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PhD Student, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium, Department of Intensive Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium, fax 0032 9 240 49 95, Dominique.Vandijck{at}UGent.be
Professor, Faculty of Medicine and Health Sciences, Ghent University, Researcher, Intensive Care Medicine Department, Ghent University Hospital
Professor of Medicine, Faculty of Medicine and Health Sciences, Ghent University Head, Intensive Care Department, Ghent University Hospital
Published Online, October 2, 2007. www.theannals.com, DOI 10.1345/aph.1H516a
To date, there was only one study reporting the lack of simple clinical factors to allow the clinician to effectively identify patients likely infected with non-albicans species or with possible fluconazole-resistant fungi.2 Similar to other reports, one of our previous observations (n = 308) demonstrated that exposure to fluconazole at the individual patient level prior to the onset of candidemia increased the likelihood of infection caused by Candida non-albicans species compared with those who had not been treated with this antifungal (58.6% vs 40.8%; p = 0.001).3,4 The absence of this association in the present report by Davis et al. may at least partly be due to the underpowering of the cohort studied.
Next, an episode of candidemia has been associated with important socioeconomic costs due to longer hospital stay, additional diagnostic and therapeutic interventions, and loss of societal productivity. However, when comparing patients with non-albicans species with those with C. albicans candidemia, Davis et al. did not find any differences in financial outcomes. We wonder why the authors did not include the nonsurvivors in their economical analysis, as they are part of daily clinical practice as well and represent use of substantial resources.5
Finally, we agree with the authors' statement that highlights the need for surveillance of unit-specific Candida distribution to assist the clinician in choosing the most appropriate empirical therapy. We use an intensive screening policy in our unit, in which site-specific surveillance cultures are obtained 3 times weekly. After evaluation, our monitoring determined that two-thirds of the episodes of candidemia were preceded by candidal colonization.6 In patients who also had fever of unexplained origin, preemptive therapy was started. Surveillance sampling likely contributed to the short delay in the start of antifungal treatment (median <24 h). This observation, together with the facts that blood cultures have low sensitivity for isolating Candida spp. (<50%) and the time necessary for processing blood cultures takes about 48 hours, stresses the importance of early preemptive therapy in cases of persistent, multisite, candidal colonization.
References
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