Candidemia in the Critically Ill: Initial Therapy and Outcome in Mechanically Ventilated Patients

Overview

Journal BMC Anesthesiol

Publisher Biomed Central

Specialty Anesthesiology

Date 2013 Nov 1

PMID 24172136

Citations 6

Authors

Marcela A Ferrada

Andrew A Quartin

Daniel H Kett

Michele I Morris

Affiliations

Soon will be listed here.

Abstract

Background: Mortality among critically ill patients with candidemia is very high. We sought to determine whether the choice of initial antifungal therapy is associated with survival among these patients, using need for mechanical ventilatory support as a marker of critical illness.

Methods: Cohort analysis of outcomes among mechanically ventilated patients with candidemia from the 24 North American academic medical centers contributing to the Prospective Antifungal Therapy (PATH) Alliance registry. Patients were included if they received either fluconazole or an echinocandin as initial monotherapy.

Results: Of 5272 patients in the PATH registry at the time of data abstraction, 1014 were ventilated and concomitantly had candidemia, with 689 eligible for analysis. 28-day survival was higher among the 374 patients treated initially with fluconazole than among the 315 treated with an echinocandin (66% versus 51%, P < .001). Initial fluconazole therapy remained associated with improved survival after adjusting for non-treatment factors in the overall population (hazard ratio .75, 95% CI .59-.96), and also among patients with albicans infection (hazard ratio .62, 95% CI .44-.88). While not statistically significant, fluconazole appeared to be associated with higher mortality among patients infected with glabrata (HR 1.13, 95% CI .70-1.84).

Conclusions: Among ventilated patients with candidemia, those receiving fluconazole as initial monotherapy were significantly more likely to survive than those treated with an echinocandin. This difference persisted after adjustment for non-treatment factors.

Citing Articles

Initial micafungin treatment does not improve outcomes compared to fluconazole treatment in immunocompromised and critically ill patients with candidaemia.

Theodore D, Henneman A, Loo A, Shields R, Eschenauer G, Sobieszczyk M J Antimicrob Chemother. 2024; 79(8):1877-1884.

PMID: 38831614 PMC: 11290885. DOI: 10.1093/jac/dkae175.

Prophylaxis of Invasive Fungal Infection in Neonates: A Narrative Review for Practical Purposes.

Ferrando G, Castagnola E J Fungi (Basel). 2023; 9(2).

PMID: 36836279 PMC: 9962596. DOI: 10.3390/jof9020164.

Characteristics of candidemia in COVID-19 patients; increased incidence, earlier occurrence and higher mortality rates compared to non-COVID-19 patients.

Kayaaslan B, Eser F, Kalem A, Bilgic Z, Asilturk D, Hasanoglu I Mycoses. 2021; 64(9):1083-1091.

PMID: 34085319 PMC: 8242769. DOI: 10.1111/myc.13332.

Candidemia in the ICU: Does Initial Antifungal Matter?.

Bennett J, Powers J Crit Care Med. 2018; 46(3):482-483.

PMID: 29474331 PMC: 5920524. DOI: 10.1097/CCM.0000000000002903.

Candidaemia observed at a university hospital in Milan (northern Italy) and review of published studies from 2010 to 2014.

Milazzo L, Peri A, Mazzali C, Grande R, Cazzani C, Ricaboni D Mycopathologia. 2014; 178(3-4):227-41.

PMID: 25056143 DOI: 10.1007/s11046-014-9786-9.

References

Stevens V, Lodise T, Tsuji B, Stringham M, Butterfield J, Ashley E . The utility of acute physiology and chronic health evaluation II scores for prediction of mortality among intensive care unit (ICU) and non-ICU patients with methicillin-resistant Staphylococcus aureus bacteremia. Infect Control Hosp Epidemiol. 2012; 33(6):558-64. DOI: 10.1086/665731. View

Quartin A, Schein R, Kett D, Peduzzi P . Prior healthcare utilization as a predictor of survival for medical intensive care unit patients. Crit Care Med. 2000; 28(8):3053-9. DOI: 10.1097/00003246-200008000-00063. View

Pappas P, Kauffman C, Andes D, Benjamin Jr D, Calandra T, Edwards Jr J . Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009; 48(5):503-35. PMC: 7294538. DOI: 10.1086/596757. View

Angus D, Lidicker J, Clermont G, Carcillo J, Pinsky M . Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001; 29(7):1303-10. DOI: 10.1097/00003246-200107000-00002. View

Reboli A, Rotstein C, Pappas P, Chapman S, Kett D, Kumar D . Anidulafungin versus fluconazole for invasive candidiasis. N Engl J Med. 2007; 356(24):2472-82. DOI: 10.1056/NEJMoa066906. View

Garey K, Rege M, Pai M, Mingo D, Suda K, Turpin R . Time to initiation of fluconazole therapy impacts mortality in patients with candidemia: a multi-institutional study. Clin Infect Dis. 2006; 43(1):25-31. DOI: 10.1086/504810. View

Pfaller M, Diekema D . Epidemiology of invasive candidiasis: a persistent public health problem. Clin Microbiol Rev. 2007; 20(1):133-63. PMC: 1797637. DOI: 10.1128/CMR.00029-06. View

Kolleff M . Appropriate antibiotic therapy for ventilator-associated pneumonia and sepsis: a necessity, not an issue for debate. Intensive Care Med. 2003; 29(2):147-9. DOI: 10.1007/s00134-002-1614-x. View

Johnston J . Determinants of mortality in patients with severe sepsis. Med Decis Making. 2005; 25(4):374-86. DOI: 10.1177/0272989X05278933. View

10.

Schelenz S . Management of candidiasis in the intensive care unit. J Antimicrob Chemother. 2008; 61 Suppl 1:i31-4. DOI: 10.1093/jac/dkm430. View

11.

Reller M, Mallonee A, Kwiatkowski N, Merz W . Use of peptide nucleic acid-fluorescence in situ hybridization for definitive, rapid identification of five common Candida species. J Clin Microbiol. 2007; 45(11):3802-3. PMC: 2168530. DOI: 10.1128/JCM.01127-07. View

12.

Khan A, Khan S, Zimmerman V, Baddour L, Tleyjeh I . Quality and strength of evidence of the Infectious Diseases Society of America clinical practice guidelines. Clin Infect Dis. 2010; 51(10):1147-56. DOI: 10.1086/656735. View

13.

Marriott D, Playford E, Chen S, Slavin M, Nguyen Q, Ellis D . Determinants of mortality in non-neutropenic ICU patients with candidaemia. Crit Care. 2009; 13(4):R115. PMC: 2750162. DOI: 10.1186/cc7964. View

14.

Wiblin T, Blumberg H, Saiman L, Patterson J, Rinaldi M, Pfaller M . National epidemiology of mycoses survey (NEMIS): variations in rates of bloodstream infections due to Candida species in seven surgical intensive care units and six neonatal intensive care units. Clin Infect Dis. 1999; 29(2):253-8. DOI: 10.1086/520194. View

15.

Zimmerman J, Kramer A, McNair D, Malila F . Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients. Crit Care Med. 2006; 34(5):1297-310. DOI: 10.1097/01.CCM.0000215112.84523.F0. View

16.

Kuse E, Chetchotisakd P, da Cunha C, Ruhnke M, Barrios C, Raghunadharao D . Micafungin versus liposomal amphotericin B for candidaemia and invasive candidosis: a phase III randomised double-blind trial. Lancet. 2007; 369(9572):1519-1527. DOI: 10.1016/S0140-6736(07)60605-9. View

17.

Pfaller M, Messer S, Hollis R, Boyken L, Tendolkar S, Kroeger J . Variation in susceptibility of bloodstream isolates of Candida glabrata to fluconazole according to patient age and geographic location in the United States in 2001 to 2007. J Clin Microbiol. 2009; 47(10):3185-90. PMC: 2756923. DOI: 10.1128/JCM.00946-09. View

18.

Betts R, Rotstein C, Colombo A, Thompson-Moya L, Smietana J, Lupinacci R . Comparison of caspofungin and amphotericin B for invasive candidiasis. N Engl J Med. 2002; 347(25):2020-9. DOI: 10.1056/NEJMoa021585. View

19.

Gudlaugsson O, Gillespie S, Lee K, Vande Berg J, Hu J, Messer S . Attributable mortality of nosocomial candidemia, revisited. Clin Infect Dis. 2003; 37(9):1172-7. DOI: 10.1086/378745. View

20.

Andes D, Safdar N, Baddley J, Playford G, Reboli A, Rex J . Impact of treatment strategy on outcomes in patients with candidemia and other forms of invasive candidiasis: a patient-level quantitative review of randomized trials. Clin Infect Dis. 2012; 54(8):1110-22. DOI: 10.1093/cid/cis021. View