Reducing Candida-Related Shock With Empiric Treatment


The microbial cause of infection is often not known at the time antibiotics are prescribed for patients in Candida-related septic shock, but delaying therapy has been associated with a mortality rate of > 90%. Researchers from St. Louis College of Pharmacy, Barnes-Jewish Hospital, BJC HealthCare, and Washington University, all in St. Louis, Missouri, conducted a pilot study that found empiric antifungal treatment could shorten the time to administration of appropriate treatment for Candida-related septic shock.

The Barnes-Jewish Hospital intensive care unit (ICU) averages 1,400 admissions per year, the researchers say, with a 10% prevalence of Candida as the cause of septic shock. They add that the rate of resistance to fluconazole in all species of Candida combined is about 15%. In this before-after study, 15 patients who presented before December 31, 2012, were in the standard-care group. They received antibiotics, including antifungal drugs, at the discretion of the treating physician. The remaining 13 (treated after January 1, 2013) received empiric therapy with micafungin 100 mg/d or fluconazole 800 mg IV on day 1, followed by 400 mg/d IV. The choice of antifungal agent was left to the ICU team and clinical pharmacist but was partly based on whether the patient had any prior exposure to fluconazole, in which case micafungin was prescribed.

Sixteen patients received appropriate antifungal therapy. The remaining 12 patients received delayed antifungal therapy, 1 of which received no antifungal therapy before death.

The mean time from onset of shock to appropriate therapy was statistically shorter in the empiric therapy group (10.6 hours vs 40.5 hours). The mean time from culture collection to appropriate therapy was also statistically shorter in the empiric therapy group (13.7 hours vs 43.3 hours in the standard care group; P = .001). Patients who received empiric therapy were more likely to have received appropriate therapy within 12 hours (69.2% vs 6.7%) and within 24 hours (76.9% vs 40%).

The shorter time to appropriate treatment meant a slight but noticeable difference in survival. Twelve patients died during hospitalization, but those who received appropriate therapy within 24 hours of onset of hypotension had greater hospital survival rates: 68.8% vs 41.7%.

Micek ST, Arnold H, Juang P, et al. Clin Ther. 2014;36(9):1226-1232.
doi: 10.1016/j.clinthera.2014.06.28.

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