Abstract
IntroductionColonisation of the lower respiratory tract with Candida species occurs in 25% of mechanically ventilated critically ill patients, and is associated with increased morbidity. Nebulised amphotericin B has been used to eradicate Candida as part of selective decontamination of the digestive tract (SDD) protocols, but its effectiveness is unknown. We aimed to determine the effectiveness of nebulised amphotericin B in eradicating Candida respiratory tract colonisation in patients receiving SDD.MethodsWe included consecutive mechanically ventilated patients during a four-year period. Microbiological screening was performed upon admission and twice weekly thereafter according to a standardised protocol. A colonisation episode was defined as the presence of Candida species in two consecutive sputum samples taken at least one day apart. To correct for time-varying bias and possible confounding, we used a multistate approach and performed time-varying Cox regression with adjustment for age, disease severity, Candida load at baseline and concurrent corticosteroid use.ResultsAmong 1,819 patients, colonisation with Candida occurred 401 times in 363 patients; 333 of these events were included for analysis. Decolonisation occurred in 51 of 59 episodes (86%) and in 170 of 274 episodes (62%) in patients receiving and not receiving nebulised amphotericin B, respectively. Nebulised amphotericin B was associated with an increased rate of Candida eradication (crude HR 2.0; 95% CI 1.4 to 2.7, adjusted HR 2.2; 95% CI 1.6 to 3.0). Median times to decolonisation were six and nine days, respectively. The incidence rate of ventilator-associated pneumonia, length of stay and mortality did not differ between both groups.ConclusionsNebulised amphotericin B reduces the duration of Candida colonisation in the lower respiratory tracts of mechanically ventilated critically ill patients receiving SDD, but data remain lacking that this is associated with a meaningful improvement in clinical outcomes. Until more evidence becomes available, nebulised amphotericin B should not be used routinely as part of the SDD protocol.
Highlights
Colonisation of the lower respiratory tract with Candida species occurs in 25% of mechanically ventilated critically ill patients, and is associated with increased morbidity
Colonisation of the lower respiratory tract (LRT) by Candida occurs in 25% of critically ill patients receiving mechanical ventilation and in 50% of patients suspected of ventilatorassociated pneumonia (VAP), and has been associated with longer intensive care unit (ICU) stay, a prolonged duration of mechanical ventilation, an increased risk of bacterial VAP, and possibly increased in-hospital mortality [1,2,3,4]
Experimental and clinical studies have shown that Candida colonisation was associated with an increased risk for VAP by Pseudomonas aeruginosa, and that systemic antifungal treatment decreased the risk for P. aeruginosa infection in colonised patients [1,9,10]
Summary
Colonisation of the lower respiratory tract with Candida species occurs in 25% of mechanically ventilated critically ill patients, and is associated with increased morbidity. We aimed to determine the effectiveness of nebulised amphotericin B in eradicating Candida respiratory tract colonisation in patients receiving SDD. Colonisation of the lower respiratory tract (LRT) by Candida occurs in 25% of critically ill patients receiving mechanical ventilation and in 50% of patients suspected of ventilatorassociated pneumonia (VAP), and has been associated with longer intensive care unit (ICU) stay, a prolonged duration of mechanical ventilation, an increased risk of bacterial VAP, and possibly increased in-hospital mortality [1,2,3,4]. Experimental and clinical studies have shown that Candida colonisation was associated with an increased risk for VAP by Pseudomonas aeruginosa, and that systemic antifungal treatment decreased the risk for P. aeruginosa infection in colonised patients [1,9,10]
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