Empirical antifungal therapy with an echinocandin in critically-ill patients: prospective evaluation of a pragmatic Candida score-based strategy in one medical ... View Full Text


Ontology type: schema:ScholarlyArticle      Open Access: True


Article Info

DATE

2014-07-11

AUTHORS

Rémi Bruyère, Jean-Pierre Quenot, Sébastien Prin, Frédéric Dalle, Clara Vigneron, Serge Aho, Cristobal Leon, Pierre-Emmanuel Charles

ABSTRACT

BackgroundInvasive candidiasis (IC) is a life-threatening ICU-acquired infection. A strong correlation between time to antifungal therapy (AFT) administration and outcome has been established. Empirical therapy benefit should be balanced with the risk of echinocandin overuse. We assessed therefore a decision rule that aimed at guiding empirical therapy.MethodsA 45-month prospective cohort study in a teaching medical ICU. All of the patients with suspected IC (uncontrolled sepsis despite broad spectrum antibiotics without any bacterial proven infection in patients with Candida score ≥ 3 points including multifocal Candida sp. colonization) were eligible. The primary endpoint was proven IC diagnosis (i.e., candidemia) following treatment onset. Timing of AFT administration was also investigated in those latter patients. Antifungal therapy step-down and discontinuation was done according to international guidelines in patients with candidemia. Otherwise, echinocandin discontinuation was encouraged in patients without proven IC, excepting when a clinical improvement was achieved without any other explanation that antifungals initiation (i.e., probable IC). In addition, a survival multivariate analysis using a Cox model was conducted.ResultsFifty-one patients were given an echinocandin with respect to our decision rule. Among them, candidemia was diagnosed thereafter in 9 patients. Over the same period, antifungal therapy was triggered by candidemia announcement (i.e., definite therapy) in 12 patients who did not fulfill criteria for empirical therapy before. Time elapsed from candidemia onset to echinocandin therapy initiation was shortened (0.4 [0.5] vs. 2.4 [2.8] hours; p = 0.04) when it was given empirically. In addition, 18 patients clinically improved under empirical antifungal therapy without any obvious other explanation, despite IC remained unproven. Moreover, echinocandin exposure duration was independently related to survival in those patients. Over the same period, our predefined criteria for empirical therapy were overruled in 55 cases. None of them develop IC thereafter. Finally, Our decision rule allowed IC early recognition of proven/probable IC with sensitivity, specificity, positive and negative predictive value of 69.2%, 82.1%, 69.2% and 82.1%, respectively.ConclusionImplementation of pragmatic guidelines for empirical AFT based on CS and fungal colonization assessment could be useful in selecting patients who really benefit from an echinocandin. More... »

PAGES

385

Identifiers

URI

http://scigraph.springernature.com/pub.10.1186/1471-2334-14-385

DOI

http://dx.doi.org/10.1186/1471-2334-14-385

DIMENSIONS

https://app.dimensions.ai/details/publication/pub.1035985649

PUBMED

https://www.ncbi.nlm.nih.gov/pubmed/25015848


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55 correlation
56 criteria
57 decision rules
58 diagnosis
59 discontinuation
60 duration
61 early recognition
62 echinocandins
63 empirical antifungal therapy
64 empirical therapy
65 endpoint
66 evaluation
67 excepting
68 explanation
69 exposure duration
70 guidelines
71 ill patients
72 improvement
73 infection
74 initiation
75 international guidelines
76 latter patients
77 medical ICU
78 model
79 multivariate analysis
80 negative predictive value
81 onset
82 outcomes
83 overuse
84 patients
85 period
86 pragmatic guidelines
87 predictive value
88 primary endpoint
89 prospective cohort study
90 prospective evaluation
91 recognition
92 respect
93 risk
94 rules
95 same period
96 sensitivity
97 specificity
98 strategies
99 strong correlation
100 study
101 survival
102 survival multivariate analysis
103 therapy
104 therapy administration
105 therapy benefit
106 therapy initiation
107 time
108 timing
109 treatment onset
110 values
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