Determine when to start EMPIRIC antifungals

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.

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.

REFERENCES

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