A major Italian study, which reviewed data from over 185,000 patients hospitalized in intensive care in Italy over a decade, sheds light on a silent emergency that is difficult to bring to light: that of invasive fungal infections. Infections that are “much more frequent than previously thought” among patients in these departments, warn the authors of the study published in ‘Mycoses’, which offers a snapshot of the real impact of candidiasis, aspergillosis and pneumocystis. In agreement with data at European level, these are also the most widespread infections among patients hospitalized in intensive care in Italy. The identikit of the most affected subjects? 63% are male, average age 68.
The study, carried out with the contribution of Gilead Sciences, is signed by a team of researchers, including experts from two hospitals in the country, Sant’Orsola-Malpighi in Bologna and the hospital-university company of Padua. Invasive fungal infections (IFI) are serious infections that can affect seriously ill people cared for in intensive care units (ICU), patients undergoing invasive medical procedures and receiving broad-spectrum antibiotics and those taking immunosuppressive drugs, the experts list. Why should they be considered an emergency? “Because they are not only a problem for severely immunosuppressed patients as they were classically considered”, Pier Luigi Viale, University of Bologna Sant’Orsola-Malpighi, first author of the retrospective observational study, conducted on administrative data relating to the period 2012-2023, highlights to Adnkronos Salute. And again, “because they are difficult to diagnose both from a clinical and microbiological point of view. Because the therapeutic armamentarium is rather limited. Because important problems of resistance to the most commonly used drugs are emerging. Because medical culture on this topic is still rather poor”.
In short, this type of infection, according to experts, represents “a current clinical challenge, which has acquired even more interest in light of the significant epidemiological changes in the post-Covid-19 era”. For example, Covid-associated pulmonary aspergillosis (Capa) and influenza-associated pulmonary aspergillosis (Iapa) are of growing concern. Another element that has been noted – we read further in the article – is that in the last decade, the rate of candidemia has increased in some contexts up to 50% with an incidence of 5.1 per 1000 admissions to intensive care. The ‘Charter-Ifi’ study retrospectively examined 186,310 patients admitted to intensive care in Italy from January 1, 2012 to September 1, 2023, using administrative databases covering approximately 10 million inhabitants. Result: 746 patients with Ifi discharged from intensive care were included (incidence equal to 4 per 1000 patients admitted to intensive care).
The three main diagnoses were candidiasis (501 patients, 2.7/1000 patients admitted to intensive care), aspergillosis (71, 0.4/1000) and pneumocystosis (55, 0.3/1000). The conditions that put you at greatest risk? The evaluation of the comorbidity profile in patients with invasive fungal infections revealed the presence of hypertension (60.5%), treatment with systemic antibiotics (45.3% in the 12 months before and 18.6% in the 3 months before hospitalization), cancer (23.1%), diabetes (24.3%) and cardiovascular disease (23.9%). Deaths occurred in 36.1% of patients with Ifi (within 30 days of discharge). The authors highlight how “this retrospective analysis among patients admitted to intensive care” describes “the burden of Ifi in intensive care”. Understanding this, they note, “could be critical to strengthening surveillance, research investments, and public health interventions as called for by WHO.”
The fungal infection, the authors warn, lengthens the time of hospitalization and contributes to the risk of death. Among the data collected, those relating to the Covid period show that during the pandemic (2020-2022) about a third of Covid patients in intensive care developed a superinfection by Aspergillus (Capa), lengthening the recovery time and increasing the risk of death. This study, Viale highlights, “has its strength in the size of the sample. Like all studies on administrative databases, it comes to evaluate a denominator of enormous dimensions, in this specific case over 185,000 admissions to intensive care, referring to a population sample of 10 million residents. With all the limitations of retrospective studies that analyze administrative databases, which usually underestimate the size of the variables researched, in this specific case, very significant prevalence values emerge, demonstrating that the problem of invasive fungal infections in intensive care is anything but a niche topic”.
A problem that is perhaps underestimated and poorly monitored. Even the WHO has had the opportunity to highlight the lack of both research and development of adequate therapeutic solutions for the most critical forms, such as Cryptococcus neoformans, Aspergillus fumigatus, Candida albicans and Candida auris, for which greater surveillance and intervention is considered essential. “The data from the study could have a strong impact on the healthcare system”, concludes Viale, because they highlight “how the problem of invasive fungal infections is not limited to large healthcare organizations. The specific culture must be divided up at all levels and it is necessary to invest in culture and diagnostic tools. In other words, every hospital must have the possibility of making a diagnosis, either directly or by referring to reference centers, in an organizational context that gives everyone the possibility of accessing diagnostic tools, infectious disease consultancy and the best therapeutic resources”.
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