Medicine has undeniably allowed people to live longer, but that longevity has brought new concerns to ICUs. Particularly among immunocompromised and oncology patients, fungal infections have additional time and opportunity to gain a stronghold.
When Brenda Shelton, MS, RN, CCRN, AOCN, began her nursing career 30 years ago, life-threatening fungal infections were less prevalent. Advances in cancer care, while beneficial on the whole, have spawned unintended consequences.
"Patients with brain tumors used to have a life expectancy of 3-12 months, but better treatment has allowed them to live a bit longer," said Shelton, clinical nurse specialist at the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore. "The last two brain tumor ICU patients we treated died of infection, not of their disease. One patient had a rare fungus, and the other had candidemia. Years ago, you would not see most of these fungal infections in patients with brain tumors because they would not live long enough."
Other types of patients - such as organ transplant recipients - were not living long enough in the past to develop chronic infections. The sheer number of available immunosuppressant agents is a boon for organ transplant patients, but all those options are still immunocompromising.
While infection prevalence is up, the good news is many new anti-fungal agents are available beyond the familiar amphotericin. Two or three viable alternatives can be used, and even if amphotericin is necessary, a less toxic liposomal form will often do the trick, Shelton said.
These remedies can and do work, she added, but preventing infections before they happen is far more desirable.
Don't Take Lightly
An expert and sought-after speaker on opportunistic infections, Shelton cautioned not to underestimate or overlook fungal infections.
"The biggest misconception is the belief that fungal infections are rare," she said. "Another misconception is fungal infections are like every other severe infection. They are harder to manage, harder to eradicate and more frequent than people realize."
Lethal microbes are nothing new, so why are fungal infections on the rise? In addition to increased longevity, Shelton believes it comes down to awareness and a failure to check.
"Nurses are not looking," she said. "Fungal cultures may require different media, handling, labeling or a different laboratory for processing. If you don't look, you won't find. And as a result you will not think fungal infections are prevalent."
Aspergillosis: Magnified 562x, this photomicrograph, stained using a fluorescent antibody-staining technique, revealed the presence of Aspergillus sp. organisms in a case of aspergillosis. courtesy CDC/ Dr. William Kaplan
One example, Shelton said, is a typical line infection, which is always a concern. A line infection with candida, however, must be dealt with even if the line is semi-permanent. "Without an immediate response," Shelton warned, "the infection is unlikely to ever clear."
Once patients leave the controlled environment of the ICU, hidden spores abound, and patients don't always get the right information about the dangers.
"When you are immunocompromised and walking through a construction area, you have a risk of getting aspergillus," Shelton said. "It may be patients love to garden, and we really don't think about telling them to wear a mask because they are disturbing the soil. We also don't tell them as they are driving to the hospital, we have huge buildings going up that are shaking the ground and creating exposure."
These "normal" activities can lead to additional hospital stays, as can improper oral care. Candida exists in healthy mouths, but Shelton points out without proper care, mechanically ventilated patients can experience overgrowth of candida in their mouths, candidal infection or candidal pneumonia.
Increasingly prevalent air filtration methods prevent mold at many facilities, including Shelton's ICU. And while these highly efficient particulate-filtration systems are required in bone marrow transplant units, they are not standard in every ICU. Shelton reports many ICUs taking organ transplant and/or HIV patients do not have the luxury of these high filtration systems, which only increases the need for nurse vigilance.
Candida Pneumonia: This plane film chest X-ray revealed the presence of a pulmonary infiltrate. This, as well as other diagnostic findings, indicated the patient had candidiasis, which lead to the onset of Candida pneumonia, a fungal infection caused by members of the fungal genus, Candida sp. courtesy CDC/ Libero Ajello
When an organ transplant patient experiencing rejection comes into the ICU at many facilities nationwide, there is not necessarily a standard template of what should be looked at. "Nurses should check for fungal infection and bacteria," Shelton said. "There are serum markers, such as galactomannan, that loosely predict for the presence of a fungal infection. When I do my presentations, there is often some confusion on these topics."
Across the spectrum of nursing specialties, there is a "preemptive controversy" caused by the sheer selection of anti-fungals, and differing opinions as to what really works. While acknowledging the differing approaches among specialties to preventing infections in patients with trauma, lupus, organ transplant and HIV, among others, Shelton said oncology nurses uniformly adopt the preemptive philosophy.
"I believe in preemptive therapy," said Shelton, who is scheduled to present on the topic of fungal infections at the American Association of Critical-Care Nurses National Teaching Institute & Critical Care Exposition. "We, as oncology nurses, have strong clinical guidelines through the national comprehensive cancer network. A guideline called preventing infection supports the preemptive treatment."
Candidiasis: An HIV/AIDS patient presented with a spontaneous secondary acute oral pseudomembranous candidiasis infection. courtesy CDC/ Sol Silverman Jr., DDS
A recent survey from the Oncology Nursing Society (ONS) supports Shelton's concerns, with a whopping 68 percent of respondents agreeing with the statement: "I am increasingly concerned about invasive fungal infections (IFIs) as a complication in my high-risk patients." Drilling it down to more specific conditions, more than 75 percent of respondents indicated "patients with myelodysplastic syndromes who were neutropenic were at high to very high risk for IFIs."
An additional 79 percent of nurses in the survey categorized risk as "high to very high" for patients with acute myelogenous leukemia who were also neutropenic. On the importance of prophylaxis, ONS reported 77 percent of the nurse respondents agreed with the statement: "I am convinced antifungal prophylaxis is the best approach to managing the risk of developing IFI."
According to the ONS, the misery patients experience adds up to even more pain in the wallet, with high costs for patients and providers alike. Average hospitalization for aspergillosis is pegged at 17.5 days and $82,425 per case. For invasive candidiasis, therapy costs range from $34,000-$44,500 per patient.
The survey did not cover all types of nurses, but Shelton believes the results are an encouraging sign the awareness message is getting out.
Still, "there are definitely knowledge gaps in certain groups of nurses, and that's a problem for patients," she conceded. "I wish there were a set of best practices for what should be done with immunocompromised patients. For example, are nurses telling patients that flu mist is dangerous? You don't want patients to have their children get flu mist because that is a live vaccine.
"Beyond this, there should be a whole host of pathways and elements to consider, but that will be a good start."
Greg Thompson is a frequent contributor to ADVANCE.
Nurses who wish to learn more about the rising concern of fungal infections in the ICU may wish to attend Brenda Shelton's presentation on behalf of the American Association of Critical-Care Nurses (www.aacn.org).
Presentation: "Fungus Among Us: The Rising Concern of Fungal Infection in the ICU."
Speaker: Brenda Shelton, MS, RN, CCRN, AOCN, clinical nurse specialist at the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University
Event: AACN National Teaching Institute & Critical Care Exposition, Chicago
Date: May 2
Time: 2:15 p.m.-3:30 p.m.
Place: Room W-181 at McCormick Place
Learning Outcomes: Participants will be able to: 1) describe risk factors and clinical features of two fungal infections that may be experienced by patients in the ICU or progressive care unit; 2) compare and contrast benefits and challenges of different antifungal therapies; and 3) analyze patient case scenarios to define best practice collaborative management strategies.