Antifungal Prophylaxis in the Surgical Patient

35 Pages·2006·0.19 MB·English

AAnnttiiffuunnggaall PPrroopphhyyllaaxxiiss iinn tthhee
SSuurrggiiccaall PPaattiieenntt
JJaacckk DD.. SSoobbeell,, MM..DD..
WWaayynnee SSttaattee UUnniivveerrssiittyy SScchhooooll ooff MMeeddiicciinnee
DDeettrrooiitt,, MMII
PPPrrroooppphhhyyylllaaaccctttiiiccc,,, EEEmmmpppiiirrriiicccaaalll,,, ooorrr
PPPrrreee---eeemmmppptttiiivvveee TTThhheeerrraaapppyyy
No Signs and Full-blown
disease Markers symptoms disease Sequelae
D i s e a s e p r o g r e s s i o n
Prophylactic Pre-emptive Empirical Therapy
High-risk patient High risk on antibiotics
(transplant, chemo, ICU) with fever
Asymptomatic + colonization
(?) or novel diagnostic
Perfect JR. Oncology 2004;18:S5-S13.
SSeelleeccttiivvee AAnnttiiffuunnggaall PPrroopphhyyllaaxxiiss
• Not all patients (surgical or SICU) are at the same risk
• Not all patients are at High risk
• Definition of high risk?
- Overall risk of candidiasis ICU ~2%
- High risk ~ >10%
• Justification of antifungal prophylaxis benefits > risks
and costs
GGooaallss aanndd OObbjjeeccttiivveess ooff AAnnttiiffuunnggaall
PPrroopphhyyllaaxxiiss
• ↓ candidemia
• ↓ invasive candidiasis
• ↓ empirical use of antifungals
• ↓hospital/crude mortality
• ↓ attributable mortality
GGooaallss ooff AAnnttiiffuunnggaall PPrroopphhyyllaaxxiiss
↓ Candida colonization
No
↓ Candiduria
IInnddiiccaattiioonnss ffoorr AAnnttiiffuunnggaall PPrroopphhyyllaaxxiiss
Mr Smith (1) Elective gastrectomy No
Mr Smith (2) Acute perforated gastric ulcer Yes/No
Mr Smith (3) Missed or delayed diagnosis of Yes/No
perforated GU
Mr Smith (2) Intraoperative swab, culture Yes/No
positive. Prophylactic? Pre-
emptive? Early treatment?
Mr Smith Post-gastrectomy anastomotic leak Yes/No
– indicated?
IInnddiiccaattiioonnss ffoorr AAnnttiiffuunnggaall
PPrroopphhyyllaaxxiiss//TThheerraappyy
Based upon:
• Clinical status
• Likelihood of invasive candidiasis
• Risks of treating
• Risks of non-treating
IInnddiiccaattiioonnss ffoorr AAnnttiiffuunnggaall
PPrroopphhyyllaaxxiiss//TThheerraappyy
• Past: Amphotericin B.
Threshold for use: High
• Present: Azoles/Echinocandins.
Threshold dropped: Toxicity ↓
FFooccuuss oonn IInnvvaassiivvee CCaannddiiddiiaassiiss iinn
SSuurrggiiccaall IICCUU
• Major problem – attributable mortality 40-50%
• ICU’s have 10-fold higher incidence than wards
• ↑ incidence
- Why?
• Expansion of pool of high risk patients
• Advanced technologies e.g. vascular catheters
• i.e. ↑ risk factors
RRiisskk FFaaccttoorrss ffoorr IInnvvaassiivvee CCaannddiiddiiaassiiss
iinn SSuurrggiiccaall IICCUU PPaattiieennttss
• Prolonged length of stay
• High acuity
• Diabetes
• Renal failure
• Hemodialysis
• Broad spectrum antibiotics
• Central venous catheters
• TPN
• Immunosuppressive drugs
• Severe acute pancreatitis
• Recent surgery (transplantation)
• Candida colonization at multiple sites