Candidemia in a major regional tertiary referral hospital – epidemiology, practice patterns and outcomes

BackgroundAlthough antimicrobial stewardship programmes are one of the highest priorities in healthcare systems and many articles have been published, few refer to the implementation of antifungal stewardship and highlight specific points on which efforts should be focused.ObjectiveTo assess the percentage of patients with confirmed candidaemia in whom de-escalation was conducted, and the economic impact of step-down or step-up antifungal therapy. Additionally, we attempted to estimate the potential increase in drug minimum inhibitory concentrations or to detect resistant strains of Candida species.MethodsWe selected, retrospectively, patients who had received systemic antifungal therapy between 2011 and 2016 for documented candidaemia. Statistical analysis and diagrams were used to assess the results.ResultsOf 157 patients with confirmed candidaemia, 58 received azoles, 74 echinocandinsand 18 liposomal amphotericin B for empirical therapy. 51 patients were eligible to step-down to fluconazole but only 23 patients did so. Furthermore, in nine patients unjustified step-up from fluconazole to echinocandins or liposomal amphotericin B was carried out. The additional cost incurred bythe healthcare system due to high prices of echinocandins and liposomal amphotericin B in comparison with fluconazole was€211 837. Interestingly, it was found that one strain of C. albicans and two strains of C. glabrata were resistant to echinocandins.ConclusionThe presence of a multidisciplinary team, including an infection control specialist and a clinical pharmacist, would limit the prescription of advanced antifungal agents as empirical therapy. Moreover, this team would control the de-escalation process—where applicable—leading to a reduction in costs and, probably, a decrease in the emergence of resistant Candida species. These facts contribute to the broader discussion on the adoption of antifungal stewardship programmes.

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“…Several studies,have indicated that resistance to echinocandins has increased 4 27 28. These findings are in accordance with our results.…”

Section: Discussionsupporting

confidence: 94%

Do we need to adopt antifungal stewardship programmes?

et al. 2018

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“…Our multivariable analysis determined both neutropaenia and neutrophilia to be the clinical predictors of candiduria with candidaemia. Retrospective analyses found that neutropaenia was present in 8%‐11.6% of patients diagnosed with candidaemia . In comparison, neutropaenia was present in 8.7% of our patient population.…”

Section: Discussionmentioning

confidence: 63%

“…Retrospective analyses found that neutropaenia was present in 8%-11.6% of patients diagnosed with candidaemia. 31,32 In comparison, neutropaenia was present in 8. In regard to antibiotics, we found β-lactam/β-lactamase inhibitors to be significantly associated with elevated rates of candidaemia in candiduric patients.…”

Section: Discussionmentioning

confidence: 95%

Creation and assessment of a clinical predictive model for candidaemia in patients with candiduria

Wang

Hsueh

Kronen

et al. 2019

Mycoses

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Summary Candidaemia is the most common clinical presentation of invasive candidiasis and is a major cause of morbidity and mortality. Candiduria is a predictor for candidaemia; however, patient characteristics that are associated with concurrent candidaemia in the setting of candiduria are unclear. Identifying these characteristics could aid in the early detection of systemic disease. We performed a retrospective cohort analysis of hospitalised patients with candiduria at our institution over a 13‐year period. Our evaluation of patient characteristics included demographics, comorbidities, medications, procedures, devices, vital signs and laboratory values. We developed a multivariable logistic model to identify factors associated with candidaemia in patients with candiduria. We identified 4240 patients with candiduria, 263 (6.2%) of whom had candidaemia. Predictors for increased risk of candidaemia with candiduria included hospitalisations > 12 days, central venous catheter, parenteral nutrition, haematological and gynaecological malignancy, and receipt of β‐lactam/β‐lactamase inhibitors. Vital signs and laboratory values associated with candidaemia included elevated heart rate, temperature and creatinine, along with neutropenia and neutrophilia. Factors that demonstrated a decreased risk of candidaemia included diabetes mellitus, gastrostomy and urinary catheter with antibiotic use. The c‐statistic was 0.741 (95% CI, 0.710‐0.772). We identified a set of clinical characteristics that can predict the presence of candidaemia with candiduria.

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“…Among 231 non-albicans Candida isolates, fluconazole resistance and dose-dependent susceptibility were reported in 15 (6.49%) and 41 (17.7%), respectively (P < 0.001). The increase in non-albicans Candida infection, which is considered to be due to the increased use of fluconazole, has been reported in several studies (Diekema et al, 2012;Teo et al, 2017). Empirical or preemptive echinocandin therapy is preferred especially in critically ill patients who are at risk of exposure to azole or colonization of azole-resistant species (Cornely et al, 2012;Pappas et al, 2016).…”

Section: Discussionmentioning

confidence: 99%

Changes in the utilization patterns of antifungal agents, medical cost and clinical outcomes of candidemia from the health-care benefit expansion to include newer antifungal agents

Choi

Kim

Seong

et al. 2019

International Journal of Infectious Diseases

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Objectives: In 2014, South Korea expanded its national health insurance coverage to include newer antifungal agents, such as echinocandins. This study aimed to investigate the effects of policy change on the prescription patterns of antifungals, medical costs and clinical outcomes of candidemia. Methods: This retrospective cohort enrolled hospitalized patients with candidemia at three tertiary care hospitals in South Korea from January 2012 to December 2015. The utilization of antifungal agents, medical costs, length of hospital stay (LOS), and mortality before and after the health-care benefit expansion were compared, and the factors associated with all-cause 28-day mortality during the study period were analyzed. Results: A total of 769 candidemia cases were identified. The incidence of candidemia did not significantly vary during the study period (P = 0.253). The proportion of echinocandins, as the initial antifungal agent, and medical costs associated with candidemia significantly increased since the change in insurance coverage (P < 0.001). There was no significant difference in LOS and mortality associated with candidemia before and after the health-care benefit expansion (P = 0.696 and 0.931, respectively). Multivariate logistic regression analysis showed that initial treatment with caspofungin was associated with decreased mortality (adjusted odds ratio: 0.784; 95% confidence interval: 0.681-0.902; reference: fluconazole). Conclusions: Although the utilization of newer antifungal agents and medical cost for candidemia has significantly increased since the health-care benefit expansion, there has been no change in the outcome of candidemia. However, the further increased use of newer antifungals may improve the outcome of candidemia in this country.

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Candidemia in a major regional tertiary referral hospital – epidemiology, practice patterns and outcomes

Cited by 23 publications

References 28 publications

Do we need to adopt antifungal stewardship programmes?

Do we need to adopt antifungal stewardship programmes?

Creation and assessment of a clinical predictive model for candidaemia in patients with candiduria

Changes in the utilization patterns of antifungal agents, medical cost and clinical outcomes of candidemia from the health-care benefit expansion to include newer antifungal agents

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