Background: Candidemia remains a common cause of nosocomial bloodstream infections worldwide and is associated with high mortality. We aimed to determine whether the correct implementation of current ESCMID guidelines for the management of patients with candidemia is associated with better outcomes.
Material/methods: Prospective multicenter study of hospitalized adults with candidemia in 10 hospitals from Spain (April 2010 to May 2011). We analyzed the compliance with the following recommendations of the guidelines: early appropriate antifungal therapy, use of echinocandin or amphotericin B therapy in patients with neutropenia or septic shock, administration of a different class of antifungal drug in patients with breakthrough candidemia, source control, follow-up blood cultures, performing an ophthalmoscopic evaluation or an echocardiogram, and treatment duration according the complexity of the infection. The impact of guidelines implementation on clinical outcomes was analyzed by univariate and multivariate analysis, comparing adherent with non-adherent patients.
Results: We documented 376 episodes of candidemia, 59% of them involved male patients with a median age of 67.5 years (IQR: 54.5-76.9). The majority of cases were caused by C. albicans (44.4%), followed by C. parapsilosis (23.7%), C. glabrata (13.6%) and C. tropicalis (9.6%). A full compliance of the recommendations was performed in <15% of the episodes. Within 2 days of candidemia 56% of patients received an appropriate antifungal treatment. Forty-two percent of patients with septic shock and 65% with neutropenia received echinocandin or amphotericin B therapy and 32 of 50 (64%) cases of breakthrough candidemia episodes underwent a switch in antifungal drug, as recommended. Venous catheters were removed in 79% of cases (in 98% of episodes in whom it was considered the source of the infection). Seventy-one percent of patients had follow-up blood cultures. Ophthalmoscopy and Echocardiogram were performed in 47% and 49% of cases leading to diagnosis of ocular involvement and endocarditis in 13 (3.5%) and 7 (1.9%) patients, respectively. The duration of treatment was appropriate in 60% of cases. Early (2 days) and overall (30 days) mortality were 6.6% and 34%, respectively. Adherence with less than 50% of the recommendations was independently associated with a higher early (AOR=160.5; 95% CI, 18.8–1368; p=<.001) and overall mortality (AOR=21.1; 95% CI, 9.4–47.4; p=<.001).
Conclusions: Adherence to recommendations in patients with candidemia was poor. Non-adherence was an independent risk factor of early and overall mortality. The implementation of a bundle intervention would probably be beneficial to reach a better compliance of such recommendations.
Full conference title:
- ECCMID 26th (2016)