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Analyzing candidemia guideline adherence identifies opportunities for antifungal stewardship

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Abstract

Candidemia epidemiology varies significantly by region; thus, local data are essential for evidence-based decision-making in prophylaxis and treatment. Current management strategies are derived from large randomized controlled trials mostly executed in large high-volume tertiary care centers. Results may not be entirely transferable to smaller hospitals. This study investigates epidemiology, diagnosis, and treatment standards in six hospitals in the Cologne metropolitan area (number of inhabitants approx. one million). We assessed adherence to the current guideline of the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and the Infectious Diseases Society of America (IDSA) using the EQUAL Candida Score of the European Confederation of Medical Mycology (ECMM). Data were documented by trained medical students as part of an integrated research and teaching concept at the University of Cologne. Between January 2014 and June 2017, 77 patients had candidemia, corresponding to an incidence of 0.2 cases/1000 admissions. While 55 patients were enrolled, 22 patients were excluded due to incompletely retrievable health records. Fluconazole monotherapy was the preferred first-line treatment in cases with Candida albicans infection (21/29). A central vascular catheter was present in 40 patients and was removed in 17 (43%) during treatment. Overall mortality at 30 days was 44%. Patients reached a mean EQUAL Candida Score of 9.9 (range 8–14), which was well below the maximum score of 22 for perfect guideline adherence. In summary, management of candidemia differed from current European recommendations. It remains unclear to what extent enhanced adherence would improve patient outcome. Larger prospective studies need to answer that question.

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Acknowledgements

The authors thank the staff of the contributing hospitals.

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Authors and Affiliations

  1. Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany

    Sibylle C. Mellinghoff, Felix Köhler, Philipp Köhler, Danila Seidel & Oliver A. Cornely

  2. Department I of Internal Medicine, ECMM Diamond Center of Excellence in Medical Mycology, German Centre for Infection Research (DZIF), University of Cologne, Cologne, Germany

    Sibylle C. Mellinghoff, Florian B. Cornely, Felix Köhler, Philipp Köhler, Danila Seidel & Oliver A. Cornely

  3. German Centre for Infection Research (DZIF), Cologne, Germany

    Pia Hartmann

  4. Institute for Medical Microbiology, Immunology and Hygiene (IMMIH), University of Cologne, Cologne, Germany

    Pia Hartmann & Hilmar Wisplinghoff

  5. Wisplinghoff Laboratories, Cologne, Germany

    Pia Hartmann & Hilmar Wisplinghoff

  6. University of Varna, Varna, Bulgaria

    Florian B. Cornely

  7. University of Cologne, Cologne, Germany

    Laura Knauth, Christine Kronenberg, Sarah-Leonie Kranz, Hannah Müller, Jan-Hendrik Naendrup, Anna Ronge & Jule Rutz

  8. Evangelisches Krankenhaus Kalk, Cologne, Germany

    Carolin Krause

  9. Department of Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India

    Vidya Menon

  10. Krankenhaus Porz am Rhein, Cologne, Germany

    Stefan Pützfeld

  11. Institute for Virology and Clinical Microbiology, Witten/Herdecke University, Witten, Germany

    Hilmar Wisplinghoff

  12. Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany

    Oliver A. Cornely

  13. Department I for Internal Medicine, ECMM Excellence Center of Medical Mycology University Hospital, Kerpener Str. 62, 50937, Cologne, Germany

    Oliver A. Cornely

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  1. Sibylle C. Mellinghoff
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  4. Laura Knauth
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Correspondence to Oliver A. Cornely.

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Conflict of interest

OAC is supported by the German Federal Ministry of Research and Education and the European Commission and has received research grants from, is an advisor to, or received lecture honoraria from Actelion, Amplyx, Arsanis, Astellas, AstraZeneca, Basilea, Cidara, Da Volterra, Duke University (NIH UM1AI104681), F2G, Gilead, GSK, Janssen, Leeds University, Matinas, Medicines Company, MedPace, Menarini, Merck/MSD, Miltenyi, Paratek, Pfizer, PSI, Rempex, Roche, Sanofi Pasteur, Scynexis, Seres, Summit, Tetraphase, and Vical. FCK reports grants from the German Federal Ministry of Research and Education, and non-financial support from Miltenyi Biotec GmbH. PK reports non-financial support from Merck/MSD, non-financial support from MedImmune, and lecture honoraria from Astellas, outside the submitted work. HW has received research grants from, is an advisor to, or received lecture honoraria from the German Society for Hematology/Oncology, BeckmanCoulter, BrukerDaltonics, BioMérieux, Hologic, Siemens, BioMérieux, Cepheid, Hologic, iSense, r-biopharm, and SpecificTechnologies. All remaining authors have declared no conflicts of interest.

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Mellinghoff, S.C., Hartmann, P., Cornely, F.B. et al. Analyzing candidemia guideline adherence identifies opportunities for antifungal stewardship. Eur J Clin Microbiol Infect Dis 37, 1563–1571 (2018). https://doi.org/10.1007/s10096-018-3285-8

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