The EMPIRICUS trial-the final nail in the coffin of empirical antifungal therapy in the intensive care unit?

Current Utilization of Antifungal Agents for Intra-abdominal Infections Categorized by Patient Risk Factors During Surgical Procedures: A Literature Review

The high morbidity and mortality rates associated with invasive fungal infections have led to the overutilization of empiric antifungal therapies. With increasing antibiotic resistance, the careful consideration of prophylactic or empiric antifungal use is critical. The purpose of this review is to evaluate the available literature regarding the current practice of utilizing antifungal agents for intra-abdominal infections based on specific surgical procedures and patient risk factors. Relevant articles were identified through a comprehensive literature search of several databases using the keywords antifungal agents, postoperative period, preoperative care, surgical procedures, and intra-abdominal infections. Only articles that evaluated the use of empiric antifungals for suspected or confirmed intra-abdominal infections and surgical procedures were included in this review. Based on the available literature, antifungal prophylaxis is appropriate in patients who meet the criteria for high-risk invasive candidiasis, kidney or liver transplant recipients, severely-immunocompromised patients with perforated peptic ulcer, peritonitis, and patients on peritoneal dialysis who are failing on a therapeutic antibiotic regimen. We acknowledge that the evidence for using antifungal therapy empirically for all surgical procedures is lacking, and the following review is based on available literature and current guidelines.

Candidiasis and Other Emerging Yeasts

Purpose of Review

The review presents a comprehensive and updated information on the contemporary status of invasive candidiasis (IC), other emerging yeast infections, and the challenges they present in terms of at-risk population, specific virulence attributes, and antifungal susceptibility profile.

Recent Findings

With the advancement in medical field, there has been parallel expansion of vulnerable populations over the past two decades. This had led to the emergence of a variety of rare yeasts in healthcare settings, both Candida and non-Candida yeast causing sporadic cases and outbreaks. The advancements in diagnostic modalities have enabled accurate identification of rare Candida species and non-Candida yeast (NCY) of clinical importance. Their distribution and susceptibility profile vary across different geographical regions, thus necessitating surveillance of local epidemiology of these infections to improve patient outcomes.

Summary

The challenges in management of IC have been complicated with emergence of newer species and resistance traits. C. tropicalis has already overtaken C. albicans in many Asian ICUs, while C. auris is rising rapidly worldwide. Recent genomic research has reclassified several yeasts into newer genera, and an updated version of MALDI-TOF MS or ITS sequencing is necessary for accurate identification. Having a knowledge of the differences in predisposing factors, epidemiology and susceptibility profile of already established pathogenic yeasts, as well as new emerging yeasts, are imperative for better patient management.

T2Candida MR as a predictor of outcome in patients with suspected invasive candidiasis starting empirical antifungal treatment: a prospective pilot study

Objectives

We assessed the potential role of T2Candida MR (T2MR) and serological biomarkers [β-d-glucan (BDG) or Candida albicans germ tube antibodies (CAGTA)], alone or in combination with standard cultures, for identifying patients with suspected invasive candidiasis (IC), who may benefit from maintaining antifungal therapy.

Methods

Prospective observational multicentre study including all adult patients receiving empirical antifungal therapy for suspected IC, from January to June 2017. CAGTA, BDG and T2MR were determined at baseline and at +2 and +4 days after enrolment. Primary endpoint was the diagnostic value of CAGTA, BDG and T2MR, alone or in combination with standard culture, to predict diagnosis of IC and/or mortality in the first 7 days after starting antifungal therapy (poor outcome).

Results

Overall, 14/49 patients (28.6%) had a poor outcome (7 died within the first 7 days of antifungal therapy, whereas 7 ended with a diagnosis of IC). CAGTA [3/14 (21.4%) versus 8/35 (22.9%), P = 1] and BDG [8/14 (57.1%) versus 17/35 (48.6%), P = 0.75] results were similar in poor- and good-outcome patients. Conversely, a positive T2MR was associated with a higher risk of poor outcome [5/14 (35.7%) versus 0/35 (0.0%) P = 0.0001]. Specificity and positive predictive value of a positive T2MR for predicting poor outcome were both 100%, with a negative predictive value of 79.6%. After testing the combinations of biomarkers/standard cultures and T2MR/standard cultures, the combination of T2MR/standard cultures showed a high capacity to discriminate patients with poor outcome from those with good clinical evolution.

Conclusions

T2MR may be of significant utility to identify patients who may benefit from maintaining antifungal therapy.