The Effect on Mortality of Fluconazole or Echinocandins Treatment in Candidemia in Internal Medicine Wards

Abstract

The incidence of candidemia has increased over the past two decades, with an increased number of cases in Internal Medicine and a prevalence ranging from 24% to 57%. This single-center retrospective study was performed to evaluate the epidemiology and the risk factors associated with mortality of candidemia in patients admitted to Internal Medicine wards (IMWs) of the City of Health and Sciences, Molinette Hospital, Turin, from January 2004 to December 2012. For each patient, demographic, clinical and microbiological data were collected. A case of candidemia was defined as a patient with at least one blood culture positive for Candida spp. Amongst 670 episodes of candidemia, 274 (41%) episodes occurred in IMWs. The mortality was 39% and was associated at multivariate analysis with sepsis, cirrhosis and neurologic diseases, whilst removal of central venous catheter ≤48h was significantly associated with survival. In the 77 patients treated with early antifungal therapy the mortality was 29% and was not significantly different with caspofungin or fluconazole, whilst in patients with definitive therapy the mortality was significantly lower with echinocandins compared to fluconazole (11.7% Vs. 39%; p=0.0289), a finding confirmed by multivariate analysis. The mortality was significantly associated with sepsis, cirrhosis and neurologic diseases, whilst CVC removal ≤48h was associated with survival. In patients with early therapy, fluconazole or caspofungin were equally effective. However, echinocandins were significantly more effective as definitive treatment, a finding not explained by differences in treatment delays. Further studies are needed to understand the full potential of these different therapeutic strategies in IMWs.

Propensity Score Analysis of the Role of Initial Antifungal Therapy in the Outcome of Candida glabrata Bloodstream Infections

“…These findings are clinically relevant. Fluconazole is still the most commonly prescribed antifungal in hemodynamically stable patients who are not hospitalized in ICUs (13,28), and published data on its effectiveness for C. glabrata BSI treatment are scarce and a matter of debate. The results found here do not support initial use of fluconazole for all cases of candidemia and in all settings, but rather, they suggest that fluconazole may be a valid option as initial treatment for less severely ill patients who have not been exposed to azoles, even when C. glabrata cannot be ruled out.…”

Bloodstream infections in patients with liver cirrhosis

“…[2][3][4] Moreover, the need for frequent exposure to healthcare environment due to the complication of LC, make this population prone to develop healthcare related infections typically characterized by difficult-to-treat and multidrug resistant pathogens. 3,5,6 Infection-related mortality is high in patients with ESLD, approaching 30% within 30 days and 66% within 1 year from the hospital admission. For this reason, infection is considered an important prognostic marker in patients with ESLD.…”

Echinocandins Versus Dated Antifungals in Combination Against Opportunistic Mycotic Infections

“…Over the past two decades, the prevalence of Candidaemia has boosted as per the hospital records, which has shown the incidence ranging from 24% to 57%. In a report out of 670 cases of Candidaemia, 274 (41%) were hospital acquired, among which mortality turned out to be 39% [7] Both C. albicans and Candida non-albicans species are known to colonize the skin, gastrointestinal tract and reproductive tract in humans apart of Candidaemia, Invasive Aspergillosis (IA) which is caused by spp. of Aspergillus (Aspergillus fumigatus, Aspergillus flavus, Aspergillus terreus, and Aspergillus nidulans), has also been emerged as a major life risk in immunocompromised patients [8].…”