However, despite the difficulty in diagnosis, the key to treatment of fungal infections is early recognition. Risk factors for fungal infection include ventilated patients, prolonged ICU stays, previous antibiotics, total parenteral nutrition (TPN), high APACHE (Acute Physiological and Chronic Health Evaluation) scores, and previous abdominal surgery. Because of the delay in diagnosis, any individual with an atypical presentation of sepsis should be considered to have the possibility of a systemic fungal infection. Such presentations include: hypothermia; bradycardia; ongoing elevation in temperature or white blood cell count; or ongoing sepsis despite being on the “appropriate” empiric antimicrobiological therapy. In order to increase the accuracy of diagnosis, the role of colonization has been extensively evaluated. Emerging evidence has shown that the risk of candidemia may be related to the density and extension of fungal colonization over time. The risk of death has actually been found to be similar in patients with multiple-site fungal colonization and those with confirmed invasive candidiasis. As a result the concept of early empiric therapy has emerged. This therapy recognizes the high-risk patient who begins to show evidence of Candida colonization by positive cultures from
multiple sites. It has been suggested that such high-risk patients be started on antifungal therapy, not as prophylaxis, but as treatment. On the other hand, some experienced clinicians believe prophylactic strategies against fungal infections have proven to be ineffective at significantly reducing systemic fungal infections in an ICU. Select groups of patients such as pancreatic transplant patients may, however, benefit from such strategies.