Systemic antifungal therapy for proven or suspected invasive candidiasis: the AmarCAND 2 study View Full Text


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Article Info

DATE

2016-01-08

AUTHORS

Olivier Leroy, Sébastien Bailly, Jean-Pierre Gangneux, Jean-Paul Mira, Patrick Devos, Hervé Dupont, Philippe Montravers, Pierre-François Perrigault, Jean-Michel Constantin, Didier Guillemot, Elie Azoulay, Olivier Lortholary, Caroline Bensoussan, Jean-François Timsit, AmarCAND2 study group

ABSTRACT

BackgroundIn the context of recent guidelines on invasive candidiasis (IC), how French intensive care units (ICUs) are managing IC?MethodsThis is a prospective observational multicenter cohort study. During 1 year (2012–2013), 87 French ICUs enrolled consecutive patients with suspected or proven IC (SIC or PIC) and receiving systemic antifungal therapy (SAT). Data were collected up to 28 days after inclusion.ResultsWe studied 835 patients, 291 with PIC and 544 with SIC. At SAT initiation, patients with SIC were significantly more severe (SAPS II 50.1 ± 18.7 vs. 46.2 ± 18.0). Severe sepsis or septic shock prompted to initiate empiric SAT in 70 % of SIC. Within 4 days in median, the initial SAT was modified in 49 % of patients with PIC vs. 33 % patients with SIC. Modifications were most often motivated by mycological results, and de-escalation was the most frequent change. Regarding compliance to IC management guidelines, echinocandin was used for 182 (62.5 %) patients with PIC, and 287 (52.7 %) of those with SIC; central venous catheter was removed in 87 (54.3 %) of patients with candidaemia, and 43 of the remaining patients received echinocandin; and de-escalation was undertaken after 5 days of SAT in 142 patients, after 10 days in 13 patients. As 20.6 % of SIC were secondarily documented, 403/835 (48 %) patients had finally a proven IC. Candida albicans was the main pathogen (65.3 %), then Candida glabrata (15.9 %). The 28-day mortality rates were 40.0 % in candidaemia, 25.4 % in cIAI, and 26.7 % in deep-seated candidiasis. In the overall population of patients with proven IC, four independent prognostic factors were identified: immunosuppression (Odds Ratio (OR) = 1.977: 1.03–3.794 95 % confidence interval (CI), p = 0.04), age (OR = 1.035; 1.017–1.053 95 % CI; p < 0.001), SAPS >46 on ICU admission (OR = 2.894; 1.81–4.626 95 % CI; p < 0.001), and surgery just before or during ICU stay (OR = 0.473; 0.29–0.77 95 % CI; p < 0.001).ConclusionWhen SAT is initiated in French ICUs, the IC is ultimately proven for 48 % of patients. Empiric SAT is initiated in severely ill ICU patients. The initial SAT is often adapted, with de-escalation to fluconazole when possible. Mortality rate remains high. More... »

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URI

http://scigraph.springernature.com/pub.10.1186/s13613-015-0103-7

DOI

http://dx.doi.org/10.1186/s13613-015-0103-7

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https://app.dimensions.ai/details/publication/pub.1015101526

PUBMED

https://www.ncbi.nlm.nih.gov/pubmed/26743881


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    "description": "BackgroundIn the context of recent guidelines on invasive candidiasis (IC), how French intensive care units (ICUs) are managing IC?MethodsThis is a prospective observational multicenter cohort study. During 1\u00a0year (2012\u20132013), 87 French ICUs enrolled consecutive patients with suspected or proven IC (SIC or PIC) and receiving systemic antifungal therapy (SAT). Data were collected up to 28\u00a0days after inclusion.ResultsWe studied 835 patients, 291 with PIC and 544 with SIC. At SAT initiation, patients with SIC were significantly more severe (SAPS II 50.1\u00a0\u00b1\u00a018.7 vs. 46.2\u00a0\u00b1\u00a018.0). Severe sepsis or septic shock prompted to initiate empiric SAT in 70\u00a0% of SIC. Within 4\u00a0days in median, the initial SAT was modified in 49\u00a0% of patients with PIC vs. 33\u00a0% patients with SIC. Modifications were most often motivated by mycological results, and de-escalation was the most frequent change. Regarding compliance to IC management guidelines, echinocandin was used for 182 (62.5\u00a0%) patients with PIC, and 287 (52.7\u00a0%) of those with SIC; central venous catheter was removed in 87 (54.3\u00a0%) of patients with candidaemia, and 43 of the remaining patients received echinocandin; and de-escalation was undertaken after 5\u00a0days of SAT in 142 patients, after 10\u00a0days in 13 patients. As 20.6\u00a0% of SIC were secondarily documented, 403/835 (48\u00a0%) patients had finally a proven IC. Candida albicans was the main pathogen (65.3\u00a0%), then Candida glabrata (15.9\u00a0%). The 28-day mortality rates were 40.0\u00a0% in candidaemia, 25.4\u00a0% in cIAI, and 26.7\u00a0% in deep-seated candidiasis. In the overall population of patients with proven IC, four independent prognostic factors were identified: immunosuppression (Odds Ratio (OR)\u00a0=\u00a01.977: 1.03\u20133.794 95\u00a0% confidence interval (CI), p\u00a0=\u00a00.04), age (OR\u00a0=\u00a01.035; 1.017\u20131.053 95\u00a0% CI; p\u00a0<\u00a00.001), SAPS >46 on ICU admission (OR\u00a0=\u00a02.894; 1.81\u20134.626 95\u00a0% CI; p\u00a0<\u00a00.001), and surgery just before or during ICU stay (OR\u00a0=\u00a00.473; 0.29\u20130.77 95\u00a0% CI; p\u00a0<\u00a00.001).ConclusionWhen SAT is initiated in French ICUs, the IC is ultimately proven for 48\u00a0% of patients. Empiric SAT is initiated in severely ill ICU patients. The initial SAT is often adapted, with de-escalation to fluconazole when possible. Mortality rate remains high.", 
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14 schema:description BackgroundIn the context of recent guidelines on invasive candidiasis (IC), how French intensive care units (ICUs) are managing IC?MethodsThis is a prospective observational multicenter cohort study. During 1 year (2012–2013), 87 French ICUs enrolled consecutive patients with suspected or proven IC (SIC or PIC) and receiving systemic antifungal therapy (SAT). Data were collected up to 28 days after inclusion.ResultsWe studied 835 patients, 291 with PIC and 544 with SIC. At SAT initiation, patients with SIC were significantly more severe (SAPS II 50.1 ± 18.7 vs. 46.2 ± 18.0). Severe sepsis or septic shock prompted to initiate empiric SAT in 70 % of SIC. Within 4 days in median, the initial SAT was modified in 49 % of patients with PIC vs. 33 % patients with SIC. Modifications were most often motivated by mycological results, and de-escalation was the most frequent change. Regarding compliance to IC management guidelines, echinocandin was used for 182 (62.5 %) patients with PIC, and 287 (52.7 %) of those with SIC; central venous catheter was removed in 87 (54.3 %) of patients with candidaemia, and 43 of the remaining patients received echinocandin; and de-escalation was undertaken after 5 days of SAT in 142 patients, after 10 days in 13 patients. As 20.6 % of SIC were secondarily documented, 403/835 (48 %) patients had finally a proven IC. Candida albicans was the main pathogen (65.3 %), then Candida glabrata (15.9 %). The 28-day mortality rates were 40.0 % in candidaemia, 25.4 % in cIAI, and 26.7 % in deep-seated candidiasis. In the overall population of patients with proven IC, four independent prognostic factors were identified: immunosuppression (Odds Ratio (OR) = 1.977: 1.03–3.794 95 % confidence interval (CI), p = 0.04), age (OR = 1.035; 1.017–1.053 95 % CI; p < 0.001), SAPS >46 on ICU admission (OR = 2.894; 1.81–4.626 95 % CI; p < 0.001), and surgery just before or during ICU stay (OR = 0.473; 0.29–0.77 95 % CI; p < 0.001).ConclusionWhen SAT is initiated in French ICUs, the IC is ultimately proven for 48 % of patients. Empiric SAT is initiated in severely ill ICU patients. The initial SAT is often adapted, with de-escalation to fluconazole when possible. Mortality rate remains high.
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20 schema:keywords BackgroundIn
21 Candida albicans
22 Candida glabrata
23 French intensive care units
24 ICU admission
25 ICU patients
26 ICU stay
27 MethodsThis
28 PIC
29 ResultsWe
30 SAPS
31 SiC
32 admission
33 age
34 albicans
35 antifungal therapy
36 cIAI
37 candidaemia
38 candidiasis
39 care unit
40 catheter
41 central venous catheters
42 changes
43 cohort study
44 compliance
45 consecutive patients
46 context
47 data
48 days
49 echinocandins
50 factors
51 frequent changes
52 glabrata
53 guidelines
54 ill ICU patients
55 immunosuppression
56 inclusion
57 independent prognostic factor
58 initiation
59 intensive care unit
60 invasive candidiasis
61 main pathogens
62 management guidelines
63 median
64 modification
65 mortality rate
66 multicenter cohort study
67 mycological results
68 observational multicenter cohort study
69 overall population
70 pathogens
71 patients
72 population
73 prognostic factors
74 prospective observational multicenter cohort study
75 rate
76 recent guidelines
77 results
78 sepsis
79 septic shock
80 severe sepsis
81 shock
82 stay
83 study
84 surgery
85 systemic antifungal therapy
86 therapy
87 units
88 venous catheters
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