Prevention of acquired invasive fungal infection with decontamination regimen in mechanically ventilated ICU patients: a pre/post observational study

Abstract

Background

Invasive fungal infections acquired in the intensive care unit (AFI) are life-threating complications of critical illness. However, there is no consensus on antifungal prophylaxis in this setting. Multiple site decontamination is a well-studied prophylaxis against bacterial and fungal infections. Data on the effect of decontamination regimens on AFI are lacking. We hypothesised that multiple site decontamination could decrease the rate of AFI in mechanically ventilated patients.

Methods

We conducted a pre/post observational study in 2 ICUs, on adult patients who required mechanical ventilation for >24 h. During the study period, multiple-site decontamination was added to standard of care. It consists of amphotericin B four times daily in the oropharynx and the gastric tube along with topical antibiotics, chlorhexidine body wash and nasal mupirocin.

Results

In 870 patients, there were 27 AFI in 26 patients. Aspergillosis accounted for 20/143 of ventilator-associated pneumonia and candidemia for 7/75 of ICU-acquired bloodstream infections. There were 3/308 (1%) patients with AFI in the decontamination group and 23/562 (4%) in the standard-care group (p = 0.011). In a propensity-score matched analysis, there were 3/308 (1%) and 16/308 (5%) AFI in the decontamination group and the standard-care group respectively (p = 0.004) (3/308 vs 11/308 ventilator-associated pulmonary aspergillosis, respectively [p = 0.055] and 0/308 vs 6/308 candidemia, respectively [p = 0.037]).

Conclusion

Acquired fungal infection is a rare event, but accounts for a large proportion of ICU-acquired infections. Our study showed a preventive effect of decontamination against acquired fungal infection, especially candidemia.

Take home message

• Acquired fungal infection (AFI) incidence is close to 4% in mechanically ventilated patients without antifungal prophylaxis (3% for pulmonary aspergillosis and 1% for candidemia).

• Aspergillosis accounts for 14% of ventilator-associated pneumonia and candidemia for 9% of acquired bloodstream infections.

• Immunocompromised patients, those infected with SARS-COV 2 or influenza virus, males and patients admitted during the fall season are at higher risk of AFI.

• Mechanically ventilated patients receiving multiple site decontamination (MSD) have a lower risk of AFI.

Keywords:

• Critical care
• pneumonia
• acquired infection
• fungal infection
• pulmonary aspergillosis
• candidemia

Acknowledgment

NM would like to thank Christophe Camus for his wise advices and the time spent on transmitting his knowledge in the field of decontamination.

Ethical approval

This study respects the French reference method MR004. Patients or closest relatives were informed of the retrospective collection of the data and only those who did not oppose participation in the study were enrolled. The Rennes Hospital ethics committee approved the study protocol (Comité d’Ethique du CHU de Rennes) (avis 19–52).

Contribution

All authors participated to acquisition of data, NM, FLG, FR and PF participated to the conception and design of the study, NM performed the analysis and interpretation of data, NM drafted the article, all authors finally approved the submitted version.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data will be made available on appropriate demand, please contact Nicolas Massart for more information.

Additional information

Funding

No external funding was received.