Surgical perspective on invasive Candida infections

Invasive and disseminated Candida infections have become a major source of morbidity and mortality in the modern surgical intensive care unit. The most common risks for invasion and dissemination are the use of antibiotics, central venous lines, total parenteral nutrition, burns, immunosuppression, and other markers for severity of illness (APACHE > 10, ventilatory use for > 48 hours). Data suggest that colonization can be a late predictor of invasive disease in today's critically ill surgical patient and that prophylaxis or early treatment in high risk patients is warranted, particularly before invasive/disseminated disease becomes life-threatening. When advanced disease is present, the diagnosis of invasive or disseminated Candida infection is often prompted by clinical suspicion and supported by consistent clinical data; laboratory tests alone lack sufficient sensitivity and specificity to direct therapeutic decision-making. Once the diagnosis of invasive or disseminated Candida infection is ascertained, early systemic treatment, along with treatment of localized infection, is as fundamental as with any other serious infectious disease. Reported toxicity and efficacy supports the use of fluconazole for most patients with invasive/disseminated Candida infections. For the most critically ill surgical patient amphotericin B remains the treatment of choice. Prophylaxis and early treatment strategies with minimally toxic agents may diminish the need to use more toxic therapy in the most severely ill patients.