Beruflich Dokumente
Kultur Dokumente
Candidiasis
Rudi Wisaksana
Internal Medicine Department
Hasan Sadikin Hospital
Bandung
Fungal problems
▪ The incidence of fungal infections is
increasing
▪ The spectrum of fungal disease is changing
▪ Selection of fungi is a reality
▪ Resistance of fungi is on the rise
▪ Cross resistance is increasingly recognized
INCREASE IN FUNGAL INFECTIONS
• Better diagnosis
• More broadspectrum antibiotics
• Higher age of patient population
• More complex interventions
(e.g.transplants)
• More intensive cytotoxic therapy
• More immunosuppressive therapy
• Less mortality from other causes
• More high risk patients
SYSTEMIC FUNGAL INFECTIONS
AND GROUPS AT RISK
▪ Prolonged deep neutropenia (>7 days;<500/mm )
3
■ Epidemiologic
■ Endemic: Environmental sources
■ Opportunistic: Normal human microbial flora
Signs and symptoms
■ No specific signs
■ Resemble bacterial infections:
■ Septic shock
■ Severe sepsis
■ Multi organ failure
■ Signs appear early but diagnosis is late
Possible
Etiology of deep fungal infection
Anatomic Epidemiologic
3.0
Incidence of candidaemia
2.5
2.0
1.5
1.0
0
1999 2000 2001 2002 2003
35
Hospital mortality (%)
30
25
20
15
10
5
0
< 12 12–24 24–48 > 48
■ Initiation of therapy > 12 h after the first positive blood sample was
associated with a greater risk of mortality than appropriate therapy given
within 12 h
Morrell M, et al. Antimicrob Agents Chemother 2005; 49:3640–5
47th Annual ICAAC* 2007
■ Blood culture:
■ Definitive diagnosis but
■ sensitivity only 50-60%; positive in the late stage
Yera et al., Eur J Clin Microbiol Infect Dis 2001, 20: 864-70. Sendid et al., J Med Microbiol 2002, 51:433-42.
Sendid et al., J Clin Microbiol 1999, 37:1510-7.
ANTIFUNGAL
STRATEGIES
■ Prophylaxis
■ Empirical use
■ Pre-emptive use
■ Treatment
WHAT DOES EMPIRICAL or PRE-
EMPTIVE MEAN?
Empirical :
▪ based on observation or experiment , not on theory
▪ regarding sense-data as valid information
Pre-emptive :
▪ to make a bid in an auction high enough to prevent further bidding
▪to obtain by acting in advance of others
▪to occupy public land in order to lay claim to it
▪to purchase goods before they are formally put on sale
▪to go on the offensive in order to avert an enemy attack
Oxford Dictionary
Concepts of antifungal
strategies
Likelihood of Fungal Disease Treatment
-
➢Remote 0-4% Prophylaxis
9
3
8
3
CT
7
3
(°C)
6
PC +
R
Galactomanna + Cultur + Tissu +
Granulocytes (log10x109/L)
1 n e e
Disease
00 Remot Possibl Probable Prove
likelihood e e disease n
1
0.
1
- - 0 7 1 2 2 3 4 4 5 6
14 7 4 Days1after 8 5 2 9 6 3
transplant
Candida Colonization Index
# of drugs
L-AmB
ABCD
ABLC
Terbinafine
Itraconazole
Fluconazole
Ketoconazole
Miconazole
5-FC
Candidemia in Non Neutropenic Patients
Yes No