PhD Student, Dept. of Infectious Diseases, Aarhus University Hospital
Treatment of Candidaemia in Denmark
Management of candidaemia is challenged by complex protocols for prophylactic, pre-emptive, empirical, and targeted treatment. Guidelines are applied nationwide, hence evaluation of guidelines in a nationwide setting would be important. Denmark is known for a high incidence and mortality for candidaemia patients, hence an evaluation of treatment adherence and effect are important.
Abstract: Candidemia is a common healthcare-associated bloodstream infection that is continuing to increase in incidence. Candidemia is associated with significant morbidity and mortality, which may be potentiated by delays in the initiation of early and appropriate therapy. Recently, the epidemiology of candidemia has shifted, and infections due to non-albicans Candida species as the causative pathogens have increased in frequency. Several studies have been published over the past 5 years in relation to the management of candidemia. Echinocandins have demonstrated favorable clinical responses with a low incidence of adverse effects in patients with candidemia due to both Candida albicans and non-albicans Candida species and, as such, have emerged as the preferred initial therapy.
Pub.: 29 Jan '15, Pinned: 20 Jun '17
Abstract: Candidemia is a growing problem in hospitals all over the world. Despite advances in the medical support of critically ill patients, candidiasis leads to prolonged hospitalization, and has a crude mortality rate around 50%. We conducted a multicenter surveillance study in 16 hospitals distributed across five regions of Brazil to assess the incidence, species distribution, antifungal susceptibility, and risk factors for bloodstream infections due to Candida species. From June 2007 to March 2010, we studied a total of 2,563 nosocomial bloodstream infection (nBSI) episodes. Candida spp. was the 7th most prevalent agent. Most of the patients were male, with a median age of 56 years. A total of 64 patients (46.7%) were in the ICU when candidemia occurred. Malignancies were the most common underlying condition (32%). The crude mortality rate of candidemia during the hospital admission was 72.2%. Non-albicans species of Candida accounted for 65.7% of the 137 yeast isolates. C. albicans (34.3%), Candida parapsilosis (24.1%), Candida tropicalis (15.3%) and Candida glabrata (10.2%) were the most prevalent species. Only 47 out of 137 Candida isolates were sent to the reference laboratory for antifungal susceptibility testing. All C. albicans, C. tropicalis and C. parapsilosis isolates were susceptible to the 5 antifungal drugs tested. Among 11 C. glabrata isolates, 36% were resistant to fluconazole, and 64% SDD. All of them were susceptible to anidulafungin and amphotericin B. We observed that C. glabrata is emerging as a major player among non-albicans Candida spp. and fluconazole resistance was primarily confined to C. glabrata and C. krusei strains. Candida resistance to echinocandins and amphotericin B remains rare in Brazil. Mortality rates remain increasingly higher than that observed in the Northern Hemisphere countries, emphasizing the need for improving local practices of clinical management of candidemia, including early diagnosis, source control and precise antifungal therapy.
Pub.: 26 Jan '16, Pinned: 20 Jun '17
Abstract: Candida glabrata isolates have reduced in vitro susceptibility to azoles, which raises concerns about the clinical effectiveness of fluconazole for treating bloodstream infection (BSI) by this Candida species. We aimed to evaluate whether the choice of initial antifungal treatment (fluconazole vs. echinocandins or liposomal amphotericin B [L-AmB]-based regimens) has an impact on the outcome of C. glabrata BSI. We analysed data from a prospective, multicentre, population-based surveillance program on candidaemia conducted in 5 metropolitan areas of Spain (May 2010-April 2011). Adult patients with an episode of C. glabrata BSI were included. Main outcomes were 14-day mortality and treatment failure (14-day mortality and/or persistent C. glabrata BSI for ≥48 hours despite antifungal initiation). The impact of using fluconazole as initial antifungal treatment on the patients' prognosis was assessed by logistic regression analysis with addition of a propensity score approach. A total of 94 patients with C. glabrata BSI were identified. Of these, 34 had received fluconazole and 35 had received an echinocandin/L-AmB-based regimen. Patients in the echinocandin/L-AmB group had poorer baseline clinical status. Patients in the fluconazole group were more frequently (55.9% vs 28.6%) and much earlier (median 3 vs 7 days) switched to another antifungal regimen. Overall, 14-day mortality was 13% (9/69) and treatment failure 34.8% (24/69), with no significant differences between the groups. On multivariate analysis, after adjusting for baseline characteristics by propensity score, fluconazole use was not associated with an unfavourable evolution (adjusted OR for 14-day mortality: 1.16, 95% CI 0.22-6.17; adjusted OR for treatment failure: 0.83, 95% CI 0.27-2.61). In conclusion, initial fluconazole treatment was not associated with a poorer outcome compared to echinocandins/L-amB regimens in patients with C. glabrata BSI.
Pub.: 16 Mar '16, Pinned: 20 Jun '17
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