For empiric candidemia treatment, echinocandin tops fluconazole



LAS VEGAS – An echinocandin should be used for empiric therapy in critically ill candidemia patients awaiting culture results, according to investigators from Wayne State University in Detroit.

The reason is that Candida glabrata is on the rise in the critically ill, and it’s often resistant to fluconazole, the usual empiric choice, said Dr. Lisa Flynn, a vascular surgeon in the department of surgery at the university.

Dr. Flynn and her colleagues came to their conclusion after reviewing outcomes in 91 critically ill candidemia patients.

Just 40% (36) had the historic cause of candidemia, Candida albicans, which remains generally susceptible to fluconazole; 25% (23) had C. glabrata, and the rest had C. parapsilosis or other species.

Before those results were known, 53% (48) of patients were treated empirically with fluconazole and 36% (33), with the echinocandin micafungin. Most of the others received no treatment.

Seventy percent (16) of C. glabrata patients got fluconazole, the highest rate in the study of inappropriate initial antifungal therapy; probably not coincidently, 56% (13) of the C. glabrata patients died; the mortality rate in patients with other candida species was 32% (22). On univariate analysis, mortality increased from 18% to 37% if C. glabrata was cultured (P = .04).

"When we looked at glabrata versus all other candida species, we found significant increases in in-hospital mortality" that corresponded to a greater likelihood of inappropriate initial treatment, she said at the annual meeting of the Surgical Infection Society.

For that reason, "we are proposing that initial empiric antifungal therapy start with an echinocandin in the critically ill patient and then deescalate to fluconazole if [indicated by] culture data," she said.

It’s sound advice, so long as "your incidence of Candida glabrata is high," session moderator Dr. Addison May said after the presentation.

"It really depends on your hospital’s rate, and how frequently it’s [isolated]. It’s important to understand what you need to empirically treat with," but also important to use newer agents like micafungin judiciously, to prevent resistance, said Dr. May, professor of surgery and anesthesiology at Vanderbilt University in Nashville, Tenn.

C. glabrata patients were more likely than others to be over 60 years old; they had longer hospital and ICU stays, as well.

The mean APACHE II (Acute Physiology and Chronic Health Evaluation II) score in the study was 25, and the mean age was 57 years; 54% (49) of patients were men, and 68% (62) were black. In the previous month, almost half had surgery and a quarter had been on total parenteral nutrition.

Central lines were the source of infection in 84% (76).

On multivariate analysis, inappropriate initial antifungal treatment, vasopressor therapy, mechanical ventilation, and end-stage renal disease were all significant risk factors for death.

Dr. May and Dr. Flynn said they had no relevant financial disclosures.

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