Methods: Retrospective study of adult ICU patients at NewYork-Presbyterian Hospital from 2012-2014. Patients were included if they had ≥1 positive blood culture with Candida spp., received ≥3 consecutive days of initial treatment with fluconazole (FLUC) or micafungin (MICA), and no prior episode of CAND within 30 days. Patients with polymicrobial bloodstream infection or C. kruseiCAND were excluded. The primary outcome was complete response (CR) at day 14, defined as clinical improvement and sterilization of blood cultures. Secondary outcomes included day 14 microbiological (MicroS) and clinical success (ClinS), 28-day mortality (Mort), and recurrent CAND within 90 days.
Results: 92 pts were included: 30 received FLUC and 62 received MICA. C. albicans (45%) and C. glabrata (30%) were the most common species. Most patients were male (60%) with a median age of 65 yrs (IQR 50-80), 41% had recent surgery, and 44% were immunosuppressed. With the exception of more C. tropicalis in the FLUC group (17% vs. 2%; p=0.013) there were no baseline differences between groups. There was no difference between FLUC and MICA treated patients in day 14 CR (37% vs. 36%; p=1.0), day 14 MicroS (70% vs. 71%; p=1.0), day 14 ClinS (40% vs. 37%; p=0.968), 28-day M (50% vs. 43%; p=0.719), or recurrent CAND (69% vs. 58%; p=0.698). Outcomes did not differ by species or among patients with shock. Shorter hospital stay prior to CAND, lower Pitt Bacteremia Score, and C. glabrataCAND were associated with 14-day CR. On multivariable analysis with MICA therapy forced into the model, all of these factors remained independent predictors of 14-day CR, but MICA therapy did not predict CR (OR 0.78, 95% CI 0.28,2.2; p=0.634).
Conclusion: In ICU patients, initial therapy with FLUC or MICA was associated with similar clinical outcomes and mortality. These data underscore the fact that antifungal treatment is only one of several determinants of patient outcomes, including severity of illness and underlying diseases. Larger, multicenter studies should be conducted to determine the impact of treatment among ICU patients with CAND.
A. Loo, None
G. Eschenauer, None
R. K. Shields, Merck: Grant Investigator , Research support
Astellas: Grant Investigator , Research support
C. J. Kubin, None
M. Sobieszczyk, None