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Bench-to-bedside review: Candida infections in the intensive care unit
Marie Méan1, Oscar Marchetti, Thierry Calandra
1Infectious Diseases Service, Department of Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.
Abstract:
Invasive mycoses are life-threatening opportunistic infections and have emerged as a major cause of morbidity and mortality in critically ill patients. This review focuses on recent advances in our understanding of the epidemiology, diagnosis and management of invasive candidiasis, which is the predominant fungal infection in the intensive care unit setting. Candida spp. are the fourth most common cause of bloodstream infections in the USA, but they are a much less common cause of bloodstream infections in Europe. About one-third of episodes of candidaemia occur in the intensive care unit. Until recently, Candida albicans was by far the predominant species, causing up to two-thirds of all cases of invasive candidiasis. However, a shift toward non-albicans Candida spp., such as C. glabrata and C. krusei, with reduced susceptibility to commonly used antifungal agents, was recently observed. Unfortunately, risk factors and clinical manifestations of candidiasis are not specific, and conventional culture methods such as blood culture systems lack sensitivity. Recent studies have shown that detection of circulating beta-glucan, mannan and antimannan antibodies may contribute to diagnosis of invasive candidiasis. Early initiation of appropriate antifungal therapy is essential for reducing the morbidity and mortality of invasive fungal infections. For decades, amphotericin B deoxycholate has been the standard therapy, but it is often poorly tolerated and associated with infusion-related acute reactions and nephrotoxicity. Azoles such as fluconazole and itraconazole provided the first treatment alternatives to amphotericin B for candidiasis. In recent years, several new antifungal agents have become available, offering additional therapeutic options for the management of Candida infections. These include lipid formulations of amphotericin B, new azoles (voriconazole and posaconazole) and echinocandins (caspofungin, micafungin and anidulafungin).
Insights
Invasive candidiasis is a critical fungal infection in ICUs. Advances in diagnosis and new antifungal treatments improve patient outcomes, especially with rising non-albicans Candida resistance.
Area of Science:
- Medical Mycology
- Infectious Diseases
- Critical Care Medicine
Background:
- Invasive mycoses, particularly invasive candidiasis, are significant causes of morbidity and mortality in critically ill patients.
- Candida species are a leading cause of bloodstream infections, especially in intensive care units (ICUs).
- A concerning trend shows a rise in non-albicans Candida species with reduced antifungal susceptibility.
Purpose of the Study:
- To review recent advances in the epidemiology, diagnosis, and management of invasive candidiasis.
- To highlight the challenges in diagnosing invasive candidiasis due to non-specific risk factors and limitations of conventional methods.
- To discuss the evolution of antifungal therapies for Candida infections.
Main Methods:
- Literature review focusing on recent studies and clinical observations.
- Analysis of epidemiological trends in Candida bloodstream infections.
- Evaluation of diagnostic markers beyond traditional cultures.
- Assessment of current and emerging antifungal treatment options.
Main Results:
- Invasive candidiasis is a major ICU-associated infection, with Candida species being the fourth most common cause of bloodstream infections in the USA.
- While Candida albicans remains prevalent, non-albicans species like Candida glabrata and Candida krusei are increasing, posing treatment challenges.
- Conventional methods like blood cultures have limited sensitivity; newer markers like beta-glucan show diagnostic promise.
- Newer antifungal agents, including lipid formulations of amphotericin B, newer azoles, and echinocandins, offer improved safety and efficacy profiles compared to older therapies.
Conclusions:
- Early diagnosis and prompt initiation of appropriate antifungal therapy are crucial for improving outcomes in invasive candidiasis.
- The emergence of drug-resistant non-albicans Candida necessitates continuous monitoring and adaptation of treatment strategies.
- Advances in diagnostics and the availability of novel antifungal agents represent significant progress in managing this life-threatening infection.
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