Epidemiology, diagnosis, and therapy of fungal infections in surgery.

Over the past decade, the incidence of hospital-acquired bloodstream infections caused by Candida strains has risen, while the implicated species have changed. Candida tropicalis, Candida parapsilosis, and Candida glabrata all have increased in incidence. Data from the Centers for Disease Control and Prevention reveal that, between 1980 and 1990, Candida emerged as the sixth most common nosocomial pathogen (7.2%) and was the fourth most common pathogen in nosocomial bloodstream infections, surpassed only by coagulase-negative staphylococci, Staphylococcus aureus, and enterococci. The incidence of candidemia is dramatically higher in high-risk critical-care units: 25% of cases occur in surgical intensive-care units (ICUs) versus 25% in bone marrow transplantation units, 20% in medical ICUs, 20% in general medical wards, and 10% in oncology-hematology units. Burns and gastrointestinal surgery predispose to nosocomial candidemia. Independent risk factors include prior therapy with multiple antibiotics, isolation of Candida from sites other than blood, and prior hemodialysis. Crude mortality exceeds 55% and is associated with older age and concomitant renal failure, hepatic failure, acute respiratory diseases, or postoperative shock. In addition to extreme vigilance for early recognition of Candida sepsis in critically ill surgical patients, the high risk for candidemia probably necessitates fungal surveillance cultures and initiation of preemptive antifungal therapy in high-risk surgical patients.