Evolución del consumo de antifúngicos en pacientes críticos. Estudio multicéntrico observacional, 2006-2010

Olaechea-Astigarraga, Pedro; Álvarez-Lerma, Francisco; Palomar-Martínez, Mercedes; Insausti-Ordeñana, J.; López-Pueyo, M.J.; Seijas-Betolaza, Iratxe; Otal-Entraigas, Juan José; Gimeno-Costa, Ricardo; Gracia-Arnillas, María Pilar

doi:10.1016/j.eimc.2012.02.006

Cited by 15 publications

(11 citation statements)

References 16 publications

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“…Because of difficulties in the diagnosis IC in ICU settings, up to two thirds of critically ill patients with suspicion of fungal infection are given empirical antifungals [ 17 , 18 ], a strategy with a well-recognized negative impact on adverse effects, risk of resistances [ 5 ], length of stay, patient’s outcome, and health care costs [ 19 , 20 ]. In the present series, 51 % of patients received SAT and 75.6 % of them did not have documented IC.…”

Section: Discussionmentioning

confidence: 99%

Contribution of Candida biomarkers and DNA detection for the diagnosis of invasive candidiasis in ICU patients with severe abdominal conditions

et al. 2016

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BackgroundTo assess the performance of Candida albicans germ tube antibody (CAGTA), (1 → 3)-ß-D-glucan (BDG), mannan antigen (mannan-Ag), anti-mannan antibodies (mannan-Ab), and Candida DNA for diagnosing invasive candidiasis (IC) in ICU patients with severe abdominal conditions (SAC).MethodsA prospective study of 233 non-neutropenic patients with SAC on ICU admission and expected stay ≥ 7 days. CAGTA (cutoff positivity ≥ 1/160), BDG (≥80, 100 and 200 pg/mL), mannan-Ag (≥60 pg/mL), mannan-Ab (≥10 UA/mL) were measured twice a week, and Candida DNA only in patients treated with systemic antifungals. IC diagnosis required positivities of two biomarkers in a single sample or positivities of any biomarker in two consecutive samples. Patients were classified as neither colonized nor infected (n = 48), Candida spp. colonization (n = 154) (low-grade, n = 130; high-grade, n = 24), and IC (n = 31) (intra-abdominal candidiasis, n = 20; candidemia, n = 11).ResultsThe combination of CAGTA and BDG positivities in a single sample or at least one of the two biomarkers positive in two consecutive samples showed 90.3 % (95 % CI 74.2–98.0) sensitivity, 42.1 % (95 % CI 35.2–98.8) specificity, and 96.6 % (95 % CI 90.5–98.8) negative predictive value. BDG positivities in two consecutive samples had 76.7 % (95 % CI 57.7–90.1) sensitivity and 57.2 % (95 % CI 49.9–64.3) specificity. Mannan-Ag, mannan-Ab, and Candida DNA individually or combined showed a low discriminating capacity.ConclusionsPositive Candida albicans germ tube antibody and (1 → 3)-ß-D-glucan in a single blood sample or (1 → 3)-ß-D-glucan positivity in two consecutive blood samples allowed discriminating invasive candidiasis from Candida spp. colonization in critically ill patients with severe abdominal conditions. These findings may be helpful to tailor empirical antifungal therapy in this patient population.

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Section: Discussionmentioning

confidence: 99%

Contribution of Candida biomarkers and DNA detection for the diagnosis of invasive candidiasis in ICU patients with severe abdominal conditions

et al. 2016

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“…Duration of mechanical ventilation (12.5 [4,9] versus 20 d (0, 36), p = 0,007) and ICU stay (18 [5-28] versus 24 d [15–38], p = 0.001) were significantly shorter in patients with prolonged empirical antifungal treatment compared with those with non prolonged empirical antifungal treatment. However, ICU mortality was similar in the two groups (46 versus 52%, p = 0.62).…”

Section: Resultsmentioning

confidence: 99%

“…Empirical antifungal treatment was used in a large percentage (27%) of ICU patients, during a large percentage (48%) of their ICU stay. A recent Spanish multicenter study [9] analyzed 8240 antifungal prescriptions during a 5 year-period. An increase in antifungal use was reported to the year 2008, with a subsequent stabilization.…”

Section: Discussionmentioning

confidence: 99%

“…Further studies should determine the impact of clinical, and biological markers use on duration of empirical antifungal treatment, and patient outcomes. For example, the use of PCR [20,21], galactomannan [22], and biomarkers for invasive fungal disease, such as mannan, anti-mannan [9,23,24], and β-D-glucan [25-29], could be helpful for reducing duration of empirical antifungal treatment. In our ICU, galactomannan, and biomarkers for invasive fungal disease are available, and used by physicians.…”

Section: Discussionmentioning

confidence: 99%

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Factors predicting prolonged empirical antifungal treatment in critically ill patients

Zein

Parmentier-Decrucq

Kalaoun

et al. 2014

Ann Clin Microbiol Antimicrob

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ObjectiveTo determine the incidence, risk factors, and impact on outcome of prolonged empirical antifungal treatment in ICU patients.MethodsRetrospective observational study performed during a one-year period. Patients who stayed in the ICU >48 h, and received empirical antifungal treatment were included. Patients with confirmed invasive fungal disease were excluded. Prolonged antifungal treatment was defined as percentage of days in the ICU with antifungals > median percentage in the whole cohort of patients.ResultsAmong the 560 patients hospitalized for >48 h, 153 (27%) patients received empirical antifungal treatment and were included in this study. Fluconazole was the most frequently used antifungal (46% of study patients). Median length of ICU stay was 19 days (IQR 8, 34), median duration of antifungal treatment was 8 days (IQR 3, 16), and median percentage of days in the ICU with antifungals was 48% (IQR 25, 80). Seventy-seven patients (50%) received prolonged empirical antifungal treatment. Chemotherapy (OR [95% CI] 2.6 [1.07-6.69], p = 0.034), and suspected infection at ICU admission (3.1 [1.05-9.48], p = 0.041) were independently associated with prolonged empirical antifungal treatment.Duration of mechanical ventilation and ICU stay were significantly shorter in patients with prolonged empirical antifungal treatment compared with those with no prolonged empirical antifungal treatment. However, ICU mortality was similar in the two groups (46 versus 52%, p = 0.62).ConclusionEmpirical antifungal treatment was prescribed in a large proportion of study patients. Chemotherapy, and suspicion of infection at ICU admission are independently associated with prolonged empirical antifungal treatment.

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“…Several studies have found that fluconazole is still the most frequently prescribed antifungal agent despite the market introduction of echinocandins and mold-active azoles. [20][21][22][23] In terms of available benchmarking data, one study examined antifungal utilization between 2001-2003 and 2008-2011 at 5 academic teaching hospitals in Germany. 20 These hospitals were tertiary care referral centers with all major services including HCT, SOT, and level one trauma capabilities.…”

Section: Antifungal Utilization In Adults and Pediatricsmentioning

confidence: 99%

Antifungal stewardship considerations for adults and pediatrics

2016

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Antifungal stewardship refers to coordinated interventions to monitor and direct the appropriate use of antifungal agents in order to achieve the best clinical outcomes and minimize selective pressure and adverse events. Antifungal utilization has steadily risen over time in concert with the increase in number of immunocompromised adults and children at risk for invasive fungal infections (IFI). Challenges in diagnosing IFI often lead to delays in treatment and poorer outcomes. There are also emerging data linking prior antifungal exposure and suboptimal dosing to the emergence of antifungal resistance, particularly for Candida. Antimicrobial stewardship programs can take a multi-pronged bundle approach to ensure suitable prescribing of antifungals via postprescription review and feedback and/or prior authorization. Institutional guidelines can also be developed to guide diagnostic testing in at-risk populations; appropriate choice, dose, and duration of antifungal agent; therapeutic drug monitoring; and opportunities for de-escalation and intravenous-to-oral conversion.

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Evolución del consumo de antifúngicos en pacientes críticos. Estudio multicéntrico observacional, 2006-2010

Cited by 15 publications

References 16 publications

Contribution of Candida biomarkers and DNA detection for the diagnosis of invasive candidiasis in ICU patients with severe abdominal conditions

Contribution of Candida biomarkers and DNA detection for the diagnosis of invasive candidiasis in ICU patients with severe abdominal conditions

Factors predicting prolonged empirical antifungal treatment in critically ill patients

Antifungal stewardship considerations for adults and pediatrics

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