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Initial Antifungal Therapy for Critical Ill Patients When and Which ?

Initial Antifungal Therapy for Critical Ill Patients When and Which ?. 2012-02-21. 林口長庚 胸腔內科 林鴻銓 Lin, Horng-Chyuan Division of Pulmonary Infectious & Immunological Disease Department of Thoracic Medicine Chang Gung Memorial Hospital Chang Gung University. Fungal Infections in the ICU.

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Initial Antifungal Therapy for Critical Ill Patients When and Which ?

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  1. Initial Antifungal Therapy for Critical Ill PatientsWhen and Which ? 2012-02-21 林口長庚 胸腔內科 林鴻銓 Lin, Horng-Chyuan Division of Pulmonary Infectious & Immunological Disease Department of Thoracic Medicine Chang Gung Memorial Hospital Chang Gung University

  2. Fungal Infections in the ICU Characteristics of fungal infection Aspergillus and Candida (75%) Impact of invasive fungal infection on outcomes of severe sepsis: a multicenter matched cohort study in critically ill surgical patients,Critical Care 2008, 12:R5

  3. 40 35 30 25 20 15 10 5 0 Candida - the Third Most Common Cause of BSI in the ICU Cause of nosocomial BSI in the ICU (US; 1995-2002) 35.9% BSI=Blood stream infection. ICU=Intensive care unit. Wisplinghoff H et al. Clin Infect Dis. 2004;39:309-317. Cause of infection (%) 16.8% 10.1% 9.8% 4.7% CoNS Staph Candida Entero-coccus Pseudo-monas

  4. More than 50% of Systemic Candida Infection - Caused by Candida albicans Europe(1992-2001; N=775) US(1992-2001; N=3683) 13% C glabrata 18% 14% C parapsilosis 13% C albicans58% C albicans54% 8% C tropicalis 10% 3% C krusei 2% 5% Other spp 2% Pfaller MA et al. Clin Microbiol Infect. 2004;10(suppl 1):11-23.

  5. Consensus Statement on the Management of Invasive Candidiasis in ICU in the Asia-Pacific Region Distribution of Candida spp. associated with candidaemia in selected Asian countries International Journal of Antimicrobial Agents 34 (2009) 205–209

  6. Risk Factors for Invasive Candidiasis Use of antibacterials The catheter Medical interventions Underlying Diseases Neutropenia Candida colonization Colonization Host factors Damaged mucosa

  7. Risk Factors for Invasive Candidiasis Chemotherapy Dialysis Central venous catheters Antibiotic use (risk increases with each additional antibiotic) Parenteral nutrition Prior surgery (especially abdominal) Length of ICU stay of 7 days Nasogastric tubes Gastric acid suppression Medical interventions Candida colonization Extremes of age Neutropenia Renal failure Higher APACHE II score Trauma/burns Bowel perforation Host factors

  8. Diagnostic Tests for Invasive Candidiasis Infection Invasion Colonization

  9. Early Antifungal Intervention Strategies in ICU Patients Antifungal therapy Crit Care Med 2010; 38[Suppl.]:S380 –S387

  10. Development of Anti-fungal Agents 1st Tri-azoles Fluconazole itraconazole 2nd Tri-azole: Vfend Echinocandins: Cancidas Polyenes Nystatin Amphotericin B Lipid Amphotericin B Ambisone Abelcet Amphocil EarlyAzoles Clotrimazole Miconazole Ketoconazole Micafungin Posaconazole 2004 1950~ 1990~ 1970~80 2002~ 1997~

  11. Diseases caused by Aspergillus infection Invasive Aspergillosis Chronic Necrotizing Aspergillosis Aspergillomas ABPA allergic sinusitis Neutropenia Hematopoietic Stem Cell Transplantation Solid Organ Transplantation AIDS Chronic Granulomatous Disease Structural lung disease General debilitation Preexisting Fibrocavitatory lung diseases Asthma Bronchiectasis Cystic fibrosis Immune Response Patients in MICUs ?

  12. “Halo Sign” Is an Early Indicator of Invasive Pulmonary Aspergillosis Halo Sign Greene RE, et al. Clin Infect Dis. 2007; 44:373-379. VFE-M-0804007

  13. Invasive Pulmonary Aspergillosis in Non-neutropenic Critically Ill Patients Intensive Care Med (2007) 33:1694–1703

  14. Antifungal Drugs for Invasive Pulmonary Aspergillosis in Critically Ill Patients in ICU Intensive Care Med (2007) 33:1694–1703

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