You are taking care of a patient that is s/p heart transplant that has been complicated by intestinal rupture, abdominal surgery, need for dialysis and prolonged stay in the ICU. The individual has been on piperacillin-tazobactam for more than 10 days due to the abdominal sepsis. Over the past 24 hours the blood pressure has dropped, and the patient has been less responsive.
Should you start anti-fungal therapy?
Is there any other testing that you could do that will alter you to a fungal infection?
Beside sending blood cultures, you wonder about sending a 1,3-Beta-D-Glucan. Would this be the test that tells you a fungal infection is present?
This is not an uncommon scenario or issue or problem we face in medicine (general medicine, critical care, and ID), when to start anti-fungal therapy. Over the past 30 years there has been an increase in the incidence in invasive candidal infections (ICI), especially in the ICU. Unfortunately, outcomes have not changed and in some patient populations may have worsened. Empirical antifungal therapy has failed to demonstrate a survival benefit, even in patients with sepsis that is acquired in the ICU, Candidal colonization and multi-organ failure. Prophylactic antifungal therapy in the surgical setting has been ineffective at reducing mortality in the immune competent. One approach is assessing risk factors (prolong ICU stay, invasive devices, TPN, abdominal surgery in the past 7 days, prior antimicrobial use for >48 hours and renal replacement therapy) and assessing the 1,3-Beta-D-Glucan (BDG). The BDG is a cell wall polysaccharide found in most fungi. The pooled sensitivity is 74-86% and the pooled specificity is 49-71%, so not a great test. With a low pre-test probability, a BDG <80 pg/ml has a good NPV, but a very low PPV.
This brings us to the recent advanced published study by Bloos et al (1-3)-Beta-D-Glucan guided antifungal therapy in adults with sepsis, Int Care Med 2022. The aim of this study was to test whether BDG-guidance shortens time to antifungal therapy and there by reduces mortality of sepsis in persons at high risk for invasive candida infections (ICI). And an Editorial. Continue reading