Which antifungal treatment in real life? You decide !! I am listening or

17 Pages·2011·0.73 MB·English

by  Sofie Debie

H.-Hartziekenhuis Roeselare - Menen vzw
Wilgenstraat 2 -8800 Roeselare
Which antifungal treatment in real life?
You decide !! I am listening or I ‘ll try to.
candidiasis
(cid:138) 85 year old man
(cid:138) In May and July 2011 two abdominal interventions for
rectum cancer with temporary ileostomy
(cid:138) Prolonged ICU stay
(cid:138) Slow response due to postoperative paralytic ileus
(cid:138) Central venous catheter and total parenteral nutrition
(cid:138) Meropenem during +/- one month
(cid:138) Blood cultures positive for yeasts and
pseudomycelium in four sets on 8 September
(separate venipuncture sites)
(cid:138) Catheter removed and tip positive for the same yeast.
Urine positive for the same agent
candidiasis
(cid:138) Which yeasts are the possible agents of this
fungaemia?
(cid:138) Which yeasts are not “in the running” if this
proves to be a single agent?
(cid:138) And now: which antifungal agent to start with in
this azole naive patient ?
(cid:138) Fluconazole ?
(cid:138) Echinocandin ?
(cid:138) Voriconazole ?
(cid:138) Posaconazole ?
(cid:138) Amphoterin B or a lipid formulation ?
candidiasis
(cid:138) Possible agents: Candida albicans, Candida
parapsilosis
(cid:138) If this is not a mixed infection: Candida glabrata
is excluded, as well as Saccharomyces cerevisiae
(role of Enterol® in Belgium)
(cid:138) 2010: 14 cases of candidaemia (11 Candida
albicans, 3 Candida glabrata). Candida sp.: 10th
place on the ranking score of our septicemia
agents
(cid:138) Fluconazole is started on 9 September
candidasis
(cid:138) Is this a high risk patient for invasive
candidiasis?
(cid:138) Do we have to ask for other investigations and
why?
candidiasis
“the Candida score”:
A bedside scoring system (“Candida score”) for early antifungal
treatment in nonneutropenic critically ill patients with Candida colonization. León C et al. Crit
Care Med 2006 34 (3): 730-737.
candidiasis
The list of risk factors used in our institution:
Risicofactoren voor invasieve candidose en candidemie op
intensieve zorgen:
(cid:138) Breedspectrumantibiotca (langdurig)
(cid:138) Chirurgie (vooral abdominale waarbij de darmwand ingesneden
wordt)
(cid:138) Diabetes
(cid:138) Nierinsufficiëntie
(cid:138) Hemodialyse
(cid:138) Totale parenterale voeding
(cid:138) Immuunsuppressieve therapie (vooral corticoïden)
(cid:138) Maligniteit en chemotherapie
(cid:138) Transplantatie
(cid:138) Zeer ernstige algemene toestand of sepsis (gaan dan ook meestal
dood met een Candidaprobleem en niet door een invasieve
candidose)
(cid:138) Langdurige hospitalisatie
(cid:138) Candida kolonisatie op verschillende plaatsen
(cid:138) Centraal veneuze katheter?
candidiasis
(cid:138) The patient doesn’t respond well
(cid:138) On 11 September again positive blood cultures
(two sets): persistant candidaemia under
fluconazole
(cid:138) What is going wrong?
(cid:138) Resistance ?
(cid:138) Endocarditis ?
(cid:138) Metastatic infection (bone, CNS, ….)
(cid:138) Other suggestions ?
candidiasis
Deep venous thrombosis
candidiasis
(cid:138) Role of ophthalmoscopy?
(cid:138) What if the blood cultures had been obtained via
the central catheter instead of a peripheral site?
(cid:138) What if the patient had received an azole before
his candidaemia episode?
(cid:138) Does severity (stable vs. unstable patient) of
illness would influence your antifungal choice?
(cid:138) If you want to use an echinocandin, which one do
you prefer (caspofungin, anidulafungin or
micafungin)?