Biomarker-guided antifungal therapy in patients with suspected invasive candidiasis: Ready for prime time?

Excerpt

Fungi and especially Candida spp. are responsible for around 20% of all microbiologically documented infections in the intensive care unit (ICU), and the incidence of invasive fungal infections (IFI) has increased steadily [1]. As reported recently, 28-day crude mortality rates remain high in those patients, around 40% [2]. Delayed antifungal therapy (AFT) is associated with significant increase in hospital mortality and health care costs and is mainly linked to late diagnosis [3, 4]. Accordingly, blood cultures are positive in only 50–70% of cases of candidemia and time to positivity is longer than in bacteremia [2]. As a result, empirical AFT is broadly used in the ICU. However, despite efforts aiming at improving AFT management, we should admit that we still fail to target the right patients. Actually, although recommended by recent guidelines, the broadly applied risk factors based approach (i.e., disease severity, previous use of antibiotics, total parenteral nutrition, recent digestive surgery and Candida colonization) leads to AFT administration to patients in whom IFI remains unproven in up to 80% of the cases [5‐7]. In addition, such a liberal strategy was shown to be ineffective regarding patients’ outcome: a recent double blinded randomized controlled trial (RCT) showed that empirical treatment of critically ill patients with ICU-acquired sepsis, Candida colonization and multiple organ failure with micafungin, compared with placebo, did not increase fungal infection-free survival at day 28 [8]. …