MEDical wards Invasive Candidiasis ALgorithms (MEDICAL):Consensus proposal for management

Abstract

Introduction A majority of invasive Candida infections occur in medical wards; however, evidence for management in this setting is scarce and based primarily on the intensive care or surgical setting. On behalf of the Italian Society for Anti-Infective Therapy (SITA) and the Italian Federation of Associations of Hospital Doctors on Internal Medicine (FADOI), the MEDICAL group produced practical management algorithms for patients in internal medicine wards. Methods The MEDICAL group panel, composed of 30 members from internal medicine, infectious disease, clinical pharmacology, clinical microbiology and clinical epidemiology, provided expert opinion through the RAND/UCLA method. Results Seven clinical scenarios were constructed based on clinical severity and probability of invasive candidiasis. For each scenario, the appropriateness of 63 different diagnostic, imaging, management, or therapeutic procedures was determined in two Delphi rounds. The necessity for performing each appropriate procedure, was then determined in a third Delphi round. Results were summarized in algorithms. Discussion The proposed algorithms provide internal medicine physicians and managers with an easy to interpret tool that is exhaustive, clear and suitable for adaption to individual local settings. Attention was paid to individual patient management and resource allocation

(1,3)-β-D-glucan-based diagnosis of invasive Candida infection versus culture-based diagnosis in patients with sepsis and with an increased risk of invasive Candida infection (CandiSep): study protocol for a randomized controlled trial

“…in blood culture or other primary sterile body fluidsNo antifungal therapy • Candida spp. proven in blood culture or other primary sterile body fluidsStart antifungal therapy according to European guidelines(1,3)-β-D-glucan ≥ 80 pg/ml in one of two measurementsImmediately start antifungal therapy for ICI according to European guidelines [16] • No Candida spp. in blood culture or other primary sterile body fluidsAntifungal therapy is discontinued • Candida spp.…”

“…If relevant, this type of interference would significantly reduce the clinical usability of BDG assays in critically ill patients. Current guidelines hesitate in giving a general recommendation for initiating antifungal therapy relying on BDG results [8, 9, 16]. …”

Antifungal agents for invasive candidiasis in non-neutropenic critically ill adults: What do the guidelines recommend?

“…We identified 7230 relevant titles and selected 19 CPGs for inclusion ( Figure 1) (Aguado et al, 2011, Alothman et al, 2014, Bassetti et al, 2013, Bow et al, 2010, Chen et al, 2014, Colombo et al, 2013, Cornely et al, 2012, Elhoufi et al, 2014, JSMM, 2013, Kohno et al, 2016, Kung et al, 2018, Limper et al, 2011, Luo et al, 2014, Montravers et al, 2015, Pappas et al, 2016, Ruhnke et al, 2011, Scudeller et al, 2016, Scudeller et al, 2014, Zaragoza et al, 2014. Table 1 presents the main characteristics of included CPGs.…”

“…burn patients who have received two different broad spectrum antibiotics for a minimum of five days) (Luo et al, 2014). With the exception of the ESCMID guideline (Cornely et al, 2012), echinocandins were recommended as the initial drug in all 16 CPGs that supported empirical or pre-emptive treatment (Alothman et al, 2014, Bassetti et al, 2013, Bow et al, 2010, Chen et al, 2014, Colombo et al, 2013, Elhoufi et al, 2014, JSMM, 2013, Kohno et al, 2016, Kung et al, 2018, Luo et al, 2014, Montravers et al, 2015, Pappas et al, 2016, Ruhnke et al, 2011, Scudeller et al, 2016, Scudeller et al, 2014, Zaragoza et al, 2014. Fluconazole and liposomal amphotericin B (L-AMB) were listed as other initial agents in six (Bow et al, 2010, Elhoufi et al, 2014, JSMM, 2013, Kohno et al, 2016, Kung et al, 2018, Montravers et al, 2015 and two (Bassetti et al, 2013, Ruhnke et al, 2011 CPGs, respectively.…”

“…Fluconazole and liposomal amphotericin B (L-AMB) were listed as other initial agents in six (Bow et al, 2010, Elhoufi et al, 2014, JSMM, 2013, Kohno et al, 2016, Kung et al, 2018, Montravers et al, 2015 and two (Bassetti et al, 2013, Ruhnke et al, 2011 CPGs, respectively. Fluconazole was recommended as an appropriate alternative drug in five CPGs (Alothman et al, 2014, Bassetti et al, 2013, Colombo et al, 2013, Pappas et al, 2016, Scudeller et al, 2014, L-AMB in seven (Alothman et al, 2014, Chen et al, 2014, Colombo et al, 2013, JSMM, 2013, Pappas et al, 2016, Scudeller et al, 2016, Scudeller et al, 2014, voriconazole in five (Alothman et al, 2014, Bassetti et al, 2013, Chen et al, 2014, Luo et al, 2014, Scudeller et al, 2014, and amphotericin B deoxycholate in four (Alothman et al, 2014, Chen et al, 2014, JSMM, 2013, Kung et al, 2018.…”