Invasive candidiasis in the ICU: prophylaxis versus preemptive treatment

Candidemia/invasive candidiasis has increased in incidence over the past 15 years. Because of numerous risk factors, intensive care unit patients have a predilection for this type of infection. Most of these infections are acquired endogenously, but occasionally may result from an exogenous source. Antifungal prophylaxis and preemptive antifungal therapy have been developed to prevent candidemia/invasive candidiasis. Antifungal prophylaxis with azoles has been demonstrated to reduce candidemia, overall mortality, and attributable mortality. This strategy is also effective for the prevention of invasive fungal infection in liver transplant recipients. Preemptive treatment appears to be a more focused intervention that uses markers (eg, the presence of colonization) and serologic testing to trigger the initiation of antifungal therapy. Further developments in serologic testing are necessary to enhance the precision of selecting the patients at risk for candidemia/invasive candidiasis. The optimum agent to be used prophylactically and for preemptive therapy requires further clinical investigation.