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Empirical Therapy of Fungal Infections in the Non-neutropenic Child or Adult
Invasive candidiasis represents the most important and frequent fungal infection in non-neutropenic children and adults [247, 339, 436, 1416, 2147]. Patients at high risk include:
- Surgical patients
- Burn patients
- Heroin addicts
The risk for any form of disseminated candidiasis increases with the presence of the usual risk factors for invasive candidiasis:
- Use of multiple antibiotics
- Central venous catheters
- Parenteral hyperalimentation
- Steroids
- Candidal colonization
Unfortunately, there is no diagnostic tool that allows a clear and early identification of the syndrome produced by invasive candidiasis in any of the previously listed populations (for details, see diagnostic strategies for invasive candidiasis). Thus, even when empirical therapy to treat early occult Candida infections in non-neutropenic patients seems attractive, there is no data on when and how to use appropriately an antifungal regimen in these populations at risk [1915].
On a practical basis, empirical therapy can be considered when the following conditions are met:
- The patient is persistently febrile,
- No other source of fever is present,
- Broad spectrum antibiotics have been used recently,
- A central venous catheter has been used recently, AND
- Colonization of at least one body site is detected.
Other sources of fever that should be sought include sinusitis (is the patient nasally intubated?), cholecystitis (this can be quite subtle), pulmonary embolism (this can be subtle), drug fever (check for rash and circulating eosinophils), pneumonia, and wound infection.
Absence of colonization is a strong negative predictive factor [1745], whereas colonization at multiple sites raises the risk of invasive disease [1808]. Thus heavy emphasis is placed on the requirement for colonization.
If empirical therapy is begun, it should be used at full therapeutic dose. If no response is seen within five days, alternate diagnoses should be sought.
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References
247. Bisbe, J., J. M. Miro, X. Latorre, A. Moreno, J. Mallolas, J. M. Gatell, J. P. Delabellacasa, and E. Soriano. 1992. Disseminated candidiasis in addicts who use brown heroin - report of 83 cases and review. Clin. Infect. Dis. 15:910-923.
339. Burchard, K. W., L. B. Minor, G. J. Slotman, and D. S. Gann. 1983. Fungal sepsis in surgical patients. Arch. Surg. 118:217-221.
436. Chiou, C.-C., T.-T. Wong, H.-H. Lin, B. Hwang, R.-B. Tang, K.-G. Wu, and B.-H. Lee. 1994. Fungal infection of ventriculoperitoneal shunts in children. Clin. Infect. Dis. 19:1049-1053.
1416. Mahr, C. C., J. J. Fildes, E. J. Becker, K. K. Nagy, S. M. Krosner, R. R. Roberts, R. F. Smith, K. Joseph, C. M. O'Neill, and J. A. Barrett. 1995. The alarming rate of fungal recovery in critically ill trauma patients with unresolved sepsis. Crit. Care Med. 23 (No. 1, Suppl):A154.
1745. Pelz, R., P. A. Lipsett, S. Swoboda, T. Perl, W. Merz, L. Rocco, R. Brower, J. Hammond, and C. Hendrix. 1998. Do surveillance cultures predict fungal infeciton in critically ill patients? 36th Annual Meeting of the Infectious Diseases Society of America, Abstract No. 103.
1808. Pittet, D., M. Monod, P. M. Suter, E. Frenk, and R. Auckenthaler. 1994. Candida colonization and subsequent infections in critically ill surgical patients. Ann. Surg. 220:751-758.
1915. Rex, J. H., T. J. Walsh, J. D. Sobel, S. G. Filler, P. G. Pappas, W. E. Dismukes, and J. E. Edwards. 2000. Practice guidelines for the treatment of candidiasis. Clin. Infect. Dis. 30:662-678.
2147. Stamos, J. K., and A. H. Rowley. 1994. Candidemia in a pediatric population. Clin. Infect. Dis. 20:571-575.
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