Early Stepdown From Echinocandin to Fluconazole Treatment in Candidemia: A Post Hoc Analysis of Three Cohort Studies

Background. There are no clear criteria for antifungal de-escalation after initial empirical treatments. We hypothesized that early de-escalation (ED) (within 5 days) to fluconazole is safe in fluconazole-susceptible candidemia with controlled source of infection. Methods. This is a multicenter post...

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Detalles Bibliográficos
Autores: Moreno García, Estela, Puerta-Alcalde, Pedro, Gariup, Giuseppe, Fernández Ruiz, Mario, López Cortés, Luis Eduardo, Cuervo Requena, Guillermo, Salavert, Miguel, Merino, Paloma, Machado, Marina, Guinea, Jesús, García Rodríguez, Julio, Garnacho Montero, José, Cardozo Espinola, Celia, Peman,Javier, Montejo, Marta, Fortún, Jesús, Almirante, Benito, Castro, Carmen, Rodríguez Baño, Jesús, Aguado, José María, Martínez, J. Alfredo, 1957-, Carratalà, Jordi, Soriano Viladomiu, Alex, Garcia Vidal, Carolina
Tipo de recurso: artículo
Estado:Versión publicada
Fecha de publicación:2021
País:España
Institución:Universidad de Barcelona
Repositorio:Dipòsit Digital de la UB
OAI Identifier:oai:diposit.ub.edu:2445/181487
Acceso en línea:https://hdl.handle.net/2445/181487
Access Level:acceso abierto
Palabra clave:Candidiasi
Terapèutica
Candidiasis
Therapeutics
Descripción
Sumario:Background. There are no clear criteria for antifungal de-escalation after initial empirical treatments. We hypothesized that early de-escalation (ED) (within 5 days) to fluconazole is safe in fluconazole-susceptible candidemia with controlled source of infection. Methods. This is a multicenter post hoc study that included consecutive patients from 3 prospective candidemia cohorts (20072016). The impact of ED and factors associated with mortality were assessed. Results. Of 1023 candidemia episodes, 235 met inclusion criteria. Of these, 54 (23%) were classified as the ED group and 181 (77%) were classified as the non-ED group. ED was more common in catheter-related candidemia (51.9% vs 31.5%; P = .006) and episodes caused by Candida parapsilosis, yet it was less frequent in patients in the intensive care unit (24.1% vs 39.2%; P = .043), infections caused by Nakaseomyces glabrata (0% vs 9.9%; P = .016), and candidemia from an unknown source (24.1% vs 47%; P = .003). In the ED and non-ED groups, 30-day mortality was 11.1% and 29.8% (P = .006), respectively. Chronic obstructive pulmonary disease (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.48-10.61), Pitt score > 2 (OR, 4.39; 95% CI, 1.94-9.20), unknown source of candidemia (OR, 2.59; 95% CI, 1.14-5.86), candidemia caused by Candida albicans (OR, 3.92; 95% CI, 1.48-10.61), and prior surgery (OR, 0.29; 95% CI, 0.08-0.97) were independent predictors of mortality. Similar results were found when a propensity score for receiving ED was incorporated into the model. ED had no significant impact on mortality (OR, 0.50; 95% CI, 0.16-1.53). Conclusions. Early de-escalation is a safe strategy in patients with candidemia caused by fluconazole-susceptible strains with controlled source of bloodstream infection and hemodynamic stability. These results are important to apply antifungal stewardship strategies.

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