Drugs

, Volume 69, Supplement 1, pp 75–78 | Cite as

Antifungal Prophylaxis and Pre-Emptive Therapy

Review Article

Abstract

In recent years, several reports have underlined the increasing role of fungal infections as a cause of morbidity and mortality in hospitalized non-haematological patients. For this reason, and also in light of the high mortality rate associated with these infections, chemoprophylaxis has been advocated for surgical patients hospitalized in intensive care units (ICUs). The available evidence suggests that the triazoles fluconazole and itraconazole are able to decrease Candida colonization and possibly infection compared with placebo, but this result has only been obtained in high-risk patients undergoing repeated surgical procedures for tertiary peritonitis. Consequently, triazole antifungal prophylaxis should be used with caution, and only in patients at high risk of invasive candidiasis, including high-risk surgical and ICU patients. A pre-emptive approach, defined as initiating antifungal treatment without confirmation of fungal infection, seems to be effective and safe.

Notes

Acknowledgements

The author thanks Melanie Gatt of Wolters Kluwer Pharma Solutions who provided assistance with English language editing. This assistance was funded by Pfizer.

The author has served as consultant for Pfizer, Merck, Astellas, Schering-Plough and Gilead, and has received honoraria from the same companies. He has also received research grants from Pfizer and Gilead.

References

  1. 1.
    Beck-Sague C, Jarvis WR. Secular trends in the epidemiology of nosocomial fungal infections in the United States, 1980–1990. National Nosocomial Infections Surveillance System. J Infect Dis 1993 May; 167(5): 1247–51Google Scholar
  2. 2.
    Martin GS, Mannino DM, Eaton S, et al. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003 Apr 17; 348(16): 1546–54PubMedCrossRefGoogle Scholar
  3. 3.
    Edmond MB, Wallace SE, McClish DK, et al. Nosocomial bloodstream infections in United States hospitals: a three-year analysis. Clin Infect Dis 1999 Aug; 29(2): 239–44PubMedCrossRefGoogle Scholar
  4. 4.
    Fridkin SK, Jarvis WR. Epidemiology of nosocomial fungal infections. Clin Microbiol Rev 1996 Oct; 9(4): 499–511PubMedGoogle Scholar
  5. 5.
    Calandra T, Bille J, Schneider R, et al. Clinical significance of Candida isolated from peritoneum in surgical patients. Lancet 1989 Dec 16; 2(8677): 1437–40PubMedCrossRefGoogle Scholar
  6. 6.
    Singh N, Wagener MM, Marino IR, et al. Trends in invasive fungal infections in liver transplant recipients: correlation with evolution in transplantation practices. Transplantation 2002 Jan 15; 73(1): 63–7PubMedCrossRefGoogle Scholar
  7. 7.
    Vincent JL, Anaissie E, Bruining H, et al. Epidemiology, diagnosis and treatment of systemic Candida infection in surgical patients under intensive care. Intensive Care Med 1998 Mar; 24(3): 206–16PubMedCrossRefGoogle Scholar
  8. 8.
    Blumberg HM, Jarvis WR, Soucie JM, et al. Risk factors for candidal bloodstream infections in surgical intensive care unit patients: the NEMIS prospective multicenter study. The National Epidemiology of Mycosis Survey. Clin Infect Dis 2001 Jul 15; 33(2): 177–86Google Scholar
  9. 9.
    Saiman L, Ludington E, Pfaller M, et al. Risk factors for candidemia in Neonatal Intensive Care Unit patients. The National Epidemiology of Mycosis Survey study group. Pediatr Infect Dis J 2000 Apr; 19(4): 319–24Google Scholar
  10. 10.
    Meersseman W, Lagrou K, Maertens J, et al. Galactomannan in bronchoalveolar lavage fluid: a tool for diagnosing aspergillosis in intensive care unit patients. Am J Respir Crit Care Med 2008 Jan 1; 177(1): 27–34PubMedCrossRefGoogle Scholar
  11. 11.
    Viscoli C, Girmenia C, Marinus A, et al. Candidemia in cancer patients: a prospective, multicenter surveillance study by the Invasive Fungal Infection Group (IFIG) of the European Organization for Research and Treatment of Cancer (EORTC). Clin Infect Dis 1999 May; 28(5): 1071–9PubMedCrossRefGoogle Scholar
  12. 12.
    Tortorano AM, Kibbler C, Peman J, et al. Candidaemia in Europe: epidemiology and resistance. Int J Antimicrob Agents 2006 May; 27(5): 359–66PubMedCrossRefGoogle Scholar
  13. 13.
    Pfaller MA, Jones RN, Doern GV, et al. Bloodstream infections due to Candida species: SENTRY antimicrobial surveillance program in North America and Latin America, 1997–1998. Antimicrob Agents Chemother 2000 Mar; 44(3): 747–51PubMedCrossRefGoogle Scholar
  14. 14.
    Bassetti M, Righi E, Costa A, et al. Epidemiological trends in nosocomial candidemia in intensive care. BMC Infect Dis 2006; 6: 21PubMedCrossRefGoogle Scholar
  15. 15.
    Eggimann P, Francioli P, Bille J, et al. Fluconazole prophylaxis prevents intra-abdominal candidiasis in high-risk surgical patients. Crit Care Med 1999 Jun; 27(6): 1066–72PubMedCrossRefGoogle Scholar
  16. 16.
    Pelz RK, Hendrix CW, Swoboda SM, et al. Double-blind placebo-controlled trial of fluconazole to prevent candidal infections in critically ill surgical patients. Ann Surg 2001 Apr; 233(4): 542–8PubMedCrossRefGoogle Scholar
  17. 17.
    Garbino J, Lew DP, Romand JA, et al. Prevention of severe Candida infections in nonneutropenic, high-risk, critically ill patients: a randomized, double-blind, placebo-controlled trial in patients treated by selective digestive decontamination. Intensive Care Med 2002 Dec; 28(12): 1708–17PubMedCrossRefGoogle Scholar
  18. 18.
    Manzoni P, Stolfi I, Pugni L, et al. A multicenter, randomized trial of prophylactic fluconazole in preterm neonates. N Engl J Med 2007 Jun 14; 356(24): 2483–95PubMedCrossRefGoogle Scholar
  19. 19.
    Shorr AF, Chung K, Jackson WL, et al. Fluconazole prophylaxis in critically ill surgical patients: a meta-analysis. Crit Care Med 2005 Sep; 33(9): 1928–35; quiz 36PubMedCrossRefGoogle Scholar
  20. 20.
    Cruciani M, de Lalla F, Mengoli C. Prophylaxis of Candida infections in adult trauma and surgical intensive care patients: a systematic review and meta-analysis. Intensive Care Med 2005 Nov; 31(11): 1479–87PubMedCrossRefGoogle Scholar
  21. 21.
    Playford EG, Webster AC, Sorrell TC, et al. Antifungal agents for preventing fungal infections in non-neutropenic critically ill patients. Cochrane Database Syst Rev 2006; (1): CD004920Google Scholar
  22. 22.
    Solomkin JS, Flohr AB, Quie PG, et al. The role of Candida in intraperitoneal infections. Surgery 1980 Oct; 88(4): 524–30PubMedGoogle Scholar
  23. 23.
    Solomkin JS, Flohr AM, Simmons RL. Indications for therapy for fungemia in postoperative patients. Arch Surg 1982 Oct; 117(10): 1272–5PubMedCrossRefGoogle Scholar
  24. 24.
    Pittet D, Monod M, Suter PM, et al. Candida colonization and subsequent infections in critically ill surgical patients. Ann Surg 1994 Dec; 220(6): 751–8PubMedCrossRefGoogle Scholar
  25. 25.
    Piarroux R, Grenouillet F, Balvay P, et al. Assessment of preemptive treatment to prevent severe candidiasis in critically ill surgical patients. Crit Care Med 2004 Dec; 32(12): 2443–9PubMedCrossRefGoogle Scholar
  26. 26.
    Leon C, Ruiz-Santana S, Saavedra P, et al. A bedside scoring system (“Candida score”) for early antifungal treatment in nonneutropenic critically ill patients with Candida colonization. Crit Care Med 2006 Mar; 34(3): 730–7PubMedCrossRefGoogle Scholar
  27. 27.
    Ruiz-Santana S, Leon C, Saavedra P, et al. Validation study of the Candida score for discriminating between colonization an invasive candidiasis in non-neutropenic critically ill patients: the Cava project [abstract no. M-1167]. 47th ICAAC-Intersciences Conference on Antimicrobial Agents and Chemotherapy; 2007 Sep 17–20; Chicago (IL)Google Scholar
  28. 28.
    Ruiz-Santana S, Castro C, Saavedra P, et al. The Cava project: (1,3)-beta-glucan and Candida score in discriminating between colonization and invasive candidiasis non-neutropenic critically ill patients [abstract no. M-563]. 47th ICAAC-Intersciences Conference on Antimicrobial Agents and Chemotherapy; 2007 Sep 17–20; Chicago (IL)Google Scholar

Copyright information

© Adis Data Information BV 2009

Authors and Affiliations

  1. 1.University of Genova, San Martino University Hospital, Infectious Disease Unit, Largo Rosanna BenziGenoaItaly

Personalised recommendations