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Infect Dis Clin North Am. Sep;31(3) doi: / . Epub Jul 5. Invasive Fungal Infections in the Intensive Care Unit.
Table of contents

JAMA — BMC Anesthesiol Current Fungal Infection Reports — Critical Care J Microbiol Immunol Infect — Clin Infect Dis — J Clin Microbiol e— Clin Infect Dis e1— Lancet Respir Med, — Ann Intern Med — Clin Microbiol Infect 24 Suppl 1:e1—e Intended for emergency transtracheal catheter ventilation when conventional ventilation by mask or endotracheal tube cannot be performed. Features and benefits The set provides clinicians with a compact solution for quickly establishing Designed for many applications. Venue is a multi-purpose, point of care system that is also well-suited to help you manage patients in shock.

It includes automated tools that enable you to quickly get the information you need to make fast decisions Precise Control Enjoy maximum performance at all stages of anesthesia A full range of ICU grade ventilation modes meet your demands through all the stages of anesthesia. Digital gas mixer with safe low flow by Optimizer The digital Masimo announced today three additional indices delta cHb, delta HHb, We conducted a systematic literature search using search engines like PubMed and Google with the use of the following single text words and combinations: Fungal infections in ICU, invasive fungal infections, antifungal therapy - recent trends.

The PubMed search was made from the year till date. The references of relevant articles were cross checked and the articles describing various types of fungal infections in the intensive care unit and recent trends in treatment of fungal infections were included. The diagnosis of fungal infections in critically ill patients is an extremely difficult task as the symptoms are invariably masked by the presence of dominant primary pathology.

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The etiology of fungal infections can be broadly subdivided into systemic infections caused by true pathogenic fungi and infections caused by opportunistic saprophytic fungi. It is the most common among endemic mycosis, and is caused by a soil-dwelling dimorphic fungus, Histoplasma capsulatum. It is endemic in most parts of the United States and in many states in India.

Review of Invasive Fungal Infections -- Rod Quilitz, Pharm.D

The portal of entry is respiratory tract, with severity of disease depending on the infecting dose. The spectrum of disease varies from mild pulmonary disease, severe pulmonary disease, chronic pulmonary disease and disseminated histoplasmosis. The chest radiograph may show multilobar infiltrates but is not diagnostic, while in patients with full-blown acquired immunodeficiency syndrome AIDS , it may show predominantly reticulonodular infiltrates.

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The diagnosis is by a high degree of suspicion, with a positive travel history to the endemic area, while the demonstration of Histoplasma antigen in urine, blood or bronchoalveolar lavage fluid of infected patients is diagnostic and rapid. If disseminated histoplasmosis is suspected, then a bone marrow biopsy may be helpful. Most infections are self-limited and require no specific treatment.

The treatment of severe and disseminated disease involves administration of amphotericin B; both the conventional and the lipid formulations can be used. However, the lipid formulation is found to be less nephrotoxic. Following initial stabilization, oral itraconazole can be added twice daily for at least 12 months.

The incidence of blastomycosis is much less than that of histoplasmosis, and the endemicity exhibit almost similar pattern as of histoplasmosis.

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The usual clinical presentation is a community-acquired pneumonia not responding to usual antibiotics. It is less common in HIV-infected patients, but, if present, produces widely disseminated disease often involving the meninges. Other sites of infections are skin, bones and genitourinary tract. Definitive diagnosis requires growth of organism from a clinical specimen. The treatment for the severe infection causing respiratory distress is by Amphotericin B both conventional and liposomal , and followed by oral itraconazole twice daily for 12 months after initial stabilization.

The meningitis usually responds to Amphotericin B with concurrent or sequential itraconazole or fluconazole. It is caused by the soil-dwelling dimorphic fungus Coccidiodes immitis , which is found to be endemic in the desert-like terrain of America. The portal of entry is by respiratory tract and the usual presentation is community-acquired pneumonia.

The most dreaded complication is meningitis, which may or may not be preceded by an acute illness. The patient presents with increasing severity of headache with altered mental status, which may lead on to development of hydrocephalus. Occasionally, it may present as stroke syndrome due to vasculitis of cerebral vessels.

The diagnosis is by demonstration of fungus from culture of respiratory secretions or of cerebrospinal fluid, and is thus more difficult. The serologic tests are usually used to establish the diagnosis.


The cerebrospinal fluid analysis in meningeal disease shows predominantly lymphocytic pleocytosis with occasional eosinophils. The treatment is often difficult as it is less susceptible to antifungal drugs as compared with histoplasmosis or blastomycosis. In severe and disseminated disease, amphotericin B liposomal or conventional is still used; however, oral fluconazole or itraconazole is considered the main drug for less-severe disease. There is, however, no consensus for treatment duration.

These fungal infections may or may not exhibit clinical symptomatology, but their occurrence greatly affect the prognosis and outcome. The most challenging aspect is the timely diagnosis, and by that time it almost causes a great damage to the cellular functions. Once diagnosed, it should be treated as an emergency that can substantially lower the morbidity and mortality among critically ill patients. These opportunistic fungal infections pose numerous challenges and difficulties in the management of critically ill patients, especially those who need broad-spectrum antibiotics for their primary pathology.

It involves fungi like Candida, Cryptococcus, Aspergillus and Zygomycetes, which are regularly associated with immunocompromised patients such as hematooncological patients, patients undergoing organ transplantation or patients with immunodeficiency syndromes. Invasive fungal infections with Candida spp. Opportunistic candidial infections in patients with AIDS have been reduced due to the advent of highly active antiretroviral therapy HAART in developed nations, but it is still high in developing nations like India due to the high cost of such therapy. Laboratory tests can aid in increasing the accuracy of the above tests in diagnosing invasive candidiasis.

The various laboratory tests involved are:. Beta-D-Glucan assay: It detects b-D-glucan, an important constituent of the cell wall of pathogenic fungi. It cannot however differentiate between Candida and Aspergillus, and is not helpful in diagnosing infection with Cryptococcus and Zygomycetes.

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A single positive test has low sensitivity for diagnosing invasive candidiasis, and serial measurements may be more sensitive. Polymerase chain reaction PCR : It detects fungal nucleic acid and has been found to have a sensitivity of Pre-emptive treatment: It is considered in those patients who have a high risk of developing candidiasis but lack a definitive diagnosis of infection.

Fluconazole in a dose of mg to mg per day is usually used, and this therapy has shown to significantly reduce the incidence of definitive candidiasis. Prophylactic treatment: The prophylactic use of fluconazole is recommended in patients receiving chemotherapy for hematologic malignancies who are expected to be neutropenic, in patients with solid organ transplantation and in patients undergoing bone marrow transplantation.

This prophylaxis can also be used in non-neutropenic at-risk intensive care patients. Definitive treatment: In patients with a definitive diagnosis of candidiasis, all catheters, including the central venous catheter, should be removed and invasive candidiasis such as endophthalmitis should be excluded. In clinically stable patients, fluconazole is used in a dose of mg to a maximum of mg per day for at least 2 weeks after the last positive blood culture unless azole resistance is suspected. Echinocandins caspofungin, micafungin, anidulafungin should be preferred if NAC such as C.

In unstable and severely ill patients, amphotericin B conventional or liposomal alone or in combination with fluconazole, echinocandins caspofungin, micafungin, anidulafungin , voriconazole or high-dose fluconazole mg per day may be used. The duration of therapy should be 14 days after the first negative blood culture and clinical resolution of symptoms in patients with candidaemia.

Fungal infections in the ICU: advances in treatment and diag : Current Opinion in Critical Care

In patients with invasive candidiasis, antifungal treatment has to be given for a longer period of time until clinical and radiological resolution of the disease. Aspergillosis is a serious infection in the intensive care unit, which is difficult to diagnose due to the lack of definitive diagnostic criteria. Majority of infections are caused by A. In India, A. The risk factors for development of invasive aspergillosis are similar to that of invasive candidiasis, with the predominance of immunosuppression in aspergillosis.

Chronic obstructive pulmonary disease is considered to be an important risk factor for aspergillosis. The portal of entry is mainly the respiratory tract, both lungs and sinuses. Aspergillosis can be acquired in the intensive care unit through an improperly cleaned ventilation system and contaminated water. The diagnosis of aspergillosis is often difficult, and the following methods are employed:.

Culture and histopathology: Identification of the fungus in culture and tissue specimens is the gold standard for diagnosing aspergillosis, but may not be feasible in the intensive care setting due to the long time required and difficulty in obtaining tissue samples in these patients.

Galactomannan test: It is an important constituent of the cell wall and it can be detected in the serum or bronchoalveolar lavage fluid; however, brochoalveolar lavage is considered to be more sensitive. PCR: It detects the fungal nucleic acid and is sensitive when combined with other tests. Combination of bronchoalveolar lavage fluid galactomannan test with the PCR greatly increases the detection of Aspergillus spp. Detection of aspergillus from patients without any risk factors should encourage further diagnostic workup. Amphotericin B was initially used as the mainstay therapy, but, due to various adverse effects, voriconazole has now become the treatment of choice.

The treatment for invasive aspergillosis can be described as:. This should be followed by oral voriconazole mg twice daily until clinical and radiological stabilization occurs. Salvage therapy: Echinocandins are utilized in this therapy when the primary therapy fails. Intravenous Caspofungin in a dose of 70 mg on Day 1, followed by 50 mg per day thereafter is usually used; however, intravenous micafungin can also be used.

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Recently, oral posaconazole in a dose of mg every 6 hourly, followed by mg twice daily, has been found to be equally effective. Combination therapy: There has been interest in the combination of various antifungal agents for the treatment of invasive aspergillosis and combination of liposomal amphotericin B and itraconazole as well as combination of voriconazole with caspofungin has been studied and found to be equally effective. The therapy is usually continued for weeks.

The galactomannan test can be used as a marker of effectiveness of the therapy.