Special articleEPICO 2.0 project. Development of educational therapeutic recommendations using the DELPHI technique on invasive candidiasis in critically ill adult patients in special situationsProyecto ÉPICO 2.0. Desarrollo de recomendaciones terapéuticas y educativas mediante la metodología DELPHI para pacientes críticos adultos no neutropénicos con candidiasis invasiva en situaciones especiales
Section snippets
Methods
The 23 panel of specialists with a wide geographical distribution in our country, pertaining to the five scientific societies collaborating in the research. The criteria of inclusion were based on their experience in the research of candidemia and on the prognostic and clinical management of critically ill adult patients with confirmed invasive candidiasis.
The DELPHI technique was used to perform the study with the objective of optimizing the consultation process of the 23 panel members. In
First phase. DELPHI experts
‘Peritoneal candidiasis’ section
1.-Indicate your level of agreement with the following statement: In critically ill surgical patients, Candida peritonitis is a poor prognostic factor.
Rationale: The mortality rate associated with Candida peritonitis is very high, ranging from 20 to 70%.19, 23, 42
The vast majority of the experts consulted (95.6%) considered Candida peritonitis a poor prognostic factor in surgical patients. Specifically, and based on a scale of 1–5 points, where 5 represents the
Recommendations after the first phase
Once the results of the DELPHI technique applied to the management of critically ill patients with confirmed invasive candidiasis are known, the following 15 recommendations were elaborated (see Table 1), based on all of the questions that achieved a high/medium level of consensus and, thereafter, validated in the meeting held with the hospital experts.
Second phase. Meeting held with hospital experts
Using the same methodology, 60 hospital experts held a meeting in which they voted the recommendations described in Table 1. Only the statements that received a level of consensus greater than 75% were selected. The final recommendations are shown in Table 2.
Proyecto ÉPICO 2.0. Desarrollo de recomendaciones terapéuticas y educativas mediante la metodología DELPHI para pacientes críticos adultos no neutropénicos con candidiasis invasiva en situaciones especiales
El presente estudio de investigación tiene por objetivo principal analizar la situación actual del manejo del paciente crítico en los hospitales de nuestro país y obtener en esta su segunda edición una serie de recomendaciones terapéuticas en situaciones especiales en el paciente crítico y sus diversos escenarios mediante metodología DELPHI Para ello, en primer término, desde el año 2012 se ha conformado un panel de especialistas de cinco sociedades científicas – Asociación española de
Metodología
El panel de expertos ha sido constituido por 23 especialistas con una amplia distribución geográfica en nuestro país y pertenecientes a las cinco sociedades científicas colaboradoras en la investigación. La razón para su inclusión en el panel obedece a su experiencia tanto en la investigación de la candidemia como en el pronóstico y manejo clínico del paciente crítico con confirmación de candidiasis invasiva.
Para llevar a cabo el estudio se ha empleado la metodología DELPHI con objeto de
Primera fase. Expertos DELPHI
Sección Candidiasis peritoneal
1.- Valore su grado de acuerdo con el siguiente enunciado: En los pacientes críticos quirúrgicos la peritonitis candidiásica es un factor de mal pronóstico.
Rationale: La mortalidad de la peritonitis candidiásica es muy elevada, estableciéndose en torno al 20-70%19, 23, 42.
La inmensa mayoría (95,6%) de los expertos consultados considera que la peritonitis candidiásica es un factor de mal pronóstico en los pacientes quirúrgicos. Concretamente, y en una escala de 1 a
Conflict of interests/Conflicto de intereses
This consensus has been sponsored by MSD Laboratories, Spain.
Este consenso ha sido esponsorizado por laboratorios MSD, España.
Acknowledgements/Agradecimientos
Carmen Romero and Ainhoa Torres (Entheos Editorial Group) for their excellent work and dedication to this project.
A Carmen Romero y Ainhoa Torres (Editorial Entheos) por su excelente trabajo y dedicación a este proyecto.
References/Bibliografía (52)
- et al.
Recomendaciones sobre el tratamiento de la candidiasis invasiva y otras infecciones por levaduras de la Sociedad Española de Enfermedades Infecciosas y Microbiología clínica (SEIMC). Actualización 2011
Enferm Infecc Microbiol Clin
(2011) - et al.
Echinocandins in a critically ill patient during continuous venovenous renal replacement
Rev Iberoam Micol
(2012) - et al.
ESCMID* guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients
Clin Microbiol Infect
(2012) - et al.
Fungal Infection in solid organ recipients
Enferm Infecc Microbiol Clin
(2012) - et al.
Infección fúngica invasora en el trasplantado de órgano sólido
Enferm Infecc Microbiol Clin
(2012) - et al.
Population pharmacokinetics of micafungin in adult patients
Diagn Microbiol Infect Dis
(2008) - et al.
Micafungin versus liposomal amphotericin B for candidaemia and invasive candidosis: a phase III randomised double-blind trial
Lancet
(2007) - et al.
Tratamiento de las infecciones fúngicas en pacientes con neoplasias hematológicas
Med Clin (Barc)
(2009) - et al.
Relationship between the initial dose of micafungin and its efficacy in patients with candidemia
J Infect Chemother
(2007) - et al.
ESCMID* guideline for the diagnosis and management of Candida diseases 2012: adults with haematological malignancies and after haematopoietic stem cell transplantation (HCT)
Clin Microbiol Infect
(2012)
Épico project. Development of educational recommendations using the DELPHI technique on invasive candidiasis in non-neutropenic critically ill adult patients
Rev Iberoam Micol
Antifungal treatment options in the critically ill patient
Rev Iberoam Micol
Safety of anidulafungin in solid organ transplant recipients
Liver Transplant
Impact of treatment strategy on outcomes in patients with candidemia and other forms of invasive candidiasis: a patient-level quantitative review of randomized trials
Clin Infect Dis
Fluconazole dosing in continuous veno-venous haemofiltration (CVVHF): need for a high daily dose of 800 mg
Nephrol Dial Transplant
A multicenter, double-blind trial of a high-dose caspofungin treatment regimen versus a standard caspofungin treatment regimen for adult patients with invasive candidiasis
Clin Infect Dis
Essentials for selecting antimicrobial therapy for intra-abdominal infections
Drugs
Discrepancies between observed and predicted continuous venovenous hemofiltration removal of antimicrobial agents in critically ill patients and the effects on dosing
Intensive Care Med
Cancidas (caspofungin) package insert
Dosing guidelines for fluconazole in patients with renal failure
Nephrol Dial Transplant
The epidemiology of intra-abdominal flora in critically ill patients with secondary and tertiary abdominal sepsis
Infection
Anidulafungin does not require dosage adjustment in subjects with varying degrees of hepatic or renal impairment
J Clin Pharmacol
Can yeast isolation in peritoneal fluid be predicted in intensive care unit patients with peritonitis?
Crit Care Med
Eraxis (anidulafungin) package insert
Cuenca-Estrella. Infección fúngica
Recommendations in the empiric anti-infective agents of intra-abdominal infection
Rev Esp Quimioter
Cited by (12)
Antifungal agents for invasive candidiasis in non-neutropenic critically ill adults: What do the guidelines recommend?
2019, International Journal of Infectious DiseasesCitation Excerpt :All 18 candidiasis CPGs and the single burn IFI guideline included specific recommendations for targeted treatment of IC (Table 4). All 18 candidiasis CPGs recommended echinocandins as the initial drug for Candida spp. (Aguado et al., 2011, Alothman et al., 2014, Bassetti et al., 2013, Bow et al., 2010, Chen et al., 2014, Colombo et al., 2013, Cornely et al., 2012, Elhoufi et al., 2014, JSMM, 2013, Kohno et al., 2016, Kung et al., 2018, Limper et al., 2011, Montravers et al., 2015, Pappas et al., 2016, Ruhnke et al., 2011, Scudeller et al., 2016, Scudeller et al., 2014, Zaragoza et al., 2014) but the burn IFI guideline did not recommend any specific drugs for unidentified Candida spp. Fluconazole, L-AMB, amphotericin B deoxycholate (D-AMB), and voriconazole were mentioned in six (JSMM, 2013, Kohno et al., 2016, Kung et al., 2018, Limper et al., 2011, Montravers et al., 2015, Ruhnke et al., 2011), three (Bassetti et al., 2013, Kohno et al., 2016, Limper et al., 2011), two (Kung et al., 2018, Limper et al., 2011), and one (Limper et al., 2011) CPGs, respectively (Table 4).
EPICO 4.0. ‘Total quality’ in the management of invasive candidiasis in critically ill patients by analysing the integrated process
2017, Revista Iberoamericana de MicologiaJávea consensus guidelines for the treatment of Candida peritonitis and other intra-abdominal fungal infections in non-neutropenic critically ill adult patients
2017, Revista Iberoamericana de MicologiaCitation Excerpt :The safety profile of candins is better than other antifungals for SOT recipients due to the absence of nephrotoxicity in their minor interactions on the cytochrome P450. Consequently, the three echinocandins are useful in the clinical management of IC in LT recipients, although small differences among them in metabolism and elimination have been observed.43,53,65 All the panel members agreed that the use of azoles is not recommended in LT recipients with IC; if there is no alternative, monitoring immunosuppressant plasma levels would be required.
Impact of a multifaceted educational intervention including serious games to improve the management of invasive candidiasis in critically ill patients
2017, Medicina IntensivaCitation Excerpt :Although antifungal drugs approved in recent years may improve effectiveness against invasive candidiasis, scientific societies’ recommendations vary widely,12–14 and the best management strategy remains controversial. For this reason, five scientific societies in Spain collaborated in the EPICO Project, program of continued improvement in the quality of care of critically ill patients, in which the Delphi method was used to elaborate consensus guidelines for the diagnosis and treatment of invasive candidiasis in critically ill patients, developing twelve recommendations focused on epidemiology, scores, diagnostic tools, treatment and de-escalation strategies;15 and for the treatment of the invasive candidiasis in critically ill adult patients in special situations, developing 13 recommendations to improve the clinical management of this population in different specific scenarios.16 We aimed to determine whether a multifaceted educational intervention including serious games based on the EPICO Project recommendations could improve physicians’ management of neutropenic or non-neutropenic critically ill adult patients with invasive candidiasis in different scenarios.
EPICO 3.0. Management of non-neutropenic patients in medical wards
2016, Revista Iberoamericana de MicologiaThe Delphi method applied to fungal infection: There is still some way to go
2016, Revista Iberoamericana de Micologia
- ♢
All members are listed in Appendix 1.