Traitement antifongique des candidoses systémiques en réanimation

Abstract

Hospital-acquired infections secondary to Candida have undergone a considerable recrudescence in the last decade. They still represent a substantial mortality rate, particularly in ICU patients. Their bad prognosis is mainly due to delay in treatment because of the difficulties involved in diagnosis. Clear indications for treatment resulting from an international consensus have not yet been established. The therapeutic regimen includes Amphotericin B, 5-fluorocytosin, azoles (fluconazole, itraconazole), and recently, new antifungals, mainly voriconazole and caspofungin. The use of amphotericin B is restricted because of its renal toxicity and the difficulty involved in its administration. Fluconazole use is still limited because of the possible development of fungal resistance especially in case of severe infection or of previous exposure to the drug. Indeed, the emergence of fluconazole resistance in Candida albicans as well as the frequency of other naturally resistant Candida species, such as Candida krusei, seems to have increased considerably since the introduction of fluconazole at the beginning of the 1990s'. However, since the appearance of new standardized and reasonably reliable methods to measure resistance, this worrisome rise in resistance seems to be the result of the absence of standard definition criteria rather than a microbiological cause. Furthermore, the interaction between the yeast and the host is so complex that the microbiological resistance has a low predictive value, if at all, for clinical resistance. Fluconazole should be the first choice for all patients without a documented or highly suspected resistance. Amphotericin B should be reserved for particular indications such us intracranial infections. The treatment should be adjusted according to the clinical evolution and the results of sensitivity tests.