EuAsia 2017 Day 2: Not only bacteria

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?

2017-04-07 14.31.10 2017-04-07 14.20.12

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