Evolving role of early antifungals in the adult intensive care unit

Background: Invasive candidiasis (IC) is associated with significant morbidity and mortality in critically ill patients. This, in conjunction with difficulties in diagnosis, underscores the need for novel treatment strategies based on the identification of significant risk factors for IC. Objective: To review the evidence surrounding the use of early antifungals in critically ill adult patients and to present concise and specific recommendations for different early treatment strategies for IC. Data Sources and Data Extraction: Pubmed search from 1966 to July 2008 using the search terms "antifungals, critical care, prophylaxis, preemptive therapy, and empiric therapy." Examined all relevant peer-reviewed original articles, meta-analyses, guidelines, consensus statements, and review articles. Conclusion: The use of early antifungal therapy should be reserved for patients with a high risk (10% to 15%) of developing IC. Despite a large number of articles published on this topic,, there is no single predictive rule that can adequately forecast IC in critically ill patients. Until further prospective validation of existing data is completed, clinicians should assess patients on a case-by-case basis and determine the need for early antifungal treatment strategies based on frequent evaluations of risk factors and clinical status. (Crit Care Med 2009; 37:1580-1593)