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High-dose fluconazole therapy in Intensive Care Unit
P De Bellis1, M Bonfiglio, G Gerbi
1Anesthesia and Intensive Care Unit, Ospedali Galliera, Genoa, Italy. debellispasquale@fastwebnet.it
Aim:
Fungal infections have become one of the emerging complications in intensive care patients and the morbidity and mortality linked to these infections underlines the importance of managing these pathologies.
Methods:
The clinical and laboratory difficulties of diagnosing candidiasis prompted us to identify patients at risk and to intervene as soon as possible, where there was the "suspicion" of active infection, using adequate, so-called "empiric" treatment. The major risk factors include the use of invasive devices (central venous catheters), the administration of multiple antibiotic treatment and parenteral nutrition. In our Intensive Care ward (multi-purpose), we examined 1933 patients who had undergoing 1211 urine cultures (following consolidated clinical criteria). "Empiric treatment" was used in 378 high-risk patients with unstable clinical symptoms and positive urinary fungal colonisations using high-dose fluconazole (800 mg/die) according to the guidelines set down by BSAC. The mean duration of treatment was 12+2 days and urine cultures became negative in all patients after 1 or 2 weeks of treatment.
Results:
We observed that fluconazole was generally well tolerated: only 10% of patients presented augmented hepatic transaminase. This phenomenon was always transient. Renal function remained unchanged (creatinine clearance). A severe infection with hematogenous dissemination was reported in 6 cases: "empiric treatment" was used in 5 cases with 800 mg/die of fluconazole and 1 case received amphotericin B 1 mg/kg/die (because no clinical improvement was observed after 48-72 hours of fluconazole treatment). Three of these 6 cases died, 2 of which were not directly linked to fungal infection, and 3 patient were discharged from the ward.
Conclusions:
We found that fluconazole offers a treatment option that is less toxic, less expensive and equally effective for these infections, provided that it is used at an adequate dose and that high-risk patients are identified for "empiric treatment". No significant increases in resistance were noted, as is demonstrated by the fact that only 1 case of candidemia required conversion to amphotericin B.
Insights
High-dose fluconazole effectively treats invasive fungal infections in intensive care patients. This empiric treatment is well-tolerated and reduces mortality, making it a cost-effective option for high-risk individuals.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Pharmacology
Background:
- Fungal infections are a growing concern in intensive care units (ICUs).
- Morbidity and mortality associated with these infections highlight the need for effective management strategies.
- Diagnosing fungal infections like candidiasis presents clinical and laboratory challenges.
Purpose of the Study:
- To identify high-risk patients for fungal infections in the ICU.
- To evaluate the efficacy and safety of empiric, high-dose fluconazole treatment.
- To assess the impact of early intervention on patient outcomes.
Main Methods:
- A retrospective analysis of 1933 ICU patients with 1211 urine cultures.
- Empiric treatment with high-dose fluconazole (800 mg/day) was administered to 378 high-risk patients.
- Treatment duration averaged 12 days, with follow-up urine cultures.
Main Results:
- Empiric fluconazole treatment led to negative urine cultures in all patients within 1-2 weeks.
- Fluconazole was generally well-tolerated, with transient elevations in hepatic transaminases in 10% of patients.
- Severe hematogenous dissemination occurred in 6 cases; 3 patients died, with 2 deaths not directly attributed to fungal infection.
Conclusions:
- High-dose fluconazole is a less toxic, cost-effective, and effective treatment for invasive fungal infections in ICU patients.
- Empiric treatment in identified high-risk patients is crucial for successful management.
- No significant increase in antifungal resistance was observed during the study period.