Is (1,3)-β-d-glucan useless to guide antifungal therapy in ICU?

Excerpt

Over the past decades, the incidence of invasive candidiasis has increased among critically ill patients, without improvement in outcomes [1]. Risk factors include long duration of stay, invasive devices such as central venous catheter, parenteral nutrition, complicated digestive surgery, and broad-spectrum antibiotic therapy. The European EUCANDICU project reports a crude 30-day mortality of 71% for candidemia and 25% for intra-abdominal candidiasis [2]. Early initiation of antifungal treatment, together with adequate source control, are among the key levers for decreasing the mortality in patients with septic shock [3]. But we are still far from performing well enough in this matter. In a French prospective cohort including 835 critically ill patients with proven or suspected invasive candidiasis, antifungal treatment was early and appropriate in 13%, delayed in 35%, and unnecessary in 52% of cases [4]. Importantly, unnecessary antifungals were maintained for more than 10 days in median because of diagnostic uncertainties. These findings can be explained in several ways. Blood and sterile-site cultures, the current diagnostic gold standards, are limited by poor sensitivity and long delay to positivity [5]. Prophylactic antifungal therapy, mostly used in surgical settings, is ineffective to reduce mortality among immunocompetent patients, despite decreasing secondary invasive candidiasis rates [6]. Similarly, empirical antifungal treatment failed to demonstrate a benefit on survival, even in patients with sepsis acquired in intensive care unit (ICU), multiple Candida colonization and multiple organ failure [7]. …