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Candida is the most common invasive mycosis in critically ill patients.
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Candidemia in the intensive care unit extends the length of stay, increases health care costs, and carries a high crude mortality.
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The contribution of non-albicans Candida species to this infection is on the rise.
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The role of antifungal administration before culture confirmation of candidemia in critical care units remains debatable.
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Echinocandins are the drug class of choice for the treatment of established intensive care unit
Candidemia in the Intensive Care Unit
Section snippets
Key points
Background
Candida is the most common invasive fungus in critically ill patients, and the candidemia rate in ICUs is about 10 to 20 times that of non-ICU settings.1, 2 Among critical care areas, the highest incidence belongs to burn units.3 Candidemia can impose a significant operational and budgetary burden on an ICU: it was shown to prolong ICU stay by nearly 13 days in one study while adding an estimated $8570 (€7800) in attributable costs in another, driven primarily by sepsis treatment itself.4, 5
Mycology
Candida spp are detected in the laboratory by their macroscopic growth as cream- to yellow-colored colonies (Fig. 1) or by microscopic visualization of budding yeast cells (Fig. 2, inset). C albicans is a dimorphic fungus capable of existence in either the yeast or the mycelial form depending on environmental conditions such as temperature. C albicans is also noteworthy for the ability to form true hyphae or elongated buds called pseudohyphae (see Fig. 2, main panel). Its hyphae originate from
Clinical Factors
Like many ubiquitous fungi, Candida spp can inhabit normal human hosts as gut commensals and colonizers of mucocutaneous surfaces without causing disease. Superficial candidiasis occurs in the presence of defects in both the innate and the adaptive cell-mediated immune responses that are vital antifungal defenses. An example of the former is vulvovaginal candidiasis in uncontrolled diabetes mellitus promoted by impaired neutrophil chemotaxis present in diabetics.31 The latter is exemplified by
Catheter-Related Bloodstream Infection
The bloodstream is the third most common site of infection in ICUs worldwide, reported in 15% of an international critically ill population in a point-prevalence study.51 Nosocomial bloodstream infections (BSIs) are intimately related to the presence of a CVC; it is not surprising, therefore, that about 50% of BSIs occur in the ICU. Central line–associated bloodstream infections (CLABSIs) are associated with increased mortality and health care costs.52, 53 Along with Pseudomonas aeruginosa,
Culture
Growth in culture remains the gold standard for diagnosing candidal infections, but this method suffers from delayed results, the potential for inadequate sampling by clinicians, and possible suppression by antifungal therapy. Obtaining cultures from sterile nonblood sites is associated with procedural risks. In an attempt to address these shortcomings, the matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF) system has been developed for the rapid speciation
Untargeted Therapy
Untargeted antifungal therapy against Candida can be classified according to the trigger for its initiation.88 Prophylaxis refers to treatment based on clinical patient characteristics that confer increased vulnerability to IC (eg, Ostrosky-Zeichner rule). Preemptive therapy is administered for microbiological (eg, colonization) and/or serologic (eg, BG) evidence but not proof of infection. Therapy started in the face of persistent sepsis alone is considered empirical. Optimal untargeted
Outcomes
Candidemia remains a highly lethal condition linked to several clinical, microbiological, and host factors. Many, but not all, reports have found an association between greater time to administration of appropriate antifungal therapy and increased risk of death.65, 110, 111, 112, 113 The same association has been observed for source control, although at least in the case of CVCs, definitive statements are hampered by the absence of robust trial data. Although a correlation between Candida
Summary
The last decade has ushered in major changes in several aspects of ICU candidemia. It has been marked by increasing recognition of non-albicans species as prominent pathogens in this infection. Efforts to expedite diagnosis have led to advances in culture-based identification as well as in the development of molecular diagnostics. These nonculture methods generally have high NPV but low PPV. Echinocandins have supplanted azoles as first-line antifungal agents for the treatment of confirmed
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Automatic classification of Candida species using Raman spectroscopy and machine learning
2023, Spectrochimica Acta - Part A: Molecular and Biomolecular SpectroscopyCitation Excerpt :Indiscriminate or prolonged antibiotic therapy is a major factor in developing candidiasis [8], and growth in culture is still the gold standard for Candida spp. its identification and diagnosis. However, culture-based methods have several drawbacks, such as species growth ratio, risk of inadequate sampling, and possible suppression by antifungal therapy [9]. Alternative techniques not based on cultures and widely used nowadays are the polymerase chain reaction (PCR) or the enzyme-linked immunosorbent assay (ELISA) [10].
Clinical impact of Candida respiratory tract colonization and acute lung infections in critically ill patients with COVID-19 pneumonia
2022, Microbial PathogenesisCitation Excerpt :Bronchial colonization by Candida spp. is prevalent among patients who use automatic ventilation in the intensive care unit (ICU). Candida colonization has been found in approximately 30% of people who used mechanical ventilation (MV) for longer than 48 h and in 50% of those diagnosed with ventilator-associated pneumonia (VAP) [9,10]. Isolation of Candida spp. via the respiratory tract is linked to longer periods of MV, ICU admission, and hospital stay, with attendant poorer outcomes [11–13].
Can There Be a Relationship Between Oral Candidiasis and Candidemia in ICU Patients?
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Disclosure Statement: The authors have nothing to disclose.