الرحیم الرحمن الله بسم

يعلمون ال ذين وال يعلمون ذين ال يستوي هلاأللباب أولوا ر يتذك ما إن

- ازآیه بخشی الزمر ٩سوره

Are those who know and those who do not know alike? Only the men of understanding are mindful

GUIDELINE – DRIVEN DECISION MAKING IN MANAGEMENT OF

IFI IN ICU

Mansoor Masjedi ; MD FCCMAss. Prof. of anesthesia & critical care consultant

SUMS , Azar - 1394

Guideline – driven decision making in management of IFI in ICUOutline:

• Introduction• Necessity of guideline approach • Prophylactic, Preemptive or Empiric Use of Anti-fungals• Suggested treatment algorithms• Disease specific treatment• Summary

Guideline – driven decision making in management of IFI in ICUIntroduction:

IFI in the ICU → ↑ morbidity & mortality

Invasive candidiasis (IC) in ICU ˃10-fold medical or surgical wards

Delays in Rx → negative pt outcomes

Difficult to diagnose and treat

Imposes a substantial financial burden because of:longer requirements for ICU care expensive antifungal pharmacotherapygreater overall use of hospital resources

Guideline – driven decision making in management of IFI in ICUIntroduction:

Available antifungal pharmacotherapies are: complex costly drug-drug interactions Toxicity

New drugs →new therapies in ICU

Advances in diagnostics & susceptibility testing → ↑Identification of pts who require antifungal Rx Aid in drug selection

Guideline – driven decision making in management of IFI in ICUIntroduction:

Optimal management of IFI• pt risk factor identification

• diagnostic testing • early effective pharmacotherapy

Many protocols and algorithms for prevention and treatment of these infections

Invasive Mycosis

Candidiasis Aspergillosis

Decreasing immunity

SOT or BMTMICU or SICU

Loss of Barrier / immunity

Loss of barrier plus cellular immunity

Oncology

OUR MIXED CLOSED INTENSIVIST DRIVEN ICUCENTRAL ICU – NEMAZEE HOSPITAL – SHIRAZ - I.R.IRAN

Guideline – driven decision making in management of IFI in ICU

Algorhitm Developement

Can we wait for the blood culture results in candidemia?

• Retrospective cohort analysis 1/2001-12/2004: N=157 patients with candidemia

• Delay in empiric Rx of candidemia till after blood cultures turn positive resulted in higher mortality

• Start of anti-fungal Rx >12 hrs of drawing a blood culture that turns positive had AOR= 2.09 for mortality, p=0.018

Morrel M et al. 2005. Antimicrob Agents Chemother. 49(9):3640-5 

Major Risk Factors

• Prior antibiotic use • CVL• TPN• Major Sx. within a week• Steroids• Dialysis • Immunosuppression • ICU length of stay - infections rising rapidly after 7-10 d

Dimopoulos G, et al. Candidemia in immunocompromised and immunocompetent critically ill

patients: a prospective comparative study. Eur J Clin Microbiol Infect Dis. 2007

Guideline – driven decision making in management of IFI in ICUAlgorhitm Development – Diagnostic approach:

Guideline – driven decision making in management of IFI in ICUAlgorhitm Development – Medical treatment :

Guideline – driven decision making in management of IFI in ICUProphylactic, Preemptive, and Empiric Strategies :

• IFI :• Negative outcomes • Difficult definitive diagnosis early intervention either to prevent infection or to preempt severe fungal infection

is desirable.

• Candida ; most common fungal pathogens in ICU→ most strategies→on Candida spp.

Guideline – driven decision making in management of IFI in ICUProphylactic, Preemptive, and Empiric Strategies :

Prophylactic, Preemptive or Empiric Use of Anti-fungals

• PROS– High Mortality

– Difficulty in Diagnosis

– Undetected Infection

– Reduced systemic mycoses and improved mortality with prophylaxis

• CONS– Toxicity

– Expense

– Diagnosis not certain• Too much treatment

without infection• Too little treatment with

infection

World J Crit Care Med. 2014 Nov 4; 3(4): 102–112. • Invasive candidiasis in critical care setting,

updated recommendations from “Invasive Fungal Infections-Clinical Forum”, Iran

• Ashraf Elhoufi, Arezoo Ahmadi, Amir Mohammad Hashem Asnaashari, Mohammad Ali Davarpanah, Behrooz Farzanegan Bidgoli, Omid Moradi Moghaddam, Mohammad Torabi-Nami, Saeed Abbasi, Malak El-Sobky, Ali Ghaziani, Mohammad Hossein Jarrahzadeh, Reza Shahrami, Farzad Shirazian, Farhad Soltani, Homeira Yazdinejad, and Farid Zand

Guideline – driven decision making in management of IFI in ICUSummary:

• local epidemiology of Candida spp. → appropriate empiric and preemptive Rx

• local epidemiology at institution and also at unit

• Optimal management of IFI involves:• Pt. risk factor identification• Diagnostic testing • Early effective pharmacotherapy

Guideline – driven decision making in management of IFI in ICUSummary:

• Appropriate empiric regimen depends on: • Local patterns of infection and • Severity of illness

Delays in antifungal therapy → ↑mortality

To avoid delays and guide appropriate therapy,many institutions approach the management of

fungal bloodstream infection in the ICU with an algorithm

Suggested treatment algorithm for the ICU patient with invasive candidiasis(NAS: non- albicans species, CVC: central venous catheter, AmB: amphotericin B,

LipAmB: liposomal amphotericin B)

Any ?