Management of invasive fungal infections in the ICU

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INTRODUCTION: Invasive fungal infections (IFI) are becoming more and more frequent in the intensive care unit (ICU), affecting not only immunocompromised patients. Invasive pulmonary aspergillosis, invasive candidiasis, and mucormycosis are associated with substantial mortality. Management of these patients remains challenging because the histopathological confirmation is often unfeasible. Consequently, clinicians must rely on a probabilistic approach integrating host factors, clinical and radiological features, and mycological evidence. AREAS COVERED: This narrative review summarizes current evidence on the epidemiology, risk factors, definitions, diagnostic strategies, and management of critically ill patients with IFI. We discuss adaptations of diagnostic criteria for critically ill patients, with a special focus on performance and limitations of non-culture-based tools. Diagnostic work-up and therapeutic strategies are discussed with a focus on ICU-specific considerations. EXPERT OPINION: Management of IFI in the ICU requires an individualized approach combining early clinical suspicion based on clinical risk stratification, targeted use of culture and non-culture-based tests, and timely initiation of antifungal therapy. Refining risk stratification, validation of molecular diagnostics in large ICU cohorts, and multidisciplinary collaboration are warranted to improve outcomes in this highly vulnerable population.