Empirical Antifungal Therapy in Immunocompromised Patients with Septic Shock

Introduction to Antifungal Therapy

The Surviving Sepsis Campaign guidelines recommend empirical antifungal therapy only for Candida species when specific risk factors exist, as stated by the Surviving Sepsis Campaign 1, 2, 3

Immunocompromised status, such as neutropenia, chemotherapy, transplant, diabetes mellitus, chronic liver or renal failure, is a risk factor for Candida infection, according to the Surviving Sepsis Campaign 1, 2, 3
Prolonged invasive vascular devices, total parenteral nutrition, necrotizing pancreatitis, recent major abdominal surgery, prolonged broad-spectrum antibiotic administration, and prolonged hospital or ICU admission are also risk factors for Candida infection, as recommended by the Surviving Sepsis Campaign 1, 2, 3
Recent fungal infection and multisite Candida colonization are additional risk factors for Candida infection, as stated by the Surviving Sepsis Campaign 1, 2, 3

The Surviving Sepsis Campaign recommends using an echinocandin, such as anidulafungin, micafungin, or caspofungin, as the preferred agent for empirical antifungal therapy in patients with septic shock, as stated by the Surviving Sepsis Campaign 1, 2, 3, 4, 5
Echinocandins are preferred in patients with severe illness or septic shock, recent antifungal exposure, or suspected Candida glabrata or C. krusei, according to the Surviving Sepsis Campaign 1, 2, 3, 4, 5
Triazoles, such as fluconazole, are acceptable only in hemodynamically stable patients without prior triazole exposure and no known azole-resistant colonization, as recommended by the Surviving Sepsis Campaign 1, 2, 3, 4, 5, 6

The Surviving Sepsis Campaign does not recommend empirical mold coverage in septic shock protocols, as stated by the Surviving Sepsis Campaign 1, 2, 3, 4, 5
Mold-active therapy, such as voriconazole, posaconazole, or liposomal amphotericin B, should only be initiated when specific clinical features suggest invasive mold infection, according to the Clinical Microbiology and Infection guidelines 7

Assess for Candida risk factors, and if two or more risk factors are present and the patient has septic shock, start echinocandin empirically, as recommended by the Surviving Sepsis Campaign 1, 2, 3, 4, 5
Obtain cultures before starting antifungals when possible, and reassess daily to de-escalate or discontinue antifungals if cultures are negative and clinical improvement occurs, as stated by the Surviving Sepsis Campaign 1, 2, 3, 4, 5