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Management of Invasive Candidiasis in the Intensive Care Unit

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Abstract

Invasive candidiasis (IC) is an important infection in the intensive care unit (ICU) setting given its association with poor clinical outcomes. The epidemiology of IC is complex and, although incompletely elucidated, is characterized by considerable regional and temporal variability. Overall, there appears to be an increase in the incidence of IC and a change in distribution of the causative Candida spp. Of particular concern is an increase in the proportion of episodes caused by Candida glabrata, which is associated with reduced susceptibility to azole antifungal agents.

The management of IC has been aided by the availability of several new antifungal agents. In particular, given their broad spectrum of activity and low toxicity, the use of echinocandins as first-line therapy is increasing, especially in settings where fluconazole-resistant Candida spp. are prevalent. Fluconazole remains a reliable agent where an azole-susceptible pathogen is confirmed or in settings where resistance is uncommon. Lipid formulations of amphotericin B are now generally reserved as second-line or salvage therapy. Voriconazole and posaconazole currently enjoy limited use for IC in the ICU setting.

Although the poor outcomes associated with IC are, in part, related to the severity of underlying host factors, it is clear that optimization of treatment-related factors is also important. In particular, the speed of initiation of antifungal therapy and the achievement of pharmacodynamic parameters both influence outcomes. The most difficult challenge is early initiation of an effective antifungal drug, given the slow turnaround time and lack of sensitivity of conventional culture-based diagnostic techniques. New approaches, such as non-culture-based assays and/or clinical risk-predictive models are required to better target prophylactic, pre-emptive and empirical antifungal strategies.

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Acknowledgements

The following relevant grant support is acknowledged: National Health and Medical Research Council Project Grant 512307 (Geoffrey Playford, Jeff Lipman and Tania Sorrell), National Health and Medical Research Council Centre for Clinical Research Excellence Program Grant 264625 (Tania Sorrell), Pfizer and Merck Sharp and Dohme (Geoffrey Playford, Jeff Lipman and Tania Sorrell). The authors also declare Advisory Board membership for Pfizer (Geoffrey Playford and Tania Sorrell), Merck Sharpe and Dohme (Geoffrey Playford, Jeff Lipman and Tania Sorrell), Schering Plough (Geoffrey Playford and Tania Sorrell), AstraZeneca (Jeff Lipman), Jansen Cilag (Jeff Lipman) and Gilead (Tania Sorrell). Jeff Lipman has also received other honoraria from AstraZeneca and Jansen Cilag.

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Authors and Affiliations

  1. Infection Management Services, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, Queensland, 4102, Australia

    E. Geoffrey Playford

  2. Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia

    E. Geoffrey Playford

  3. Burns Trauma Critical Care Research Centre, University of Queensland, Brisbane, Queensland, Australia

    Jeff Lipman

  4. Department of Intensive Care, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia

    Jeff Lipman

  5. Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales, Australia

    Tania C. Sorrell

  6. Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia

    Tania C. Sorrell

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  1. E. Geoffrey Playford
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  2. Jeff Lipman
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  3. Tania C. Sorrell
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Correspondence to E. Geoffrey Playford.

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Playford, E.G., Lipman, J. & Sorrell, T.C. Management of Invasive Candidiasis in the Intensive Care Unit. Drugs 70, 823–839 (2010). https://doi.org/10.2165/10898550-000000000-00000

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