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Review
. 2023 Oct 3;27(1):382.
doi: 10.1186/s13054-023-04673-6.

Critical appraisal beyond clinical guidelines for intraabdominal candidiasis

Emilio Maseda  1 , Ignacio Martín-Loeches  2   3 , Rafael Zaragoza  4 , Javier Pemán  5   6 , Jesús Fortún  7 , Santiago Grau  8 , Gerardo Aguilar  9 , Marina Varela  10 , Marcio Borges  11 , María-José Giménez  12 , Alejandro Rodríguez  13
Affiliations
Review

Critical appraisal beyond clinical guidelines for intraabdominal candidiasis

Emilio Maseda et al. Crit Care. .

Abstract

Background: Regardless of the available antifungals, intraabdominal candidiasis (IAC) mortality continues to be high and represents a challenge for clinicians.

Main body: This opinion paper discusses alternative antifungal options for treating IAC. This clinical entity should be addressed separately from candidemia due to the peculiarity of the required penetration of antifungals into the peritoneal cavity. Intraabdominal concentrations may be further restricted in critically ill patients where pathophysiological facts alter normal drug distribution. Echinocandins are recommended as first-line treatment in guidelines for invasive candidiasis. However, considering published data, our pharmacodynamic analysis suggests the required increase of doses, postulated by some authors, to attain adequate pharmacokinetic (PK) levels in peritoneal fluid. Given the limited evidence in the literature on PK/PD-based treatments of IAC, an algorithm is proposed to guide antifungal treatment. Liposomal amphotericin B is advocated as first-line therapy in patients with sepsis/septic shock presenting candidemia or endophthalmitis, or with prior exposure to echinocandins and/or fluconazole, or with infections by Candida glabrata. Other situations and alternatives, such as new compounds or combination therapy, are also analysed.

Conclusion: There is a critical need for more robust clinical trials, studies examining patient heterogeneity and surveillance of antifungal resistance to enhance patient care and optimise treatment outcomes. Such evidence will help refine the existing guidelines and contribute to a more personalised and effective approach to treating this serious medical condition. Meanwhile, it is suggested to broaden the consideration of other options, such as liposomal amphotericin B, as first-line treatment until the results of the fungogram are available and antifungal stewardship could be implemented to prevent the development of resistance.

Keywords: Antifungal stewardship; Decision algorithm; Echinocandins; Guidelines; Intraabdominal candidiasis; Intraabdominal penetration; Liposomal amphotericin B; PK/PD.

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Conflict of interest statement

EM and MB have received consultancy fees and payment for lectures from Astellas. Pharma S.A. (Madrid, Spain), Pfizer, Novartis, Angellini, and Merck Sharp and Dohme; IM-L reports grants from Grifols, consulting fees from Gilead and MSD, lecture honoraria from MSD, Gilead and Mundipharma, and advisory board and lectures for Pfizer, MSD and Menarini, outside the submitted work; RZ has received financial compensation for consulting/speaking/researching from Gilead and MSD; JP has received financial compensation for consulting/speaking/researching from Pfizer, Gilead and MSD; JF has received financial compensation for consulting/speaking/researching from Pfizer, Gilead, MSD, Shionogi, Astellas, Novartis, Roche; SG and MV declare no conflict of interest; GA received financial support for speaking at meetings organised on behalf of Pfizer, Merck Sharp and Dohme (MSD) and Gilead; M-JG received grants from Gilead S.L and Tedec-Meiji Pharma for PK/PD analysis and consultancy; and AR has received financial compensation for speaking from Pfizer, Gilead, MSD, Shionogi and BioMerieux.

Figures

Fig. 1
Fig. 1
Proposed algorithm on the use of antifungals in ICU patients with intraabdominal candidiasis
See this image and copyright information in PMC

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