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IreneColoretti andMassimoGirardis

infectious focus and prevent further spread of the infection.

promptly initiated with molecules and dosages based on patient risk factors for difcult-to-treat microorganisms, available cultures, and clinical conditions.

Commonly used biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) may help identify this condition. PCT has been largely investigated in sepsis, demonstrating the ability to differentiate infectious from non-infectious systemic inammatory response syndrome [6]. PCT was proposed to be more sensitive when compared to other biomarkers as an early indicator of uncontrolled infection after major surgery [7], especially when considering its dynamic changes rather than concentration itself [8]. The WSES/GAIS/SIS-E/WSIS/AAST guidelines proposed clinical pathways for patients with IAI, indicating PCT and CRP as laboratory markers to be considered for early diagnosis and antibiotic discontinuation [1]. A recently published meta-analysis evaluated the diagnostic accuracy of PCT as a diagnostic biomarker for postoperative infection/sepsis following major abdominal surgery in ten studies involving 1611 patients, with high heterogeneity among the included studies [9]. The authors concluded that PCT performs only moderately well as a diagnostic test for postoperative infection/sepsis, demonstrating limited pooled sensitivity (median 72%; 95% CI 66–78%) and specicity (median 62%; 95% CI 59–64%). Otherwise, serial PCT measurements seem to be accurate in eval­uating the efcacy of treatments to eradicate the infection. In this setting, PCT has been proposed to guide the discontinuation of antibiotic therapy and was demon­strated to be cost-effective [10]. In the recent multicenter MOSES study, the authors investigated the role of an early decrease in PCT levels in predicting mortality [11]. Results showed that patients with an initial increase in PCT from baseline to day 1

A patient with complicated IAI is at high risk of developing secondary infections due to opportunistic pathogens, and, among these, fungal infections are frequent. The incidence of invasive Candida infection (ICI) in septic patients is increasing [13]. The mortality burden for these patients reaches 80% if no antifungal treatment is started within the rst 24h of septic shock [14]. Current guidelines suggest early antifungal treatment in critically ill patients with a high risk of ICI but contain few indications on selecting appropriate patients [12]. A recent report from the EUCANDICU project [13] showed a cumulative incidence of candidemia and ICI of 5.52 and 1.84 episodes per 1000 ICU admissions, with crude 30-day mortality signicantly higher in candidemia/IAC patients. A fundamental easy-to-measure biomarker related to ICI is 1,3-β-d-glucan (BDG). BDG serum concentrations are elevated in patients with ICI [15]. Studies identied a cut-off value of 80pg/mL to diagnose candidemia and abdominal candidiasis [16], even though higher specic­ity was achieved by elevating the cut-off to 200pg/mL [17]. BDG performance was demonstrated to be superior to clinical prediction models and colonization indexes, showing in settings at low pretest probability (IC rate < 5%) high sensitivity (74–86%) and a negative predictive value >95% [18]. Due to these features, moni­toring BDG in patients at risk of candidiasis has the role of ruling out the infection and de-escalating antifungal treatments [19]. A recent trial proposed a systematic approach in patients at high risk for ICI [20] suggesting that antifungal coverage may be appropriate, with re-assessment at 72–96h. In the re-assessment, BDG lev­els of 80 pg/mL or lower and clinical stability should encourage antifungal de­escalation and ensure infection control. Otherwise, values of BDG between 80–200pg/mL and clinical instability deserve further evaluation, and values above 200pg/mL suggest ICI.