Pathogens in severe sepsis: New paradigms for fungi treatment

Candida is one of the most frequent pathogens in bloodstream infections, and is associated with significant morbidity and mortality. The epidemiology of the species responsible for candidemia, both at the local and worldwide levels, has been changing, shifting from C. albicans to non-albicans species, which can be resistant to fluconazole (C. krusei and C. glabrata) or difficult to eradicate because of biofilm production (C. parapsilosis). Numerous ICU patients have multiple risk factors for developing this infection, which include prolonged hospitalisation, use of broad-spectrum antibiotics, presence of intravascular catheters, parenteral nutrition, high APACHE score, etc. Moreover, delaying the specific therapy was shown to further increase morbidity and mortality. In order to minimise the impact of this infection, several management strategies have been developed, namely prophylaxis, empirical and pre-emptive therapy. Compared to prophylaxis, empirical and pre-emptive approaches allow reducing the exposure to antifungals by targeting only the patients at high risk of candidemia, without delaying therapy until the moment blood Candida is identified in blood cultures. The agents recommended for initial treatment of candidemia in critically ill patients include echinocandins and a lipid formulation of amphotericin B.