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Abstract

Introduction: C. glabrata (CG) and C. krusei (CK) are important species causing candidemia. IDSA guidelines indicate that echinocandin (ECH) is the preferred treatment (Tx) for CG/CK, due to potential resistance to fluconazole (FLU). This study evaluated resource utilization, Tx patterns and clinical outcomes for inpatients with CG/CK candidemia. Methods: This retrospective study used Cerner’s Health Facts data from 7/2005-3/2012. Adult inpatients with?1 blood culture (BCx) with CG or CK and timing of initial Tx with ECH or FLU relative to index BCx were studied. Descriptive outcome measurements included AF-LOS (length-of-stay following first antifungal [AF] order), mortality and measures of resource utilization. Results: CG/CK made up 32% (607/1914) of all Candida bloodstream infections. Initial Tx occurred with ECH (n=156, 26%), FLU (n=285, 47%), other AF agents (n=8, 1%); or no AF (n=158, 26%). 5% (n=21) of the patients had CK and 31% of the CG/CK cohort were infected with multiple Candida species. Initial Tx with FLU (>48h prior 34%; 48h prior to 72h after 47%; >72h after 19%) occurred earlier than ECH (>48h prior 13%; 48h prior to 72h after 55%; >72h after 33%) (P<0.001). For patients (pts) switching AF Tx (ECH n=32 (21%); FLU n=191 (67%), P=0.006), ECH pts stayed on initial Tx longer before switching vs FLU pts (10 vs 6 days, P<0.001). Significantly more ECH vs FLU pts had parenteral nutrition (35% vs 25%), dialysis (14% vs 8%), sepsis/septic shock (62% vs 52%), and hematologic dysfunction (39% vs 28%), while a higher proportion of FLU pts were admitted to ICU (47% vs 31%, P=0.001). Unadjusted AF-LOS appeared similar for FLU and ECH pts (21.7 vs 19.3 days, P=0.13); however, was notably greater with FLU for CK patients alone (39.3 vs 17.1 days, P=0.04). For CK pts, readmissions within 30 days occurred with 1 of 5 ECH pts vs 5 of 10 FLU pts (P=0.26). Overall mortality was high (ECH 31% vs FLU 24%, P=0.14). Conclusions: Pts with invasive CG/CK candidemia have high resource use and mortality. AF-LOS was considerably greater for FLU CK pts. The high proportion of CG/CK pts with initial FLU and switch to ECH supports the inadequate Tx of CK with FLU.