Assessment of Preemptive Treatment to Prevent Severe Candidiasis in Critically Ill Surgical Patients

Crit Care Med. 2004 Dec;32(12):2443-9. doi: 10.1097/01.ccm.0000147726.62304.7f.

Abstract

Objective: To assess the efficacy of a preemptive antifungal therapy in preventing proven candidiasis in critically ill surgical patients.

Design: Before/after intervention study, with 2-yr prospective and 2-yr historical control cohorts.

Setting: Surgical intensive care unit (SICU) in a university-affiliated hospital.

Patients: Nine hundred and thirty-three patients, 478 in the prospective group and 455 in the control group, with SICU stay > or =5 days.

Interventions: During the prospective period, systematic mycological screening was performed on all patients admitted to the SICU, immediately at admittance and then weekly until discharge. A corrected colonization index was used to assess intensity of Candida mucosal colonization. Patients with corrected colonization index > or =0.4 received early preemptive antifungal therapy (fluconazole intravenously: loading dose 800 mg, then 400 mg/day for 2 wks).

Measurements and main results: End points of this study were the frequency of proven candidiasis, especially SICU-acquired candidiasis. During the retrospective period, 32 patients of 455 (7%) presented with proven candidiasis: 22 (4.8%) were imported and 10 (2.2%) were SICU-acquired cases. During the prospective period, 96 patients with corrected colonization index > or =0.4 of 478 received preemptive antifungal treatment and only 18 cases (3.8%) of proven candidiasis were diagnosed; all were imported infections. Candida infections occurred more frequently in the control cohort (7% vs. 3.8%; p = .03). Incidence of SICU-acquired proven candidiasis significantly decreased from 2.2% to 0% (p < .001, Fisher test). Incidence of proven imported candidiasis remained unchanged (4.8% vs. 3.8%; p = .42). No emergence of azole-resistant Candida species (especially Candida glabrata, Candida krusei) was noted during the prospective period.

Conclusions: Targeted preemptive strategy may efficiently prevent acquisition of proven candidiasis in SICU patients. Further studies are being performed to assess cost-effectiveness of this strategy and its impact on selection of azole-resistant Candida strains on a long-term basis.

Publication types

  • Comparative Study
  • Evaluation Study

MeSH terms

  • APACHE
  • Adult
  • Age Distribution
  • Aged
  • Candidiasis / drug therapy
  • Candidiasis / epidemiology
  • Candidiasis / prevention & control*
  • Case-Control Studies
  • Chi-Square Distribution
  • Critical Care / methods
  • Cross Infection / epidemiology
  • Cross Infection / prevention & control*
  • Dose-Response Relationship, Drug
  • Drug Administration Schedule
  • Female
  • Fluconazole / therapeutic use*
  • Follow-Up Studies
  • Fungemia / drug therapy
  • Fungemia / epidemiology
  • Fungemia / prevention & control*
  • Humans
  • Incidence
  • Intensive Care Units
  • Male
  • Mass Screening / methods
  • Middle Aged
  • Probability
  • Prospective Studies
  • Retrospective Studies
  • Risk Assessment
  • Severity of Illness Index
  • Sex Distribution
  • Statistics, Nonparametric
  • Survival Analysis

Substances

  • Fluconazole