Early Stepdown From Echinocandin to Fluconazole Treatment in Candidemia : A Post Hoc Analysis of Three Cohort Studies
Moreno-García, Estela (Hospital Clínic i Provincial de Barcelona)
Puerta-Alcalde, Pedro (Hospital Clínic i Provincial de Barcelona)
Gariup, Giuseppe (Hospital Clínic i Provincial de Barcelona)
Fernández-Ruiz, Mario (Hospital Universitario 12 de Octubre (Madrid))
López Cortés, Luis Eduardo (Instituto de Biomedicina de Sevilla)
Cuervo, Guillermo (Institut d'Investigació Biomèdica de Bellvitge)
Salavert, Miguel (Hospital Universitari i Politècnic La Fe (València))
Merino, Paloma (Hospital Clínico San Carlos (Madrid))
Machado, Marina (Hospital General Universitario Gregorio Marañón)
Guinea, Jose (Hospital General Universitario Gregorio Marañón)
García-Rodríguez, Julio (Hospital Universitario La Paz (Madrid))
Garnacho-Montero, Jose (Hospital Universitario Virgen Macarena (Sevilla, Andalusia))
Cardozo, Celia (Hospital Clínic i Provincial de Barcelona)
Peman, Javier (Hospital Universitari i Politècnic La Fe (València))
Montejo, Miguel (Hospital Universitario de Cruces (Barakaldo, País Basc))
Fortún, Jesús (Hospital Universitario Ramón y Cajal (Madrid))
Almirante Gragera, Benito (Hospital Universitari Vall d'Hebron)
Castro, Carmen (Hospital Universitario Virgen de Valme (Sevilla, Andalusia))
Rodríguez-Baño, Jesús (Instituto de Biomedicina de Sevilla)
Aguado, José María (Hospital Universitario 12 de Octubre (Madrid))
Martínez, Jose Alfredo (Hospital Clínic i Provincial de Barcelona)
Carratalà, Jordi (Institut d'Investigació Biomèdica de Bellvitge)
Soriano, A (Hospital Clínic i Provincial de Barcelona)
Garcia-Vidal, Carolina (Hospital Clínic i Provincial de Barcelona)
Universitat Autònoma de Barcelona

Data:	2021
Resum:	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. This is a multicenter post hoc study that included consecutive patients from 3 prospective candidemia cohorts (2007-2016). The impact of ED and factors associated with mortality were assessed. 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). 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. Early de-escalation (within 5 days of candidemia onset) was proven to be safe in episodes caused by fluconazole-susceptible strains with a controlled source of candidemia and hemodynamic stability. These results might help strengthen antifungal stewardship strategies.
Ajuts:	European Commission. Horizon 2020 PI18/01061 Instituto de Salud Carlos III PI18/01061
Drets:	Aquest document està subjecte a una llicència d'ús Creative Commons. Es permet la reproducció total o parcial, la distribució, i la comunicació pública de l'obra, sempre que no sigui amb finalitats comercials, i sempre que es reconegui l'autoria de l'obra original. No es permet la creació d'obres derivades.
Llengua:	Anglès
Document:	Article ; recerca ; Versió publicada
Matèria:	Antifungal ; Candidemia ; De-escalation ; Invasive candidiasis ; Outcome
Publicat a:	Open Forum Infectious Diseases, Vol. 8 (may 2021) , ISSN 2328-8957

DOI: 10.1093/ofid/ofab250
PMID: 34104670

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