الفهرس 
Patient groups and risk factors
Clinical prediction of invasive candidiasis in critically ill patientsOnly 14 pages are availabe for public view
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Abstract
Summary
Candida species were reported to be one of the most common nosocomial pathogen, and the most common cause of invasive fungal infections, accounting for 70% to 90% of all invasive mycoses.
Many risk factors are associated with the development of invasive candidiasis like surgery, sepsis, the presence of vascular catheters, exposure to broad-spectrum antimicrobial agents, renal failure, mucosal colonization with, and prolonged ICU stay.
Among them, candida colonization plays a key role in the pathogenesis of invasive candidiasis. selective pressure trough antibacterial therapy alters the microbiota, resulting in overgrowth of candida species on skin and mucosal surfaces.
Invasive procedures that disrupt natural skin or mucosal barriers, such as intravascular catheters, gastrointestinal tract surgery, and chemotherapy-associated mucositis, as well as decreased host defenses, in particular neutropenia, facilitate local invasion and further candidemia host defenses against colonization of mucous membranes by candida and invasion of tissues and/or dissemination via the blood stream rely on distinct immunological mechanisms.
These infections occurred more often in the non neutropenic critically ill patients than in those patients who were neutropenic or had received organ transplantation in the past.
To prove candidal infection we need one of the following criteria: Presence of candidemia, documentation of one blood culture, ophthalmic examination with candidalendophthalmitis, isolation of candida species in significant samples (e.g., pleural fluid, pericardial fluid), or histologically documented candidiasis.
The severity of the underlying disease is an important factor for mortality and overall mortality is consistently higher in candidaemic ICU patients than in candidaemic patients in general.
Clinical prediction of invasive candidiasis in critically ill patients:
1. Colonization-based assessment of the risk of invasive candidiasis: the presence of candida spp. in more than two body sites
2. The Ostrosky-Zeichner prediction rule: high risk for patients under systemic antibiotic treatment, or with indwelling central venous catheter, and at least two of the following factors: Total parenteral nutrition, dialysis, major surgery, pancreatitis, any use of steroids, use of other immunosuppressive agents.
3. Candida score:designed to recognize the best candidates for early antifungal therapy in an ICU setting. It is obtained by adding the statistical weight of each risk factor:Clinical sepsis (2 points), surgery (1 point), TPN (1 point), multifocal colonization (1 point).
Laboratory diagnosis of candida infection is either by conventional microbiological methods which can be poorly sensitive, but they are essential for isolating and identifying the etiological agent of an infection, andnon-culture-based microbiological tools like (1,3)-b-D-Glucan detection, fungal DNA detection, c. albicans germ tubes anti-bodies detection, and Mannan and anti-mannan antibodies, or combination both.
Prevention of nosocomial candidemia is similar to that of many other nosocomial infections and should involve three “low-tech” strategiesimproved hand hygiene, optimal catheter placement and care, and prudent antimicrobial use.
Antifungal prophylaxis has proven to be effective in decreasing invasive candidiasis in neutropenic patients. Implementation of targeted antifungal prophylaxis has been shown to be effective in certain ICU settings,be justified only if major efforts have been made to improve hand hygiene, catheter care, and antimicrobial use practices, and the rate of nosocomial candidemia within the ICU remains high.
The treatment of invasive candidiasis and candidemia can be described as prophylactic, pre-emptive, empiric or curative.
Prophylactic treatment covers all the situations where the patient is not infected and lacks the signs and symptoms of infection. In pre-emptive treatment, based on evaluation of the patient’s risk factors combined with positive surrogate markers of infection, the goal is to decrease candida-related mortality.
Empiric therapy describes individuals with symptoms of infection with no obvious source who need therapy based on clinical grounds. Finally, curative treatment focuses on a microbiologically documented pathogen.
Four classes of antifungal drugs are currently available for the treatment of invasive fungal diseases in critically ill patients. They include:
• polyenes/amphotericin B.
• Azoles compounds (itraconazole, fluconazole, voriconazole andposaconazole).
• Echinocandins (caspofungin, micafungin, and anidulafungin).
• pyrimidine analogues.
Rates of reduced antifungal susceptibility or resistance ranging from <5% to> 30% have been reported.