Objectives: Invasive fungal infections (IFI) remain a main cause of death after heart surgery,
in spite of the advances in pharmacological therapy. Caspofungin is an echinocandin
with high efficacy against IFI in surgical and intensive care patients. However, the
recommended dosis of caspofungin can lead to hepatic failure in patients with impaired
hepatic function. Our aim was to assess the effectiveness and safety of a reduced
dosage of caspofungin in patients at the ICU with a higher risk of hepatic failure
after major cardiac surgery.
Methods: 134 consecutive patients presenting with suspicion of IFI after heart surgery and
treated with low dose caspofungin (loading dose 50mg/d; maintenance 35mg/d) were retrospectively
studied. Demographics, surgical procedure, type of infection, responsible pathogen,
outcome, and adverse events were analyzed.
Results: 134 patients (96 males, 38 females; mean age 66±14 y) were studied; Procedure: CABG:
17.9%; HTX: 16.4%; VAD: 11.2%; valve surgery: 25.4%; others: 29.1%. Type of infection:
catheter-related infection: 11.2%, positive blood culture 0.7%, pulmonary infection
69.4%, positive smears 3.0%, others 7.5% and no proven evidence for fungal infection
8.2%. 41 patients (30.6%) suffered from diabetes mellitus, and 12 patients (9%) from
active malignomas. The fungal infection was the primary infection only in 36% of the
patients. Only 15.7% of the patients stayed without bacterial co-infection during
the antifungal therapy. Duration of treatment was 10.2±6.6d. Outcomes: 62.9% of the
patients showed clinical improvement, in 18.7% of the patients healing without residues
could be achieved. Side effects were reported in 4.5% of the cases, but did not necessitate
a change of treatment. 33.6% of the patients died within 30 days after the diagnosis
of IFI.
Conclusions: Low-dose caspofungin proved safe and effective in our collective of patients and
may be an alternative to other antifungals, and to the recommended dose of caspofungin
in high risk patients with impaired hepatic function. Prospective trials are mandatory
to evaluate the possible application of low dosed caspofungin in the treatment and
prophylaxis of Candida and Aspergillum infections at the ICU.
