EPICO PROJECT. Development of educational recommendations using the DELPHI technique on invasive candidiasis in non- neutropenic critically ill adult patients                                
 

THE EPICO PROJECT GROUP
             

Introduction. Although there has been an improved management of Invasive Candidiasis in the last decade, controversial issues still remain, especially in the diagnostic and therapeutic approaches.
Objectives. We sought to identify the core clinical knowledge and to achieve high level agreement recommendations required to care for critically ill adult patients with Invasive Candidiasis.
Methods. Prospective Spanish survey reaching consensus by the Delphi technique, anonymously conducted by electronic e-mail in a first term to 25 national multidisciplinary experts in invasive fungal infections from five national scientific societies, including Intensivists, Anesthesiologists, Microbiologists, Pharmacologists and Infectious Disease Specialists, responding to 47 questions prepared by a coordination group after a strict review of the literature in the last five years. The educational objectives spanned five categories, including epidemiology, diagnostic tools, prediction rules, and treatment and de-escalation approaches. The level of agreement achieved among the panel experts in each item should exceed 75% to be selected. In a second term, after extracting recommendations from the selected items, a face to face meeting was performed where more than 80 specialists in a second round were invited to validate the preselected recommendations.
Measurements and Main Results. In the first term, 20 recommendations were preselected (Epidemiology 4, Scores 3, Diagnostic tools 4, Treatment 6 and De-escalation approaches 3). After the second round, the following 12 were validated: Epidemiology: Think about Candidiasis in your ICU and do not forget that non-albicans species also exist. Diagnostic tools: Blood cultures should be performed under suspicion every 2-3 days and, if positive, every 3 days until obtaining the first negative result. Obtain sterile fluid and tissue, if possible (direct examination of the sample is important). Use nonculture based methods of microbiological tools, whenever possible. Determination of antifungal susceptibility is mandatory. Scores: As screening tool, use the Candida Score and determine multicolonization in high risk patients. Treatment: Start early. Choose Echinocandins. Withdraw the catheter. Fundoscopy is needed. De-escalation: Only applied when knowing susceptibility determinations and after 3 days of clinical stability. The higher rate of agreement was achieved in the optimization of microbiological tools and the withdrawal of the catheter, whereas the lower rate corresponded to de-escalation therapy and the use of scores.
Conclusions. The management of invasive candidiasis in ICU patients requires the application of a broad range of knowledge and skills that our summarized in our recommendations. These recommendations may help to identify the potential patients, standardize their global management and improve their outcomes, based on the DELPHI methodology.

Rev Esp Quimioter 2013:26(2):131-150 [pdf]

Relevance of the detection of Streptococcus pneumoniae antigen in human urine in the diagnosis of lower respiratory tract infections                                  
 

A. SORLÓZANO, S. CEDEÑO, J. GUTIÉRREZ-FERNÁNDEZ, P. POLO, J. M. NAVARRO                   

Background and objective. Techniques membrane antigen immunochromatographic detecting in urine the pneumococcal polysaccharide C, have developed significantly, increasing requests for antigenuria to clinical microbiology laboratories. We evaluated the impact of the application of this test in the diagnosis of infections of lower respiratory tract.
Patients and method. Six hundred and sixteen determinations were performed by antigenuria BinaxNOW® S. pneumoniae in as many patients over 14 years admitted to the Hospital Universitario Virgen de las Nieves (Granada) between November 2010 and March 2011.
Results. In 91.1% of patients who were determined antigenuria the presence of respiratory symptoms justified the request. Only 8.4% of 616 antigenurias performed were positive. S. pneumoniae was isolated from the respiratory sample culture in 8 of these 52 patients. In 29.8% of patients the diagnosis of lower respiratory tract infection was based on clinical, radiological and/or analytical, as antigenurias were negative and did not involve any other additional microbiological test.
Conclusions. We believe that this technique should be used in a complementary manner, and never to the detriment of other microbiological tests, especially in hospitalized patients.

Rev Esp Quimioter 2013:26(1):39-42 [pdf]

Treatment of invasive fungal infections in high-risk haematological patients: What have we learnt in the past 10 years? 

CARLOS VALLEJO, LOURDES VÁZQUEZ, JOSÉ RAFAEL CABRERA MARTÍN, ENRIC CARRERAS, JULIO GARCÍA RODRÍGUEZ, ISABEL RUIZ CAMPS, JESÚS FORTÚN, JOSEP MENSA, JOSÉ BARBERÁN             

Invasive fungal infection (IFI) caused by filamentous fungi remains a very severe infectious complication in patients with onco-haematological diseases. Last advances in the diagnostic and therapeutic fields, today we know that their contributions are limited. Something similar can be said of clinical trials especially in relation to some changes in the characteristics of the host. The development of promising diagnostic techniques and the relative expansion in the number of antifungal agents has been associated with diversification of therapeutic strategies (prophylaxis with extended-spectrum azoles and preemptive antifungal treatment). However, the low sensitivity of AGA testing in some circumstances, and the potential delay in starting treatment due to logistic reasons, has been reflected by a greater mortality in certain type of patients and a significant increase in the days of treatment. All these circumstances has once again focus attention to the empirical approach as a central strategy in high-risk patients. The objective of this article is to review the clinical experience in the treatment of IFI in onco-haematological patients according to data published in the literature in the last decade and to present a set of recommendations.

Rev Esp Quimioter 2013:26(4):378-386 [pdf]

Epidemiology, diagnosis and treatment of fungal respiratory infections in the critically ill patient                                
 

JOSÉ GARNACHO-MONTERO, PEDRO OLAECHEA, FRANCISCO ALVAREZ-LERMA, LUIS ALVAREZ-ROCHA,  JOSÉ BLANQUER, BEATRIZ GALVÁN, ALEJANDRO RODRIGUEZ, RAFAEL ZARAGOZA, JOSÉ-MARÍA AGUADO, JOSÉ MENSA, AMPARO SOLÉ, JOSÉ BARBERÁN
             

Objective. To elaborate practical recommendations based on scientific evidence, when available, or on expert opinions for the diagnosis, treatment and prevention of fungal respiratory infections in the critically ill patient, including solid organ transplant recipients.
Methods. Twelve experts from two scientific societies (The Spanish Society for Chemotherapy and The Spanish Society of Intensive Care and Coronary Units) reviewed in a meeting held in March 2012 epidemiological issues and risk factors as basis for a document about prevention, diagnosis and treatment of respiratory fungal infections caused by Candida spp., Aspergillus spp or Zygomycetes.
Results. Despite the frequent isolation of Candida spp. from respiratory tract samples, antifungal treatment is not recommended since pneumonia by this fungal species is exceptional in non-neutropenic patients. In the case of Aspergillus spp., approximately 50% isolates from the ICU represent colonization, and the remaining 50% cases are linked to invasive pulmonary aspergillosis (IPA), an infection of high mortality. Main risk factors for invasive disease in the ICU are previous treatment with steroids and chronic obstructive pulmonary disease (COPD). Collection of BAL sample is recommended for culture and galactomannan determination. Voriconazole and liposomal amphotericin B have the indication as primary therapy while caspofungin has the indication as salvage therapy. Although there is no solid data supporting scientific evidence, the group of experts recommends combination therapy in the critically ill patient with sepsis or severe respiratory failure. Zygomycetes cause respiratory infection mainly in neutropenic patients, and liposomal amphotericin B is the elective therapy.
Conclusions. Presence of fungi in respiratory samples from critically ill patients drives to different diagnostic and clinical management approaches. IPA is the most frequent infection and with high mortality.

Rev Esp Quimioter 2013:26(2):173-188 [pdf]

Identification of fungal clinical isolates by matrix-assisted laser desorption
ionization-time-of-flight mass spectrometry                                
 

LAURA FERREIRA, FERNANDO SÁNCHEZ-JUANES, SILVIA VEGA, MAGDALENA GONZÁLEZ, Mª INMACULADA GARCÍA, SILVIA RODRÍGUEZ, JOSÉ MANUEL GONZÁLEZ-BUITRAGO, JUAN LUIS MUÑOZ-BELLIDO
             

Background. Recently, bacterial identification by MALDI-TOF MS has acquired a high relevance in terms of speed and reliability. Conventional mycological identification has some disadvantages: it is frequently slow, reliability is sometimes low, and an extensive experience is required. The risk population for fungal infections, and therefore their clinical significance has progressively increased in recent years.
Methods. 153 yeast and mould clinical isolates were analyzed by MALDI-TOF MS and conventional identification. When both methods were discrepant to the genus or species level, ITS-2 sequencing was performed.
Results. The correlation in yeasts identification between conventional identification methods and MALDI-TOF MS was extremely high (99.2% to the species level and 100% to the genus level). The only discrepancy was checked by ITS-2 sequencing and confirmed the MALDI-TOF identification. The correlation in moulds identification was more heterogeneous. 68.7% of the isolates showed correlation at least to the genus level and 40.6% to the species level. Therefore, the correlation between conventional identification and MALDI-TOF MS in fungal identification was, in whole, 87% to the species level, and 93.5% to the genus level.
Conclusions. Identification of fungi by MALDI-TOF MS is reliable and shows potential advantages over conventional identification methods.

Rev Esp Quimioter 2013:26(3):193-197 [pdf]