‘Substantial’ number of patients with candidemia may be treated improperly, study finds
An analysis of U.S. surveillance data revealed that nearly 30% of patients with candidemia initially received fluconazole, resulting in potentially inappropriate treatment, researchers reported.
The analysis was prompted by the Infectious Diseases Society of America changing its treatment guidelines for candidemia in 2016, explained Jeremy A.W. Gold, MD, an Epidemic Intelligence Service officer for the CDC’s Mycotic Diseases Branch.
“Because of the increasing frequency of infections caused by non-albicans Candida, rising levels of fluconazole resistance, and evidence that echinocandins are more effective than fluconazole, IDSA began recommending echinocandins over fluconazole as first-line treatment for adults with candidemia,” Gold told Healio.
“The updated guidelines also recommend performing fluconazole antifungal susceptibility testing (AFST) on all bloodstream Candida,” he said. “ We wanted to understand current candidemia treatment practices to see whether clinicians were adhering to the latest guidelines. At CDC, we coordinate in-depth, population-based surveillance for candidemia at nine sites across the country through the Emerging Infections Program; data from this system were well suited to study treatment practices.”
Between 2017 and 2018, the CDC’s Emerging Infections Program conducted active population-based candidemia surveillance at nine U.S. sites. For the study, Gold and colleagues assessed factors associated with initial antifungal treatment for the first candidemia case among adults using multivariable logistic regression models and compared the first antifungal drug received with species and AFST results from initial blood cultures to identify instances of potentially inappropriate treatment.
The study demonstrated that of the 1,835 patients who received antifungal treatment for candidemia, 29.6% were initially treated with fluconazole rather than an echinocandin, which is recommended as first-line treatment for candidemia. Gold said this resulted in “potentially inappropriate treatment for a substantial number of patients.”
The study also showed that more than half of patients (56%) initially treated with fluconazole grew a non-albicans species, which tend to be more resistant to fluconazole than albicans species. Further, among patients initially treated with fluconazole who had AFST results for this drug, about 10% had a fluconazole-resistant isolate. Gold said nearly half of all patients did not receive fluconazole AFST as recommended by IDSA guidelines to identify resistant infections.
“Our findings highlight opportunities to improve adherence to IDSA treatment guidelines for patients with candidemia, particularly regarding antifungal drug selection and AFST utilization,” Gold said.
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