Pre-emptive strategies in non bacterial infection (J De Waele @CriticCareDoc)
Invasive candidiasis has a high mortality (>50%) and expensive (>USD 40K), yet difficult to diagnosis
Terminology important – prophylaxis, pre-emptive, empirical vs directed therapy
Cochrane review available
Risk factors – antibiotic exposure, CVC, TPN, surgery, length of stay, etc BUT ICU climate has changed, better antiobiotic stewardship, less TPN etc
How to predict development of invasive candidiasis
- Colonisation index – number of positive sites/total sites
- Candida score – surgery, TPN, sepsis
- Clinical prediction rule
Key messages
- Antifungal stewardship
- Untargeted antifungal treatment complex issue
- Optimal pt population for prophylaxis difficult to identify
- Recurrent intestinal leakage after surgery most obvious indication
- Major impact of antifungal strategies remain to be demonstrated
- Invasive disease incidence lower – changing risk factors?
References:
Antifungal agents for preventing fungal infections in critically ill adults and children with a normal number of neutrophils in the blood
Clinical prediction rules for invasive candidiasis in the ICU: ready for prime time?
Empirical Micafungin Treatment and Survival Without Invasive Fungal Infection in Adults With ICU-Acquired Sepsis, Candida Colonization, and Multiple Organ Failure. The EMPIRICUS Randomized Clinical Trial
Clinical Practice Guidelines for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America
Invasive candidiasis: current therapy in critical care (H Qiu)
Major difficulty is differentiating colonisation vs infection
Fungal infection is under diagnosed – post-mortem findings
Candida albican is the major species BUT the situation is changing: Development of flucanozole resistance is increasing in countries e.g. China
Prediction scores have high negative predictive value but poor positive predictive value
Take home message
- Move common that thought
- High mortality
- Earlier therapy not easy
- Get it right first time (echinocandins)
- De-escalate
- Resistance if under treated/dosed
References:
ESCMID† guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients
Severe dengue fever: the role of the intensivist (CM Chen)
Global burden – increase population, global warming, rapid urbanisation
Tropical climate
Spread by the female Aedes mosquito
Dengue classification 1997 – undifferentiated, dengue fever, dengue hemorrhagic fever; updated in 2009 into classes A, B and C
Diagnosis – serology
Dengue fever can cause multi-organ failure
Co-current bacterial infection not uncommon
References:
WHO Dengue guidelines 2009
Critical care for dengue in adult patients: an overview of current knowledge and future challenges
