Invasive candidiasis: turning risk into a practical prevention policy?

See the article by Blumberg et al. on pages 177–86. For 3 decades, systemic antifungal use was virtually a 1-drug act—amphotericin B. Administration of antifungal agents to critically ill patients was dominated by fear of toxicity rather than knowledge of its efficacy. In the past decade, the availability of azole antifungal agents with enhanced pharmacokinetic and safety profiles completely revolutionized systemic antifungal use. If anything, their arrival caught cli-nicians unprepared, and guidelines for the optimal use of triazoles lagged behind common practice utilization. Use of azole drugs in the surgical intensive care unit (SICU) has become an established fact of life, with use unimpeded by the slow development or, in many areas, complete absence of useful data. In the meantime, the frequency of in-vasive, often life-threatening candidal infections has increased dramatically [1, 2], largely as a function of medical technological advances (e.g., vascular catheters, total parenteral nutrition [TPN], hemo-dialysis) and the enhanced ability of cli-nicians to keep critically ill patients alive. Much early attention was focused on patients with neutropenia, and considerable progress has been made in validating the efficacy of antifungal prophylaxis and conducting prospective, randomized, controlled trials that support the use of an-tifungal agents for the treatment of persistently febrile patients with neutro-penia who do not respond to antibiotics [3, 4]. These 2 policies have resulted in control of and actual reduction in the frequency of bloodstream infections (BSIs) due to Candida species and systemic can-didiasis in patients with neutropenia. Now attention has turned toward patients without neutropenia. In fact, most BSIs due to Candida species now occur in patients who have been hospitalized in intensive care units (ICUs), especially adult SICUs and neonatal ICUs. Moreover , throughout the world, the dominance of Candida albicans has been challenged by the increased prevalence of serious infection caused by non-albicans Candida species. Candida species are now the fourth most common bloodstream isolates, following coagulase-negative staphylococci, Staphylococcus aureus, and enterococci [5–7]. Although BSIs caused by Candida species continue to be the primary end point in observational and interventional studies, invasive candidal infections that involve the abdominal cavity, bone, soft tissue, or other sites are no less important and are responsible for considerable morbidity and death. Several retrospective studies have identified multiple risk factors for candidal BSI in patients in the ICU [8–14]. Most of the risk factors have been repeatedly verified, although others are more controversial. Major risk factors include use …