Empiric anti-Candida therapy for patients with sepsis in the ICU how little is too little.docVIP

Available online /content/13/4/180 Commentary Empiric anti-Candida therapy for patients with sepsis in the ICU: how little is too little? Yoav Golan Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA Corresponding author: Yoav Golan, ygolan@ Published: 21 August 2009 Critical Care 2009, 13:180 (doi:10.1186/cc7977) This article is online at /content/13/4/180 ? 2009 BioMed Central Ltd See related research by Zilberberg et al., /content/13/3/R94 Abstract antifungal resistance [7]. Clinicians caring for ICU patients with sepsis frequently wonder in which circumstances is the administration of an empiric anti-Candida agent advisable? Which agent is most attractive? Similar to other clinical questions, the best experimental design to evaluate treatment strategies is the clinical trial. But like any trial that evaluates an empiric strategy, the required sample size, and, therefore, the cost and ability to enroll enough patients, are often prohibitive. When data from clinical trials are not available, an alternative research design needs to be utilized. Prior analyses suggest that empiric fluconazole for ICU patients with sepsis is cost-effective. Using updated estimates of efficacy and cost, Zilberberg and colleagues compare the use of mica- fungin with that of fluconazole. The authors conclude that mica- fungin is an attractive alternative to fluconazole. This conclusion is driven by recent reduction in micafungin’s cost and by better activity of micafungin against azole-resistant Candida species. Their results are limited by inflated estimates of efficacy, life expec- tancy and risk of Candida sepsis. This commentary explores the rationale for early anti-Candida strategies in the ICU and highlights the contribution and limitations of the article by Zilberberg and colleagues. Decision