Invasive fungal infections in ICU- [Greek]
Authors: Schizodimos Th, Soulountsi V.
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Invasive fungal infections are a growing problem in critically ill patients and are associated with increased morbidity and mortality. Complex medical and surgical problems, disruption of natural barriers, multiple invasive procedures and prolonged antibiotic treatment are some of the factors contributing to the alarming increase of fungal infections in the Intensive Care Unit (ICU) setting. In terms of occurrence rates, the most important fungal infections are invasive candidiasis (IC) and invasive pulmonary aspergillosis (IPA). Invasive candidiasis in ICU patients includes mainly candidemia, primary or catheter-related, and intra-abdominal candidiasis. Candida bloodstream infections occur at highest rates in the ICU population, with this setting accounting for 33–55% of all candidemias. The epidemiology of Candida infections is not constant. Incidence rates, species distribution, and even antifungal susceptibility seem to be changing.The Candida species that are responsible for more than 90% of all IC including candidemias are C. albicans, C. glabrata, C. krusei, C. parapsilosis, and C. tropicalis. Although the most common Candida species responsible for bloodstream infection remains C. albicans, the past two decades has seen a rising proportion of infections caused by non-albicans species. This changing spectrum has been partly explained by the increasing prophylactic use of fluconazole and other antifungal regimens, the presence of a central venous catheter, the mean number of antibiotics per day and neutropenia. The emergence of clinical treatment failures in Candida spp. due to resistant isolates is also described in last decade. This trend reflects the large and expanding use of newer broad-spectrum antifungal agents, such as triazoles and echinocandins. Echinocandin resistance in Candidais a great concern, as the echinocandin drugs are recommended as first line therapy for patients with IC. Invasive pulmonary aspergillosis (IPA) may be one of the most lethal and unrecognized infections in critically ill patients. Lastly, there is a growing appreciation of IPA in patients without classicrisk factors, such as critically ill patients without documented immunodeficiency. The new emerging risk factors include chronic obstructive pulmonary disease, chronic use of systemic and inhaled corticosteroids, cirrhosis, malnutrition, and severe sepsis. Data regarding the incidence of invasive aspergillosis in ICU are scarce, and the incidence varies as the diagnosis of IA remains difficult as well as the discrimination between colonization andprobable IPA in ICU patients with Aspergillus-positive endotracheal aspirate cultures. In more recent studies a recent trend of decreasing mortality in patients with aspergillosis has been described. This decreasing trend may have resulted from numerous factors, including appropriate antifungal therapy, more timely and accurate diagnostic approaches, earlier initiation of therapy and technological advances in ICU care.