A multicentre study of antifungal strategies and outcome of Candida spp. peritonitis in intensive-care units

Abstract

Information on the species causing Candida peritonitis, their in vitro susceptibility, antifungal strategies in this setting and patient outcome is still scarce. AmarCand was a prospective, non-interventional study in 271 adult intensive-care unit (ICU) patients with proven invasive Candida infection who received systemic antifungal therapy (France, 2005-2006). Of these ICU patients, 93 (median age 65 years, simplified acute physiology score II 52) had Candida peritonitis, including 73 nosocomial peritonitis, 53 concomitant bacterial peritoneal infections and 26 candidaemias. Candida species were C. albicans (n = 63/108 isolates, 58%), C. glabrata (n = 22, 20%), C. krusei (n = 9), C. kefyr (n = 5), C. parapsilosis (n = 3), C. tropicalis (n = 3), C. ciferii (n = 2) and C. lusitaniae (n = 1). Of tested isolates, 28% were fluconazole-resistant or susceptible dose-dependent (C. albicans 3/32, C. glabrata 9/14, C. krusei 4/4). Empiric antifungal treatment was started 1 day (median) after peritonitis diagnosis, with fluconazole (n = 2 patients), caspofungin (n = 12), voriconazole (n = 3), amphotericin B (n = 2), or a combination (n = 4). Following susceptibility testing, empiric antifungal treatment was judged inadequate in 9/45 (20%) patients and modified in 30 patients (fluconazole was replaced by caspofungin (n = 14) or voriconazole (n = 4)). Mortality in ICU was 38% (35/93) and was not influenced by type of Candida species, fluconazole susceptibility, time to treatment, candidaemia, nosocomial acquisition, or concomitant bacterial infection. No specific factors for death were identified. In summary, a high proportion of fluconazole-resistant or susceptible dose-dependent strains was cultured. These results confirm the high mortality rates of Candida peritonitis and plead for additional investigation in this population. Antifungal treatment for severe cases of Candida peritonitis in ICU patients remains the standard care.

Burden of Serious Fungal Diseases in Romania

“…To estimate the number of candidaemia and Candida peritonitis cases, the annual incidence of 5/100,000 and 1.5/100,000 respectively were used, in the absesce of any national or regional population incidence data [11,12].…”

Management of Intra-Abdominal Infections

“…These organisms were observed in 22% of all intra-abdominal candidiasis in Montravers et al's prospective study. This was a noninterventional study in 271 adult ICU patients with proven invasive Candida infection who received systemic antifungal therapy [193]. As a consequence, an echinocandin should probably be used as empirical antifungal therapy in critically ill patients having CA-IAIs or HAI-IAIs.…”

Intra-abdominal candidiasis: it’s still a long way to get unquestionable data

“…In the AmarCand 1 study, a prospective, multicenter, French observational study, IAC was observed in 34 % of ICU patients with proven invasive candidiasis [1]. Intra-abdominal candidiasis accounts for more than 10 % of all cases of peritonitis and is associated with mortality rates between 25 and 60 % [2,3].Intra-abdominal candidiasis shares many similarities with candidaemia, including conventional risk factors [4] and high morbidity and mortality rates [2,3,5]. While the need for early and adequate antifungal treatment of candidaemia has been clearly demonstrated, no clinical study has ever assessed the need to treat IAC, raising the question of the real pathogenicity of these organisms.…”

“…Intra-abdominal candidiasis shares many similarities with candidaemia, including conventional risk factors [4] and high morbidity and mortality rates [2,3,5]. While the need for early and adequate antifungal treatment of candidaemia has been clearly demonstrated, no clinical study has ever assessed the need to treat IAC, raising the question of the real pathogenicity of these organisms.…”