ESICM/ESCMID recommendations on practice management of invasive candidiasis in ICU
Invasive candidiasis (IC) refers to bloodstream and deep-seated candida infection (eg. peritonitis). Its incidence in the ICU has gradually increased in association with the diffusion of complex surgical procedures and typical risk factors for this infection (severe acute physiology derangement and great burden of comorbidity).
Despite the severity of the disease, associated with a 40% mortality in critically ill patients, specific guidelines dedicated to ICU were still lacking, mainly for the absence of randomised control trials (RCTs) restricted to this type of patients.
For this reason, a group of 18 experts with different backgrounds and a specific interest in the management of IC in ICU patients, reviewed the available literature to produce a list of practical recommendations on this topic. The task force used the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach to evaluate the recommendations and to assign levels of evidence. The recommendations and their strengths were decided by consensus and, if necessary, by vote (modified Delphi process).
Combining epidemiological data, clinical evidence and expert opinions, nine practical topics have been addressed: risk prediction models, conventional and non-culture-based microbiological techniques, antifungal prophylaxis, pre-emptive therapy, empirical antifungal treatment, choice of first line empirical antifungal, role of amphotericin in the critically ill patient, de-escalation of antifungal therapy and duration of treatment.
STUDY STRENGTHS & LIMITATIONS
This paper presents the first recommendations for IC, specifically focused on the critically ill patient. Effort has been made to answer specific questions emerging from the clinical practice of ICU physicians.
Guideline limitation: In the absence of evidence coming from RCTs, the resulting statements are based solely on epidemiological and clinical evidence in conjunction with expert opinion.
TAKE HOME MESSAGE
The ESICM recommendations form the first official publication aiming to guide the management of critically ill patients affected by IC. Future research (possibly RCTs) will provide better scientific evidence to define the best management strategies.
This article review was prepared and submitted by Andrea Pradella, MD Humanitas Clinical and Research Centre, Milan, Italy.
1) Martin-Loeches I, Antonelli M et al., ESICM/ESCMID task force on practical management of invasive candidiasis in critically ill patients, Intensive Care Med. 2019 Jun;45(6):789-805.