Treatment approach for fungal infections in critically ill patients admitted to intensive care units: results of a multicenter survey
Alvarez-Lerma, F.; Nolla, J.; Palomar, M.; León, Mía.A.
Enfermedades Infecciosas Y Microbiologia Clinica 21(2): 83-88
2003
ISSN/ISBN: 0213-005X PMID: 12586031 Document Number: 560522
Two consensus conferences were done in the USA and Spain to optimize the diagnosis and treatment of Candida spp. infections. Among other results, clinical scenarios in which early prescription of antifungal agents were indicated were identified. A study was conducted to determine the criteria followed by physicians for prescribing antifungal agents in critically ill patients in our country and to investigate adherence to the guidelines proposed by the consensus conferences. A questionnaire was designed and directed to 4th- and 5th-year residents in intensive care medicine and to specialists in intensive care with training in infectious diseases or other medical areas. Four case reports for which expert consensus indicates early antifungal treatment were included in the questionnaire. The case reports included recurrent peritonitis secondary to perforation of the digestive tract, with mixed flora including fungi; persistent febrile syndrome in a patient with multiple mucosal fungal colonizations treated with broad-spectrum antibiotics; candiduria and pyuria in a febrile patient; and candidaemia. A total of 135 questionnaires from 45 different intensive care units were returned (60% response rate). In the candidaemia and fungal peritonitis examples, early treatment with antifungal agents were indicated in 100% and 85.9% of responses, respectively. In cases of sepsis with multifocal candidosis and candiduria associated with pyuria and fever, early treatment was prescribed in only 41.5% and 55.6% of responses, respectively. There were no significant differences in responses regarding the degree of training of the physicians surveyed. Fluconazole prescription predominated, mainly at doses of 400 mg/day, in mixed peritonitis, disseminated candidosis and candiduria, whereas amphotericin B lipid formulations were preferentially indicated in cases of candidaemia. Antifungal treatment (early or late) was prescribed in all cases of candidaemia, in 95.5% for mixed peritonitis (fungi and bacteria), in 79.5% for multifocal candidosis in patients with persistent sepsis, and in 77.9% for candiduria with fever and pyuria. Adherence to recommendations from the consensus conferences was high among intensive medicine specialists, with no differences according to level of training in infectious diseases.