Written by Kevin Liu
Spoon Feed
For invasive pulmonary aspergillosis (IPA), combination antifungal therapy vs. monotherapy appears better. In critically ill patients, empiric or prophylactic antifungal treatment of invasive candidiasis (IC) did not show benefit.
Synopsis
This guideline review analyzes the treatment of IPA and strategies for managing IC in critically ill adults. It includes evidence from clinical studies comparing mold-active triazole monotherapy to combination therapy with triazoles and echinocandins for IPA, as well as the use of systemic antifungal prophylaxis or empiric therapy for IC. Statistically, combination therapy did not significantly reduce mortality compared to monotherapy but showed potential benefit in specific subgroups. Secondary analyses indicated no clear survival advantage of prophylactic or empiric antifungal use in IC. These findings underscore the need for tailored antifungal strategies based on individual patient risk factors and clinical scenarios. (AI-assisted)
No easy answers for invasive fungal infections
Despite 11 years of new research and new medications, mortality rates for IPA and IC remain high.
- IPA causes 90% of invasive fungal infections in hematological malignancy, with a mortality rate of 42%.
- IPA causes 72% of invasive fungal infections in stem cell transplant populations, with a 72% mortality rate.
- IC carries a mortality of 40-55%.
This update asks two big questions:
In IPA, is combination antifungal therapy better than monotherapy?
- In the primary treatment of IPA, combination therapy (triazole + echinocandin) appears better and reduces mortality, though the reference study is underpowered. Echinocandins can cause hepatic dysfunction, anemia, and thrombocytopenia.
- In salvage therapy if triazole monotherapy has failed, combination treatment with echinocandins would be an alternative to amphotericin B.
- In real-world practice, I consult infectious disease.
Should we give prophylactic or empiric treatment for IC in critically ill patients who are non-neutropenic and are not transplant recipients?
- In short, no. There was no statistically significant difference in mortality with treatment.
- While there is little harm in Candida prophylaxis, there doesn’t appear to be benefit either.
Source
Treatment of Invasive Pulmonary Aspergillosis and Preventive and Empirical Therapy for Invasive Candidiasis in Adult Pulmonary and Critical Care Patients. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2024 Nov 18. doi: 10.1164/rccm.202410-2045ST. Epub ahead of print. PMID: 39556361
