterial agent administration. Data were entered at each institution and managed centrally using Clinware software. Of the 200 patients in the study, 68 (34%) received antifungal agents. Factors associated with antifungal treatment in the 68 patients included: central venous or pulmonary artery catheter, re-surgery, carbapenem or cephem administration, prolonged antibacterial agent administration, and high body temperature. Proven or probable disseminated candidiasis was presumed or diagnosed by culture in 34 patients, and by clinical signs and/or serological tests in 34 patients. Fungi isolated from blood included Candida albicans (57%), C. tropicalis (14%), C. parapsilosis (7%), C. glabrata (7%), and others (14%). Treatment patterns were as follows: 65 patients (96%) were treated with fluconazole (60 as monotherapy and 5 with amphotericin B); 2 patients, with miconazole; and 1 patient, with amphotericin B. Excluding 6 unevaluable cases, antifungal treatment was efficacious in 75% (21/28) of the patients with positive fungal culture and in 68% (23/34) of patients diagnosed by other means.