Clinical practice guidelines for the management of invasive Candida infections in adults in the Middle East region: Expert panel recommendations

Abstract

Invasive Candida infections contribute to significant morbidity and mortality in patients with healthcare-associated infections. They represent a major burden on the public health system, and are challenging to diagnose and treat. A multidisciplinary expert panel critically reviewed available evidence to provide consensus recommendations for the management of invasive Candida infections in the Middle East. Based on diagnosis, recommendations were provided for the management of Candida infections in non-neutropenic and neutropenic patients. Polyenes (amphotericin B-deoxycholate [AmB-d] and lipid formulations amphotericin B [LFAmB]), triazoles (fluconazole, itraconazole and voriconazole), echinocandins (caspofungin, anidulafungin, and micafungin) and flucytosine are the recommended categories of antifungal agents for treatment of Candida infections. Echinocandins are preferred for treatment of proven and suspected Candida infections, especially in critically ill patients or those with previous exposure to azoles. Recommendations were also provided for infections caused by specific Candida species as well as management of different disease conditions. The experts highlighted that the guidelines should be used along with clinical judgment. Given the paucity of published data from the region, research in the form of randomized clinical trials should be given priority.

Epidemiology, Management, and Outcome of Invasive Fungal Disease in Patients Undergoing Hematopoietic Stem Cell Transplantation in China: A Multicenter Prospective Observational Study

“…Physicians 5 diagnosed and treated cases of IFD according to their usual practice, using their own judgement. In 6 patients who received antifungal treatment (at investigator discretion) the CRF was also used to 7 record initial treatment strategy against protocol definitions of prophylaxis and treatment scenarios 8 (empirical: administered to patients with immune deficiency, prolonged corticosteroid use, 9 persistent fever of unknown cause, or unresponsive to broad-spectrum antibiotics for 7 days; pre-10 emptive: administered to patients with indirect microbiological evidence of infection (antigen test); 11 targeted: administered to patients with proven IFD [11]), treatment adjustment and treatment 12 course. IFD was categorised as proven, probable or possible according to European Organization for 13 Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National 14 Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) 2008 criteria [12].…”

“…6 Statistics were primarily descriptive and were compared using analysis of variance, Wilcoxon rank-7 sum test or chi-squared test, as appropriate. Risk factors for IFD were analysed using univariate 8 analysis followed by multivariate logistic regression. Each risk factor with a P value < 0.15 on 9 univariate analysis was examined further using multivariate logistic regression, in which clinical 10 significance and interaction between variables were taken into account.…”

“…4 However, the publication of large prospective observational studies in recent years has improved 5 understanding of the epidemiological landscape in geographical areas including the USA and parts of 6 Europe [2][3][4]. These data suggest that, despite reductions in IFD-related deaths in the past decade 7 [5], IFD-related mortality following HSCT still approaches 50% [2,3], with higher rates among 8 recipients of allogeneic compared with autologous transplants, particularly in the presence of 9 Aspergillus infection [2,4]. As a result, HSCT recipients with suspected IFD often receive early 10 empirical therapy or pre-emptive treatment.…”

“…As a result, HSCT recipients with suspected IFD often receive early 10 empirical therapy or pre-emptive treatment. 11 Treatment guidelines for IFD, including some that are specific to HSCT patients, have been 12 developed by academic societies in different world regions [6][7][8][9]. Notwithstanding this guidance, 13 and despite advances in the diagnosis and prophylaxis of IFD, as well as new dose forms of 14 amphotericin B and antifungal agents, treatment is often delayed owing to non-specific disease 15 presentation and a lack of reliable diagnostic techniques, leading to poor clinical outcomes.…”

Antifungal Clinical Trials and Guidelines: What We Know and Do Not Know

“…Indeed, there are currently at least six published treatment guidelines focusing on invasive candidiasis in the non-neutropenic host (Tsuruta et al 2007;Pappas et al 2009a;Aguado et al 2011;Cornely et al 2012;Colombo et al 2013;Alothman et al 2014). Not surprisingly, these recommendations are not overlapping because of differences in interpretation of the published data, variability in local practice, differences in regional epidemiology, individual Candida spp.…”