Should we Administer Antifungal Drugs Before the Diagnosis of Invasive Fungal Infection in Non-Neutropenic Critically Ill Patients?

Cortegiani, Andrea; Russotto, Vincenzo; Raineri, Santi Maurizio; Gregoretti, Cesare; Giarratano, Antonino

doi:10.5152/tjar.2016.0010

Cited by 6 publications

(9 citation statements)

References 21 publications

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“…Moreover, we have also evidence describing the increasing rate of resistance to antifungals, even echinocandins, when used widely (9). We agree with Moghnieh et al on the need of a better selection of patients and a better timing for antifungal treatment.…”

supporting

confidence: 85%

“…In this case, the administration of antifungal agents depicts an empiric treatment, even though the selected population had a high risk of IFI based on known risk factors (i.e., broad spectrum antibiotic therapy, multi-site Candida colonization) (8). The enrolled population had a high level of critical illness (at the admission mean SOFA score 8, mean SAPS II 48) and this may lead to consider the timing of empirical antifungal treatment as "too late", potentially explaining the lack of effect on mortality (9). Third, other explanations about the paradoxical association between the reduced incidence of IFI and the absence of effect on mortality observed in the EMPIRICUS and other major trials on antifungal treatment may be interesting for the readers.…”

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confidence: 99%

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Lessons from uncertainty on antifungal treatment in ICU

2017

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confidence: 85%

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Lessons from uncertainty on antifungal treatment in ICU

2017

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“…According to available evidence from RCTs, administration of antifungal agents before definitive diagnosis of IFI may lead to a reduction in the incidence of IFI, without any survival advantages in nonneutropenic critically ill patients (35). Physicians should evaluate case-by-case risks and benefits of antifungal treatment after considering treatment timing, risk factors, local microbiological epidemiology, costs, available biomarkers, and diagnostic microbiological assays in their institutions (36,37).…”

Section: Resultsmentioning

confidence: 99%

What Is the Most Recent Evidence on the Prevention and Early Treatment of Invasive Fungal Infections in Nonneutropenic Critically Ill Patients?

Cortegiani

Russotto

Iozzo

et al. 2017

Arch Clin Infect Dis

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Invasive fungal infections (IFIs) are associated with high morbidity and mortality in intensive care units. Candida species are the most important fungal pathogens and among the most frequent causes of infection in critically ill patients. Studies have evaluated the correlation between the onset of antifungal treatment and survival. However, definitive diagnosis of IFI is time-consuming in clinical practice. Antifungal prophylaxis and preemptive or empirical treatments are among therapeutic strategies to prevent or treat early fungal infections in selected patients. Recently, new evidence from randomized controlled trials and systematic reviews has been published. Moreover, new clinical practice guidelines from international communities are available. The aim of this review was to present updated evidence on this topic.

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confidence: 99%

“…Untargeted antifungal treatment is defined as any antifungal intervention initiated before definitive microbiological evidence of fungal infection exists . At present, three different untargeted treatment strategies have been defined, namely prophylaxis, pre‐emptive and empirical therapy . Antifungal prophylaxis is used in patients with high risk of developing invasive fungal infections, including critical illness, recent abdominal surgery, haematologic malignancy, organ transplantation and treatment with glucocorticoids or broad‐spectrum antibiotics, and risk stratification has been suggested .…”

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Untargeted antifungal therapy in adult patients with complicated intra‐abdominal infection: a systematic review

Petersen

Perner

Ravn

et al. 2017

Acta Anaesthesiol Scand

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Background: Systematic reviews comparing untargeted antifungal treatment with placebo or no treatment in critically ill patients have provided conflicting results. We aimed to assess patientimportant benefits and harms of untargeted antifungal therapy vs. placebo or no treatment in adult patients with complicated intraabdominal infection. Methods: We conducted a systematic review with meta-analysis and trial sequential analysis of randomised clinical trials assessing untargeted antifungal therapy compared to placebo or no treatment in adults with complicated intra-abdominal infection. We used the Cochrane and GRADE methodologies and exclusively assessed patient-important outcomes. Two independent authors screened trials for eligibility, extracted data and assessed risk of bias. We performed conventional meta-analyses, including sensitivity and subgroup analyses, and trial sequential analysis to assess the risk of random errors and to estimate trial sequential analysis adjusted confidence intervals. Results: We included six trials (1,067 patients) in the review, and four trials reported data on the predefined outcome measures and were included in the meta-analysis. Three of the four trials had high risk of bias. We observed no statistically significant difference in mortality (relative risk 0.58, 95% confidence interval 0.24-1.39) or in any of the other patient-important outcomes between untargeted antifungal treatment and placebo or no treatment (low/very low quality of evidence). Trial sequential analysis demonstrated lack of data and high risk of random errors. Conclusions:The quantity and quality of evidence supporting untargeted antifungal treatment in adult patients with complicated intra-abdominal infection are low to very low with no firm evidence for benefit or harm.

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Should we Administer Antifungal Drugs Before the Diagnosis of Invasive Fungal Infection in Non-Neutropenic Critically Ill Patients?

Cited by 6 publications

References 21 publications

Lessons from uncertainty on antifungal treatment in ICU

Lessons from uncertainty on antifungal treatment in ICU

What Is the Most Recent Evidence on the Prevention and Early Treatment of Invasive Fungal Infections in Nonneutropenic Critically Ill Patients?

Untargeted antifungal therapy in adult patients with complicated intra‐abdominal infection: a systematic review

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