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Intensive care

The challenge of systemic Candida infections

Whereas Candida albicans remains the most important fungal pathogen among all risk groups, resulting in 40−65% of all candidaemias, a shift to non-C.albicans yeasts is being reported from several institutions

Markus Ruhnke MD Agata Mikolajewska MD Department of Internal Medicine, Charité University Medicine, Campus Charité Mitte, Berlin, Germany

In hospitalised patients, invasive fungal diseases, such as candidaemia, are an important complication in clinical practice.1,2

Candida infections have

contributed significantly to mortality in immunosuppressed patients and treatment outcomes for invasive candidosis are still less than optimal. Candidaemia is the fourth leading cause of bloodstream infections in paediatric patients, cancer patients and hospitalised patients, with mortality rates ranging from 20% in paediatric patients to 47% in intensive care unit (ICU) patients. In a large US cohort study, patients had a number of underlying conditions or risk factors including: urinary catheterisation (60%); endotracheal intubation (50%); surgery (36%); diabetes (26%); neoplasia (26%); and haemodialysis (12%).3

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specific epidemiology with regard to incidence of candidaemia as well as distribution of Candida pathogens (C. albicans versus non-C. albicans species) varies markedly from country to country as well as from hospital to hospital. C. albicans is still the most common isolate; however, there has been a shift towards more azole-resistant species (for example, C. glabrata) found in some institutions, paralleled by a

reduced susceptibility to azole antifungals such as fluconazole. The reasons for this variation are not well understood and may reflect, in part, selection mechanism (for example, due to azole prophylaxis). In some patient groups, such as in haematological patients with prolonged neutropenia, non-C. albicans species are detected much more frequently compared with non-neutropenic patients in the surgical ICUs. Candida species are the primary cause of invasive fungal infections but an increasing number of

infections are being attributed to Aspergillus species. In immunocompromised patients, Aspergillus species are an important cause of life-threatening infections. Invasive aspergillosis is a frequent cause of mortality not only in patients with haematological malignancies and recipients of allogeneic haematopoietic stem cell transplants but is also increasingly observed in ICU patients.4 Mould infections will not be discussed in this review.

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