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Prophylactic antifungal therapy in the intensive care unit
1Division of Infectious Diseases, Department of Internal Medicine, Center for the Study of Emerging and Re-Emerging Pathogens, University of Texas Medical School, Houston, TX 77030, USA. John.H.Rex@uth.tmc.edu
Summary
Antifungal prophylaxis is beneficial for specific high-risk cancer and transplant patients. However, its use in critically ill intensive care unit (ICU) patients without neutropenia is not yet proven and may be premature due to cost and resistance concerns.
Area of Science:
- Critical Care Medicine
- Infectious Diseases
- Pharmacology
Background:
- Antifungal prophylaxis is established for certain cancer patients and high-risk liver transplant recipients with identified high rates of invasive fungal infections.
- Extending antifungal prophylaxis to critically ill intensive care unit (ICU) patients without neutropenia is conceptually appealing but faces implementation challenges due to patient heterogeneity.
Purpose of the Study:
- To evaluate the potential benefits and challenges of implementing antifungal prophylaxis in a broader ICU population.
- To determine if current evidence supports widespread prophylactic antifungal use in non-neutropenic critically ill patients.
Main Methods:
- Review of existing studies on antifungal prophylaxis in specific patient subgroups.
- Analysis of the applicability and limitations of extending these strategies to diverse ICU populations.
- Consideration of factors like patient risk stratification, cost, and potential for antifungal resistance.
Main Results:
- While two studies showed benefit, this was limited to selected high-risk patient groups within the ICU.
- Broad implementation in the general ICU population is not supported by current evidence.
- Significant concerns exist regarding financial costs, development of antifungal resistance, and potential toxicity.
Conclusions:
- Widespread antifungal prophylaxis in non-neutropenic ICU patients is premature.
- Further research is required to develop and validate predictive tools for identifying ICU patients who would truly benefit from prophylaxis.
- A targeted approach is necessary to optimize antifungal use and mitigate risks.