Invasive Fungal Infection in the ICUICU / resuscitation

ICU day 8, persistent fever on broad-spectrum antibiotics; central line, TPN, recent abdominal surgery

• Positive Candida blood culture
• Periorbital or palatal black eschar
• Neutropenia with a new pulmonary infiltrate
• Persistent fungaemia beyond 72 h of therapy

• Bacterial line sepsis
• Undrained intra-abdominal collection
• Drug fever
• Venous thromboembolism
• Tuberculosis in the immunosuppressed

• Admit: Any candidaemia — it is never a contaminant
• ICU: Septic shock, persistent fungaemia, suspected mucormycosis, or endocarditis

• Every Candida blood culture is real — echinocandin, line out, repeat cultures, ID review.
• Count the 14 days from the first negative blood culture, not from the first dose.
• Mould on CT in the neutropenic: voriconazole or isavuconazole; black eschar in the diabetic: amphotericin plus surgery.

• Call a Candida blood culture a contaminant
• Leave the central line in place in candidaemia without a documented reason
• Start fluconazole first in an unstable or azole-exposed patient
• Treat Candida in sputum or a catheter urine sample without disease
• Delay debridement in mucormycosis while waiting for amphotericin

• Calling a Candida blood culture a contaminant
• Leaving the line in
• Starting fluconazole first in an unstable or azole-exposed patient
• Waiting for speciation before treating
• Treating airway Candida colonisation, which needs no antifungal

Echinocandin until stable and speciated, then step down; infectious diseases review for every candidaemia; source control decides the outcome more than the drug choice.