What are the key strategies for infection control measures to prevent fungal infections in critically ill patients in an intensive care unit (ICU)?

Infection Control Strategies for Fungal Infections in the ICU

Implement a multi-layered infection control strategy centered on environmental controls, hand hygiene, chlorhexidine bathing, targeted prophylaxis in high-incidence units, and aggressive construction/renovation protocols to prevent fungal infections in critically ill ICU patients. 1

Environmental and Engineering Controls

Construction and Renovation Management

• Perform an Infection Control Risk Assessment (ICRA) before any construction, renovation, or demolition activities to identify immunocompromised patients at risk for fungal spore exposure 1
• Construct impermeable barriers (compliant with fire codes) to prevent dust from construction areas entering patient-care zones, and seal all return air vents when rigid barriers are used 1
• Create and maintain negative air pressure in work zones adjacent to patient-care areas, with continuous monitoring of airflow inside barriers 1
• Provide construction crews with designated entrances, corridors, elevators, and protective clothing (coveralls, footgear, headgear) when traveling through patient-care areas 1
• Seal windows in construction zones and direct pedestrian traffic away from patient-care areas to minimize dust dispersion 1

Air Handling and Ventilation

• Use negative pressure isolation rooms for high-risk patients to achieve dilution and removal of airborne fungal contaminants 1
• Check low-efficiency filter banks frequently during external construction and replace as needed to prevent particulate buildup 1
• Ensure proper operation of air-handling systems after barrier erection and before setting rooms to negative pressure 1

Hand Hygiene and Personal Protective Equipment

• Enforce strict compliance with alcohol-based hand disinfection as the cornerstone of infection control—this is the single most effective measure to prevent cross-contamination 1
• Provide staff education on proper hand hygiene technique and monitor compliance rates systematically 1
• Use appropriate personal protective equipment (gowns, gloves, eye protection, face protection, respiratory protection) when performing high-risk procedures 1

Skin Decolonization

Implement daily chlorhexidine bathing for all ICU patients—this intervention decreases both catheter-associated and non-catheter-associated bloodstream infections, including candidemia. 1, 2

Surveillance and Monitoring

• Establish active surveillance programs to identify and quantify endemic and emerging multidrug-resistant fungal pathogens in your ICU 1
• Prepare timely surveillance data to guide appropriate empirical antifungal therapy in patients with suspected invasive fungal infections 1
• Monitor antibiotic consumption and provide feedback to antimicrobial stewardship teams every 3-6 months alongside resistance surveillance data 1

Targeted Antifungal Prophylaxis

When to Consider Prophylaxis

Reserve antifungal prophylaxis for ICUs with invasive candidiasis rates exceeding 5% of patients—this threshold indicates an outbreak situation requiring intervention. 1, 2

High-Risk Patient Selection

• Target prophylaxis to patients with multiple risk factors: Candida colonization at multiple sites, broad-spectrum antibiotic exposure, central venous catheters, total parenteral nutrition, recent major surgery, necrotizing pancreatitis, dialysis, or corticosteroid use 2
• In pediatric ICUs, prioritize patients with ≥3 risk factors (central venous catheter, malignancy, vancomycin >3 days, or anti-anaerobic antimicrobials >3 days), as these combinations predict 10-46% probability of candidemia 1

Prophylaxis Regimens

• Administer fluconazole 800 mg loading dose, then 400 mg daily for high-risk patients in high-incidence units 2
• Alternatively, use echinocandin prophylaxis with micafungin 100 mg IV daily in units with very high invasive candidiasis rates 2
• Critical caveat: Broad prophylaxis targeting all ICU patients showed benefit in two randomized trials (one in surgical ICU patients, another in mechanically ventilated patients), but the number needed to treat varies dramatically—9 patients in high-risk groups versus 188 in low-risk patients 1

Device and Catheter Management

• Remove or replace central venous catheters promptly in all non-neutropenic patients with candidemia—this is mandatory, not optional 2, 3
• Minimize use and duration of central venous catheters, as they represent a major risk factor for candidemia 1
• Avoid unnecessary intubation and reintubation, as these procedures increase risk of fungal colonization and subsequent infection 1

Isolation and Cohorting

• Implement isolation precautions to reduce cross-infection with multidrug-resistant fungal pathogens 1
• Maintain adequate ICU staffing levels—understaffing compromises infection control practices and increases duration of mechanical ventilation, both of which elevate fungal infection risk 1

Source Control Measures

• Contain patient secretions at the source to prevent environmental contamination 1
• Perform environmental cleaning and disinfection using protocols specific to fungal pathogens 1
• Limit aerosol-generating procedures (nebulizers, bronchoscopy) to those essential for patient care, as these increase airborne fungal transmission risk 1

Administrative Measures

• Limit contact between healthcare workers and high-risk patients through administrative controls 1
• Develop clear infection control protocols and provide comprehensive staff training before implementing new procedures 1
• Establish communication systems between critical care leadership, hospital administration, infectious disease specialists, infection control teams, and public health officials 1

Common Pitfalls to Avoid

• Do not implement universal prophylaxis in low-incidence ICUs (<5% invasive candidiasis rate)—this increases costs, promotes resistance, and provides minimal benefit given the high number needed to treat 1
• Do not neglect environmental controls during construction—fungal spore exposure from construction activities is a well-documented cause of healthcare-associated aspergillosis outbreaks 1
• Do not rely solely on prophylaxis—none of the meta-analyses demonstrated that prophylaxis addresses adverse effects, emergence of fluconazole resistance, or ecological shifts in Candida species, all critical concerns in the ICU 1
• Do not overlook the importance of timely data—delays in surveillance reporting compromise the ability to guide appropriate empirical therapy 1