LAUSR

Initial correspondence from Drs. Yamaga, Ohshimo and Shime We would like to discuss factors that potentially affect the results of a biomarker-based antifungal therapeutic algorithm in a recent issue of Intensive Care Medicine [1]. First, the Clinical Practice Guideline of the Infectious Diseases Society of America states that β-d-glucan testing is useful for excluding invasive candidiasis in the ICU setting, based on a meta-analysis presenting its high negative predictive value [2]. The authors’ algorithm, however, uses empirical antifungal therapy solely with positive anti-mannan testing, regardless of negative β-d-glucan tests, which could have resulted in overuse of antifungal therapy. Second, patients in the control group were treated until day 14, regardless of the results of serological biomarkers at days 0 and 4, which seemed to be inappropriately long as routine care. The aforementioned guideline recommends that empirical antifungal therapy should be discontinued in patients with no clinical response, no subsequent evidence of invasive candidiasis, or negative serological fungal biomarkers at 4–5 days [2]. Additionally, the long duration of antifungal therapy could have increased the cost, resulting in incorrect interpretation of the cost analysis. Third, fluconazole was the most frequently used (50%) initial antifungal therapy. This, however, is not concordant with the recommendation of the European Society of Clinical Microbiology and Infectious Diseases guidelines, in which echinocandins, but not fluconazole, are recommended for initial treatment of candidemia [3]. The reasons for the dissociation could be discussed. Finally, provision of adjunctive treatment including source control and central vascular catheter removal would be appreciated because they are also significant mortality risk factors in invasive Candida infection.