Treatment approach for fungal infections in critically ill patients admitted to intensive care units:: Results of a multicenter survey

INTRODUCTION. Two consensus conferences taking place in the United States and Spain were organized to optimize diagnosis and treatment of Candida spp. infections. Among other results, clinical scenarios in which early prescription of antifungal agents is indicated were identified. OBJECTIVE. To determine the criteria followed by physicians for prescribing antifungal agents in critically ill patients in our country and to investigate adherence to the guidelines proposed by the consensus conferences. METHODS. A questionnaire was designed and directed to 4(th)- and 5(th)-year residents in intensive care medicine and to specialists in intensive care with training in infectious diseases or other medical areas. Four case reports for which expert consensus indicates early antifungal treatment were included in the questionnaire; 1) recurrent peritonitis secondary to perforation of the digestive tract, with mixed flora including fungi; 2) persistent febrile syndrome in a patient with multiple mucosal fungal colonizations treated with broad-spectrum antibiotics; 3) candiduria and pyuria in a febrile patient; and 4) candidemia. RESULTS. A total of 135 questionnaires from 45 different ICUs were returned (60% response rate). In the candidemia and fungal peritonitis examples, early treatment with antifungal agents was indicated in 100% and 85.9% of responses, respectively, whereas for sepsis with multifocal candidiasis and candiduria associated with pyuria and fever, early treatment was prescribed in only 41.5% and 55.6% of responses, respectively. There were no significant differences in response with regard to degree of training of the physicians surveyed. Fluconazole prescription predominated, mainly at doses of 400 mg/day, in mixed peritonitis, disseminated candidiasis and candiduria, whereas amphotericin B lipid formulations were preferentially indicated in cases of candidemia. Antifungal treatment (early or late) was prescribed in all responses for candidemia, in 95.5% for mixed peritonitis (fungi and bacteria), in 79.5% for multifocal candidiasis in patients with persistent sepsis, and in 77.9% for candiduria with fever and pyuria. CONCLUSIONS. Adherence to recommendations from the consensus conferences was high among intensive medicine specialists, with no differences according to level of training in infectious diseases.