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Fungal infection in surgical patients
1Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756-0001, USA.
Abstract:
Invasive fungal infections have become a major source of morbidity and mortality in the modern surgical intensive care unit. Patients at risk for invasion and dissemination are common, and are not as ill as thought previously. Severity of illness (APACHE II score > 10, ventilator use for >48 hours), antibiotics, central venous lines, total parenteral nutrition, burns, and immunosuppression are the most common risk factors. Recognition of these risk factors should arouse a high index of suspicion for the diagnosis of invasion or dissemination. Unfortunately, laboratory tests alone lack sensitivity and specificity. Therefore, the diagnosis of invasion and dissemination in the majority of cases requires the acquisition and proper interpretation of clinical evidence. Once the diagnosis is made, early systemic treatment is warranted. Reported toxicity and efficacy supports the use of fluconazole for most patients with invasive fungal infections. However, for the most critically ill patients amphotericin B remains the treatment of choice.
Insights
Invasive fungal infections are a significant threat in surgical ICUs. Early recognition of risk factors and clinical evidence are crucial for diagnosis and prompt treatment with antifungals like fluconazole or amphotericin B.
Area of Science:
- Critical Care Medicine
- Infectious Diseases
- Surgical ICU Management
Background:
- Invasive fungal infections (IFIs) are a leading cause of morbidity and mortality in surgical intensive care units (ICUs).
- Patients at risk for IFIs are more common than previously recognized and may not present with extreme illness.
- Identified risk factors include high severity of illness (APACHE II score > 10), prolonged mechanical ventilation (>48 hours), antibiotic use, central venous catheters, total parenteral nutrition, burns, and immunosuppression.
Purpose of the Study:
- To highlight the significance of invasive fungal infections in surgical ICUs.
- To emphasize the importance of recognizing risk factors for early diagnosis.
- To discuss diagnostic challenges and treatment strategies for IFIs.
Main Methods:
- Review of clinical evidence and risk factors associated with invasive fungal infections in surgical ICU patients.
- Evaluation of diagnostic limitations of laboratory tests.
- Assessment of treatment options, including fluconazole and amphotericin B.
Main Results:
- Laboratory tests for IFIs often lack sufficient sensitivity and specificity.
- Diagnosis frequently relies on the interpretation of clinical evidence.
- Early systemic treatment is essential once IFIs are diagnosed.
Conclusions:
- A high index of suspicion is necessary for diagnosing IFIs in at-risk surgical ICU patients.
- Clinical judgment is paramount in diagnosing IFIs due to limitations in laboratory diagnostics.
- Fluconazole is recommended for most IFIs, while amphotericin B is the preferred treatment for critically ill patients.