Analyzing candidemia guideline adherence identifies opportunities for antifungal stewardship
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.
KeywordsInvasive Candida infection Invasive fungal disease Blood culture EQUAL Candida Score
The authors thank the staff of the contributing hospitals.
Compliance with ethical standards
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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