EPICO 3.0. Recommendations on invasive candidiasis in patients with complicated intra-abdominal infection and surgical patients with ICU extended stay.

Background: Although in the last decade the management of invasive fungal infections has improved, a number of controversies persist regarding the management of complicated intra-abdominal infection and surgical extended length-of-stay (LOS) patients in intensive care unit (ICU).

Aims: To identify the essential clinical knowledge and elaborate a set of recommendations, with a high level of consensus, necessary for the management of postsurgical patients with complicated intra-abdominal infection and surgical patients with ICU extended stay.

Methods: A Spanish prospective questionnaire, which measures consensus through the Delphi technique, was anonymously answered and e-mailed by 30 multidisciplinary national experts, all of them specialists in fungal invasive infections from six scientific national societies; these experts were intensivists, anesthesiologists, microbiologists, pharmacologists and specialists in infectious diseases. They answered 11 questions drafted by the coordination group after conducting a thorough review of the literature published in the last few years. For a category to be selected, the level of agreement among the experts in each should be equal to or greater than 70%. In a second round, 73 specialists attended a face-to-face meeting which was held after extracting recommendations from the chosen topics and in which they validated the pre-selected recommendations and derived algorithm.

Results: After the second Delphi round, the following 11 recommendations with high degree of consensus were validated. For "surgical patients" seven recommendations were validated: (1) risk factors for invasive candidiasis (IC), (2) usefulness of blood culture and direct examination of abdominal fluid to start empirical treatment; (3) PCR for treatment discontinuation; (4) start antifungal treatment in patients with anastomotic leaks; (5) usefulness of Candida score (CS) but not (6) the Dupont score for initiating antifungal therapy in the event of anastomotic leakage or tertiary peritonitis, and (7) the administration of echinocandins as first line treatment in this special population. For "surgical ICU extended LOS patients" four recommendations were validated: (1) risk factors for IC, (2) presence of multi-colonization by Candida as a required variable of the CS, (3) starting antifungal treatment with CS≥4, and (4) to perform non-culture-based microbiological techniques in stable septic patients without evident focus.

Conclusions: The diagnosis and management of IC in ICU surgical patients requires the application of a broad range of knowledge and skills that we summarize in our recommendations. These recommendations, based on the DELPHI methodology, may help to identify potential patients, standardize their global management and improve their outcomes.