Determine when to start EMPIRIC antifungals

Think about adding an empiric antifungal to antibiotics for intra-abdominal infections in certain patients LIKE those with recent abdominal surgery...

Overview

As a critical care pharmacist, You can help guide empiric use of systemic antifungals in adults. There are over a dozen risk factors for invasive candidiasis. But studies in patients withOUT neutropenia haven’t pinned down the best approach for empiric antifungal use.

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Clinical practice

Patient selection

Think about adding an empiric antifungal to antibiotics for intra-abdominal infections in certain patients LIKE those with recent abdominal surgery, anastomotic leak, or necrotizing pancreatitis.

Also consider starting an antifungal in an ICU patient with persistent fever despite broad-spectrum antibiotics AND who has fungal risk factors, such as parenteral nutrition, dialysis, or severe burns. Rely on clinical judgment to guide decisions, it’s too soon to say which risks are most important or if having more than one is key.
For example, consider an antifungal for a critically ill patient with sepsis, ongoing fever despite a few days of vancomycin and meropenem and receiving parenteral nutrition.

Antifungal choice

Use an echinocandin (anidulafungin [Ecalta], micafungin [Mycamine], caspofungin [Cancidas], etc) if a patient has hemodynamic instability, recent azole exposure or colonization with fluconazole-resistant Candida.

But consider fluconazole in a patient withOUT these risks AND if local data show Candida albicans is generally fluconazole-susceptible.
Save amphotericin-B as last-line due to adverse effects.

Duration

Usually continue an empiric antifungal for 2 weeks if patients respond (afebrile, etc), since invasive candidiasis without positive cultures is common. But stop empiric antifungals after 4 to 5 days if there’s no improvement and no other evidence of invasive candidiasis. Or if available, consider a beta-D-glucan test, negative results can help rule out fungal infection. But don’t rely on it to rule in infection as false positives are common.

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References

Pappas PG, Kauffman CA, Andes DR, Clancy CJ, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Feb 15;62(4):e1-50.
Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-e1143.
Martin-Loeches I, Antonelli M, Cuenca-Estrella M, Dimopoulos G, Einav S, De Waele JJ, Garnacho-Montero J, Kanj SS, Machado FR, Montravers P, Sakr Y, Sanguinetti M, Timsit JF, Bassetti Met al. ESICM/ESCMID task force on practical management of invasive candidiasis in critically ill patients. Intensive Care Med. 2019 Jun;45(6):789-805.
Thomas-Rüddel D, Schlattmann P, Pletz M, Kurzai O, Bloos F. Risk Factors for Invasive Candida Infection in Critically Ill Patients: A Systematic Review and Meta-Analysis. Chest. 2021 Oct 18:S0012-3692(21)04112-X.