Routine screening for Candida colonization

Infections caused by Candida spp. are a major cause of morbidity and mortality in critically ill patients. Although colonization with Candida spp. precedes and leads to infection [1], routine screening for Candida colonization is not recommended. In this observational retrospective study, based upon the results of a systematic screening for Candida colonization, we address the controversial issue of the management of fungal threat in the ICU.

Patients

All incoming patients admitted in a 12-bed digestive (medical and postsurgical) ICU, presenting with an organ dysfunction or a severe inflammatory response to their primary disease (C-reactive protein > 150 mg/l) were routinely scheduled for a weekly screening for fungal colonization. A colonization index (CI) was computed for every patient. In 2000, a pre-emptive antifungal therapy was administered to all patients with CI > 0.5. and subsequently interrupted when CI < 0.5. Due to economic concerns and reports of increasing resistance to antifungal drugs, we changed our therapeutical strategy in 2001 [2]. As a result, in 2002 an antifungal therapy was administered only for probable or patent infections. Evolution of CIs, candidemia and the total cost of therapy are reported for 2000 and 2002.

Results

See Table 1. The CI decreased in 92% of patients receiving pre-emptive therapy. In all patients but one, fluconazole was the drug used for pre-emptive therapy.

Table 1

Discussion

Despite the limits of our study, we can conclude: severely ill medical and postsurgical patients with digestive diseases are at risk for fungal infection and candidemia. Screening for fungal colonization allows an early determination of patients at risk for fungal infection. Pre-emptive treatment efficiently lowers the level of colonization. A small number of costly curative antifungal treatments may prove more expensive than a greater number of pre-emptive cheaper treatments.