Category: Federal Forum Posters
Purpose: Candidemia is an important nosocomial infection due to its high mortality and morbidity. Detailed investigations on the prognostic factors of candidemia based on each institution’s practical data are essential for better management. In our hospital, infectious disease (ID) consultations by an antifungal stewardship (AFS) team were implemented from October 2015. Few studies have been conducted on the impact of ID consultations on the management of candidemia. The objectives of the present study were to identify prognostic factors and evaluate the impact of ID consultations on the management of candidemia.
Methods: A total of 121 patients diagnosed with candidemia in our hospital between January 2007 and December 2016 were enrolled in the present study. Our AFS team consists of physicians and infectious disease-specialized pharmacists. Prospective audits and feedback based on the results of blood culture tests were performed. Among patients with candidemia, we provided the following items to physicians as a bundle: 1; initiation of an adequate dosage of antifungal therapy based on the Infectious Disease Society of America (IDSA) published candidiasis guidelines, 2; removal of a central venous catheter (CVC), 3; follow-up blood cultures to confirm the clearance of Candida species, 4; ophthalmological consultations to rule out endophthalmitis, 5; an adequate duration of therapy. The dosage of antifungal agents and duration of therapy were evaluated using the IDSA candidiasis guidelines. Fifteen patients who received these bundles were defined as the ID consultation group. The 30-day mortality rate was examined by Kaplan-Meier plots and the Log-rank test. A multivariate Cox hazard analysis was performed to identify factors associated with death. P values less than 0.05 were considered to be significant. The study protocol was approved by the ethics committee in our institution.
Results: The 30-day mortality rate was 33%. Systemic antifungal agents were administered to 114 patients. The median number of days from blood cultures to the initiation of antifungal therapy was 2 (range of 0-9 days). The proportion of each antifungal agent was as follows: fluconazole 28.9%, micafungin 51.2%, liposomal amphotericin B 6.6%, voriconazole 2.5%, itraconazole 2.5%, and caspofungin 2.5%.
Between patients with and without ID consultations, significant differences were observed in the appropriate dosage of antifungal therapy (ID consultations 86.6% vs. without ID consultations 44.4%), follow-up blood cultures to confirm the clearance of Candida species (ID consultations 100% vs. without ID consultations 56.5%), ophthalmological consultations (ID consultations 80% vs. without ID consultations 41.4%), and an appropriate duration of therapy (ID consultations 60% vs. without ID consultations 15.1%). No significant differences were observed in the 30-day mortality rate (ID consultations 20% vs. without ID consultations 30.3%) according to the Log-rank test (P value of 0.38). Candida albicans, the absence of antifungal therapy, an advanced age, lung diseases, and mechanical ventilation were identified as significant factors for a high mortality rate, whereas C. parapsilosis, the removal of CVC, and surgical wards were associated with a lower mortality rate.
Conclusion: Approximately 50% of patients received micafungin as an initial antifungal therapy. Our ID consultations using bundles contributed to the better management of therapy; however, no significant differences were observed in mortality rates. In terms of practical procedures, the prompt administration of antifungal therapy and removal of CVC were essential for favorable outcomes among patients with candidemia.
Ryuichi Hirano– Pharmacist, Aomori Prefectural Central Hospital, Aomori, Aomori, Japan