Candida Infective Endocarditis: an Observational Cohort Study with a Focus on Therapy

Abstract

o Candida infective endocarditis is a rare disease with a high mortality rate. Our understanding of this infection is derived from case series, case reports, and small prospective cohorts. The purpose of this study was to evaluate the clinical features and use of different antifungal treatment regimens for Candida infective endocarditis. This prospective cohort study was based on 70 cases of Candida infective endocarditis from the International Collaboration on Endocarditis (ICE)-Prospective Cohort Study and ICE-Plus databases collected between 2000 and 2010. The majority of infections were acquired nosocomially (67%). Congestive heart failure (24%), prosthetic heart valve (46%), and previous infective endocarditis (26%) were common comorbidities. Overall mortality was high, with 36% mortality in the hospital and 59% at 1 year. On univariate analysis, older age, heart failure at baseline, persistent candidemia, nosocomial acquisition, heart failure as a complication, and intracardiac abscess were associated with higher mortality. Mortality was not affected by use of surgical therapy or choice of antifungal agent. A subgroup analysis was performed on 33 patients for whom specific antifungal therapy information was available. In this subgroup, 11 patients received amphotericin B-based therapy and 14 received echinocandin-based therapy. Despite a higher percentage of older patients and nosocomial infection in the echinocandin group, mortality rates were similar between the two groups. In conclusion, Candida infective endocarditis is associated with a high mortality rate that was not impacted by choice of antifungal therapy or by adjunctive surgical intervention. Additionally, echinocandin therapy was as effective as amphotericin B-based therapy in the small subgroup analysis. Candida infective endocarditis (CIE) accounts for only 1 to 2% of all cases of infective endocarditis (IE) (1). This infection is important because it is associated with an exceptionally high mortality rate ranging from 30 to 80% (1-5). In addition, rates of fungemia have increased significantly in recent years, resulting in a growing number of patients at risk for this disease (2, 6).Due to its rarity, our understanding of the clinical features, treatment, and mortality of CIE has been derived predominantly from retrospective reviews of case series, case reports, and several small prospective series (1, 2, 7). The standard-ofcare treatment for CIE has historically been an amphotericin B-based regimen coupled with adjunctive surgical therapy. However, the options for treating invasive Candida infections changed with the development of the echinocandins. Echinocandins have fungicidal activity and exert their effect by inhibiting beta-glucan synthesis and disrupting the fungal cell wall. In 2003, caspofungin, the first echinocandin, was approved as therapy for invasive candidiasis, and since that time there has been a small but growing body of literature regarding echinocandin use in CIE (1,2,(8)(9)(10)(11)(12)(13). This has resulted in the addi...

Invasive Candidiasis

“…A prospective cohort of endocarditis via the International Collaboration on Endocarditis examined the epidemiology and treatment impact of Candida IE and noted 59% mortality at 1 year. 76 Almost three-quarters of cases were attributed to C parapsilosis and C albicans, and approximately 50% were associated with a prosthetic valve.…”

Infective endocarditis

“…Valve surgery is often employed but this approach is not clearly associated with improved outcomes 168 . Following initial parenteral therapy with an amphotericin-based regimen or an echinocandin, indefinite azole therapy is recommended, particularly if valve surgery is not performed 169,170 .…”

“…However, these pathogen-specific recommendations for surgery have been recently called into question in favour of an individualized decision-making approach based upon hemodynamic and structural indications 168,175 .…”

Heroin with a Twist: Candida Glabrata Endocarditis Concurrent with Brain Mycetomas in an IV Drug User

“…Fungi comprise less than 2% of all cases of infective endocarditis [1,2,9] with Candida spp. representing 50-80% of them and C. albicans being the most commonly isolated species (30-40%).…”