[Fluid therapy in sepsis and septic shock]. / Fluidoterapia en la sepsis y el shock séptico.

Fluid resuscitation is a crucial part of the treatment of hypotension and shock of any etiology. Particularly in septic shock, it is an essential element of the initial care bundle. Like all treatments in sepsis, it is also subject to multiple controversies: what type of fluid, how much, how long to administer it, potential risks, toxicity? The main guideline, the Surviving Sepsis Campaign, continues to indicate crystalloids as the main fluid in resuscitation. But the possibility of crystalloids balanced on 0.9% saline or combined use with albumin in the resuscitation of the septic patient is still under debate. This is probably another point where we should always consider individualizing both the type and amount of fluids to be administered in both the initial and maintenance phases of the management of sepsis and septic shock.

Efficacy and safety of anidulafungin in elderly, critically ill patients with invasive Candida infections: a post hoc analysis.

Post hoc analysis of a non-comparative, prospective, multicentre, phase IIIb study was performed to compare efficacy and safety of anidulafungin in elderly (≥65 years) versus non-elderly (<65 years) Intensive Care Unit (ICU) patients with candidaemia/invasive candidiasis (C/IC). Adult ICU patients with confirmed C/IC meeting ≥1 of the following criteria were enrolled: post-abdominal surgery; solid tumour; renal/hepatic insufficiency; solid organ transplantation; neutropenia; age ≥65 years. Patients received anidulafungin (200 mg on Day 1, 100 mg/day thereafter) for ≥10 days followed by optional azole step-down therapy for a total treatment duration of 14-56 days. The primary efficacy endpoint was global (clinical and microbiological) response at the end of all therapy (EOT). Primary efficacy analysis was performed in the modified intent-to-treat (mITT) population (n=170), excluding unknown and missing responses. In total, 80 patients (47.1%) were aged ≥65 years and 90 (52.9%) were aged <65 years; the mean age difference between the two groups was 21.9 years. Global success at EOT in mITT patients was similar in elderly (68.1%) and non-elderly (70.7%) patients (P=0.719). However, global success rates were significantly lower in elderly versus non-elderly patients at 2 and 6 weeks after EOT (P=0.045 and P=0.016, respectively). Ninety-day survival was significantly lower (P=0.006) for elderly (42.8%) versus non-elderly patients (63.3%). The incidence and profile of adverse events were similar in elderly and non-elderly patients. Anidulafungin was effective and safe for treatment of C/IC in elderly ICU patients, despite higher baseline severity of illness scores.

Critical overview of clinical guidelines relating to invasive fungal infections.

The incidence of invasive fungal infections (IFIs) has continued to grow in recent years. IFIs are associated with significant morbidity and mortality as well as costs. The diagnostic and therapeutic approaches to IFI have changed significantly in recent years, fostered by the introduction of new diagnostic methods and new antifungal products. There are also new therapeutic approaches such as de-escalation, pre-emptive antifungal treatment or combined treatment with antifungals. All of these aspects have been described in many trials, meta-analyses and reviews. There are also different clinical guidelines for IFIs with diagnostic and therapeutic recommendations. They are of unquestionable value and at the same time represent different perspectives on the problem. The lack of homogeneity when selecting and drafting the recommendations is a problem, and some of them are based more on personal opinion than on evidence. In this paper, we have put together a critical overview of the role of guidelines for IFIs, with emphasis on non-neutropenic critical patients.