Invasive aspergillosis in critically ill patients: attributable mortality and excesses in length of ICU stay and ventilator dependence☆
Introduction
The importance of fungi as pathogens in intensive care units (ICUs) is increasing as a result of advances in life-support systems, wider use of broad-spectrum antibiotics and invasive devices, and an increasing proportion of susceptible patients.1 Nosocomial invasive aspergillosis can occur in any severely immunocompromised or chronically debilitated host. It is by far the greatest infectious threat to survival, in the setting of profound granulocytopenia during and after induction chemotherapy, bone marrow transplantation and certain solid-organ transplant patients. Conversely, cases of community-acquired pulmonary infection due to Aspergillus spp. have been described in presumably immunocompetent individuals. Intercurrent invasive pulmonary aspergillosis has been associated with chronic obstructive pulmonary disease (COPD) and influenza pneumonitis in patients with other pre-existing structural lung disease, as well as in patients with acquired immunodeficiency syndrome (AIDS). The development of respiratory failure in the disease heralds a particularly poor prognosis. Despite adequate anti-fungal therapy, mortality varies from 50 to 100%. There are substantial variations depending on patient characteristics.2., 3. Few studies describe the epidemiology and outcome of invasive aspergillosis in ICU patients, without any data on attributable mortality. In view of the severe underlying disease of such patients, it is often very difficult to distinguish mortality attributable to fungal infection, from mortality due to disease. In this context, matched cohort studies are more appropriate in determining attributable mortalities.4 The primary objective of the present study was to determine outcome and attributable mortality of invasive aspergillosis infections in patients admitted to a general ICU by means of a matched cohort study. The secondary objective of this study was to investigate the excess length of stay in the ICU, as well as the excess length of mechanical ventilator dependency in ICU patients with invasive aspergillosis as these are the utmost important indicators for cost estimation in ICU setting.
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Setting
The present study was conducted in the Ghent University Hospital, a 1060-bed, tertiary care centre with a 54-bed ICU, including a surgical and medical ICU, an ICU for cardiac surgery and a unit for severely burned patients. Approximately 3300 patients are admitted to the ICU each year. The surgical ICU provides all types of surgery with the need for intensive care management, including multiple trauma and solid-organ transplantations (kidney, liver and pancreas). The medical ICU serves all
Results
During the study period there were 8988 admissions in the ICUs. Of these patients, 71 were identified with positive cultures for Aspergillus spp. According to the predefined criteria 37 were classified as cases with either definite or probable invasive aspergillosis, representing an incidence of four out of 1000 ICU admissions. In 10 patients the diagnosis was definite (pulmonary involvement, two patients; pulmonary and other organ involvement, eight patients). The diagnosis of probable
Discussion
Although formerly considered to be a rare disease, invasive aspergillosis is now recognized as an emerging opportunistic infection in the critically ill. In the present study, the incidence of invasive aspergillosis in general ICU patients was four in 1000 patients. Groll et al. reported the trends of invasive mycoses from autopsy findings in a German university hospital and found a 14-fold rise in prevalence over a 12-year period.21 A large nationwide Japanese study of unselected autopsies
Acknowledgments
The authors thank P. De Waegemaeker (RN, MA) from the Hospital Hygiene Team, Ghent University Hospital, for providing microbiological data.
References (32)
- et al.
Fungal infection in the intensive care unit
J Hosp Infect
(1998) - et al.
Effects of nosocomial candidemia on outcomes of critically ill patients
Am J Med
(2002) - et al.
Evaluation of outcome in critically ill patients with nosocomial enterobacter bacteremia: results of a matched cohort study
Chest
(2003) - et al.
Reappraisal of attributable mortality in critically ill patients with nosocomial bacteraemia involving Pseudomonas aeruginosa
J Hosp Infect
(2003) - et al.
Trends in the post-mortem epidemiology of invasive fungal infections at a university hospital
J Infect
(1996) - et al.
Acute community-acquired pneumonia due to aspergillus in presumably immunocompetent hosts: clues for recognition of a rare but fatal disease
Chest
(1998) - et al.
Fungal infection: a common, unrecognised complication of acute liver failure
J Hepatol
(1991) Therapeutic outcome in invasive aspergillosis
Clin Infect Dis
(1996)- et al.
Diagnostic and therapeutic strategies for invasive aspergillosis
Semin Respir Crit Care Med
(1997) The mortality of hospital-acquired bloodstream infections: need for a new vital statistic?
Int J Epidemiol
(1988)
APACHE II: a severity of disease classification system
Crit Care Med
Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality
J Am Med Assoc
Invasive aspergillosis in the ICU: incidence and characteristics
Intensive Care Med
Defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell transplants: an international consensus
Clin Infect Dis
Evaluation of outcome of intravenous catheter-related infections in critically ill patients
Am J Respir Crit Care Med
Clinical impact of nosocomial Klebsiella bacteremia in critically ill patients
Eur J Clin Microbiol Infect Dis
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Presented in part at the 41st Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, 2001.
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