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Published on: February 14, 2018
Clinical trials of antifungal prophylaxis among patients undergoing surgery
Thierry Calandra1, Oscar Marchetti
1Infectious Diseases Service, Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. Thierry.Calandra@hospvd.ch
Abstract:
Invasive mycoses have emerged as a major cause of morbidity and mortality. Epidemiological studies have shown that surgery services have the highest rate of Candida infections in the hospital. In addition to classical risk factors, heavy Candida colonization, recurrent gastrointestinal perforations, and acute pancreatitis are frequently associated with invasive candidiasis. Because prompt initiation of antifungal therapy is critical for cure but difficult to accomplish, prevention of fungal infections may play an important role in this clinical setting; however, few prophylactic or preemptive studies have been done to date. The choice, route of administration, and dose of the antifungal and comparator regimens and the use of clinically relevant and robust study end points are critical for the trial design. Various criteria have been used to identify patients at risk of candidiasis: surgical condition, presence of multiple risk factors, colonization indexes, or expected length of stay in the intensive care unit. Some are not selective enough, and others are time consuming and expensive. Rigorous selection of high-risk patients is crucial to optimize the risk-benefit ratio of preventive antifungal strategies. The aim is to maximize chances of reducing morbidity and mortality while minimizing treatment costs, exposure of low-risk patients to adverse events, and emergence of resistant fungal strains.
Insights
Preventing invasive Candida infections in surgical patients is crucial. Early identification of high-risk individuals is key to effective antifungal prophylaxis, reducing mortality and complications.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Hospital Epidemiology
Background:
- Invasive mycoses, particularly Candida infections, are significant causes of hospital morbidity and mortality.
- Surgery services exhibit the highest rates of Candida infections.
- Risk factors include heavy Candida colonization, gastrointestinal perforations, and acute pancreatitis.
Purpose of the Study:
- To highlight the critical need for effective prevention strategies against invasive candidiasis in high-risk surgical patients.
- To emphasize the importance of rigorous patient selection for antifungal prophylaxis trials.
- To optimize the risk-benefit ratio of preventive antifungal therapies.
Main Methods:
- Review of epidemiological data on Candida infections in hospital settings.
- Analysis of various criteria used for identifying patients at risk of candidiasis.
- Discussion of critical factors for designing prophylactic or preemptive antifungal studies.
Main Results:
- Prompt antifungal therapy is vital but challenging to initiate.
- Few studies have focused on prophylactic or preemptive antifungal strategies.
- Current risk identification methods vary in selectivity, cost, and time efficiency.
Conclusions:
- Rigorous selection of high-risk patients is essential for successful preventive antifungal strategies.
- Optimizing patient selection minimizes treatment costs and adverse events.
- Preventive strategies aim to reduce morbidity and mortality while mitigating antifungal resistance.
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