Date Published: April 25, 2019
Publisher: Public Library of Science
Author(s): Masahiro Ishikane, Kayoko Hayakawa, Satoshi Kutsuna, Nozomi Takeshita, Norio Ohmagari, Giuseppe Vittorio De Socio.
Candidemia is one of the major causes of morbidity and mortality as a hospital acquired infection. Infectious diseases consultation (IDC) might be beneficial to improve candidemia outcomes; however, only limited data from short periods of time are available thus far.
An observational study of all candidemia patients at a large tertiary care hospital between 2002 and 2013 was conducted. A candidemia episode was defined as ≥ 1 positive result for Candida spp. in blood culture. Patients who died or transferred to another hospital within two days after their first positive blood culture were excluded. Independent risk factors for 30-day mortality were determined.
Among 275 patients with 283 episodes of candidemia, 194 (68.6%) were male, and the mean age was 70.0 ± 15.8 years. Central line-associated bloodstream infections, peripheral line-associated bloodstream infections, intra-abdominal infection, and unknown source comprised 220 (77.7%), 35 (12.4%), 13 (4.7%), and 15 (5.3%) episodes, respectively. A total of 126 patients (44.5%) received IDC. Factors independently associated with 30-day mortality in patients with candidemia were urinary catheters use (adjusted hazard ratio [HR] = 2.94; 95% confidence interval [CI] = 1.48–5.87; P = 0.002) and severe sepsis/septic shock (adjusted HR = 2.10; 95% CI = 1.20–3.65; P = 0.009). IDC was associated with a 46% reduction in 30-day mortality (adjusted HR = 0.54; 95% CI = 0.32–0.90; P = 0.017).
IDC was independently associated with a reduction in 30-day mortality. Only 44.5% of patients with candidemia in this cohort received IDC. Routine IDC should be actively considered for patients with candidemia.
Candidemia is one of the major causes of morbidity and mortality as hospital acquired infection, [1–5] and high overall mortality rate was reported with 25–60% [6–8]. Additionally, candidemia is related to the extended hospitalization and increased health care costs [6–8]. Clinical intervention by infectious diseases consultation (IDC) has been shown to reduce morbidity and/or mortality in several infections [9–12], including candidemia [13–16]. Underscoring the value of IDC as antifungal stewardships is important.
We showed that IDC was associated with a 46% reduction in all-cause mortality among candidemia patients within 30 days of candidemia onset. Past studies have described the positive effect of IDC on mortality with candidemia; 18–24% and 39–56% in the IDC and the non-IDC groups, respectively [13–16]. Compared the data of rates of IDC, patient characteristics at baseline, and clinical outcomes of candidemia in a hospital in North America , the rate of IDC was lower (45% vs 77%), the median age and population of male were higher (69 years old vs 53 years old; 72% vs 55%), and 30 days mortality was slightly lower (18% vs 20%) among IDC group in our results. However, these studies were limited due to small sample sizes (50–171 patients) and short study periods (1–3 years). Although our study was a retrospective cohort study, our sample size was larger (283 patients) and study period was longer (12 years) than past studies [13–16]. Moreover, because previous studies did not use the cox proportional hazard model [13–16], the evaluation of the effect of IDC on mortality with candidemia was prone to confounding effects, and might thus be incorrect. In our study, the IDC group more frequently received appropriate choice (OR = 6.48; 95% CI = 2.20–19.07; P < 0.001) and appropriate duration (OR = 3.89; 95% CI = 2.19–6.92; P < 0.001) of antifungal therapy than the non-IDC group. The duration of antifungal therapy was significantly longer in the IDC group than the non-IDC group (19 days versus 14 days; P < 0.001). Past research has also revealed that IDC intervention for candidemia led to appropriate antifungal therapy [14–16]. Source: http://doi.org/10.1371/journal.pone.0215996