Although fungal pneumonia is an
uncommon cause of hospital-acquired (HAP) in the intensive-care unit, it can be
a significant cause of morbidity and mortality.
It should be considered in patients with the appropriate risk factors, prolonged
hospitalization, or extended duration of mechanical ventilation. Common pathogens are Candida species and,
less commonly, Aspergillus in immunocompromised patients.
Fungal
pneumonia is suspected to be secondary to mucosal colonization with Candida
species or from aspiration of GI contents.
Established major risk factors associated with Candida colonization
include age > 65, history of hematologic malignancy, neutropenia, and recent
intra-abdominal operation. A course of
recent antibiotic therapy, presence of central venous catheter, and TPN administration
are risk factors as well. In addition, impaired
host defenses that contribute to developing an invasive fungal infection
include corticosteroid use, HIV positive status, rheumatologic conditions, and recent
chemotherapeutics. Special consideration
for compromised host function should also be given to patients with COPD,
cirrhosis, end-stage renal disease, and solid organ malignancy.
Diagnosis:
In
our ICU, HAP is made with the following criteria: a new infiltrate on CXR plus one of the
following: fever, leukocytosis or
neutropenia, or purulent tracheobronchial secretions. A fungal pneumonia should be considered if
the patient has the aforementioned risk factors, is not improving with
antibiotics, and there is microbiologic evidence of fungus.
Treatment:
For proven infection, systemic
Fluconazole is our first-line agent for Candida pneumonia. Empiric treatment can be considered if a
patient exhibits no improvement while receiving an appropriate antibiotic
regimen for HAP and has the aforementioned risk factors for a fungal
pneumonia. Duration of Fluconazole is 14
days. For Aspergillosis, the usual
anti-infective regimen is Voriconazole, Amphotericin B, or an echinocandins.
No comments:
Post a Comment