Clinical Investigations

Initial Antifungal Strategy Reduces Mortality in Critically Ill Patients With Candidemia: A Propensity Score–Adjusted Analysis of a Multicenter Study*

Garnacho-Montero, José MD, PhD¹; Díaz-Martín, Ana MD, PhD²; Cantón-Bulnes, Luisa MD¹; Ramírez, Paula MD, PhD³; Sierra, Rafael MD, PhD⁴; Arias-Verdú, Dolores MD, PhD⁵; Rodríguez-Delgado, Marina MD⁶; Loza-Vázquez, Ana MD⁷; Rodriguez-Gomez, Jesús⁶; Gordón, Mónica MD, PhD³; Estella, Ángel MD, PhD⁸; García-Garmendia, José Luis MD, PhD⁹

Author Information

¹Unidad Clínica de Cuidados Intensivos, H. Universitario Virgen Macarena, Seville, Spain.

²Unidad Clínica de Cuidados Intensivos, H. Universitario Virgen Rocío, Sevilla, Spain.

³Servicio de Medicina Intensiva H, Universitario La Fe, Valencia, Spain.

⁴Unidad Clínica de Cuidados Intensivos, H. Universitario Puerta del Mar, Cádiz, Spain.

⁵Unidad Clínica de Cuidados Intensivos, H. Regional Universitario Carlos Haya, Málaga, Spain.

⁶Unidad Clínica de Cuidados Intensivos, H. Reina Sofía, Córdoba, Spain.

⁷Unidad Clínica de Cuidados Intensivos, H. Universitario Virgen de Valme, Seville, Spain.

⁸Unidad Clínica de Cuidados Intensivos, H. de Jerez, Jerez, Cádiz, Spain;

⁹Unidad de Cuidados Intensivos, Servicio de Cuidados Críticos y Urgencias, H. San Juan de Dios del Aljarafe, Bormujos, Seville, Spain.

*See also p. 482.

Dr. Garnacho-Montero has served as speaker for Merck, Sharp & Dohme (MSD) and Astellas; and received an educational grant from Astellas. Dr. Ramirez has served as speaker for Pfizer, MSD, and Astellas. Dr. Rodriguez-Delgado has served as speaker for Merck, Sharp, and Dohme de España S.A. Dr. Garcia-Garmendia received an educational grant from MSD in 2015. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: [email protected]

Critical Care Medicine 46(3):p 384-393, March 2018. | DOI: 10.1097/CCM.0000000000002867

Abstract

Objective:

The objective of this study was to evaluate the impact of the empirical therapy with fluconazole or an echinocandin on 30- and 90-day mortality in critically ill patients with candidemia. The outcome of patients in whom the empirical echinocandin was deescalated to fluconazole was also assessed.

Design:

Retrospective, observational multicenter study.

Setting:

Medical and surgical ICUs in nine Spanish hospitals.

Patients:

Adult patients (≥ 18 yr) with an episode of Candida bloodstream infection during ICU admission from January 2011 to April 2016.

Interventions:

Patient characteristics, infection-related variables, therapeutic interventions, and metastatic complications were reviewed. A propensity score–adjusted multivariable analysis was performed to identify the risk factors significantly associated with 30-day and 90-day mortality.

Measurements and Main Results:

A total of 294 patients were diagnosed of candidemia in the participant ICUs. Sixty patients were excluded (other antifungals in the primary therapy or the patient died without empirical antifungal therapy). The study group comprised 115 patients who received fluconazole (30-day mortality, 37.4%) and 119 patients treated empirically with an echinocandin (30-day mortality, 31.9%). The use of an echinocandin in the empirical therapy was a protective factor for 30-day (odds ratio, 0.32; 95% CI, 0.16–0.66; p = 0.002) and 90-day mortality (odds ratio, 0.50; 95% CI, 0.27–0.93; p = 0.014) in the propensity score– adjusted multivariable analysis. Deescalation of the empirical echinocandin to fluconazole was not associated with a higher mortality or the occurrence of long-term complications.

Conclusions:

Empirical use of an echinocandin in critically ill patients with documented candidemia reduces mortality at 30 and 90 days significantly. Deescalation of the empirical echinocandin to fluconazole is safe and effective in fluconazole-susceptible infections.

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Initial Antifungal Strategy Reduces Mortality in Critically Ill Patients With Candidemia: A Propensity Score–Adjusted Analysis of a Multicenter Study*