Abstract
Non-culture-based biomarkers may improve diagnosis and antifungal treatment (AFT) of invasive candidiasis (IC). We evaluated an antifungal stewardship programme (AFSP) in a prospective intensive care unit (ICU) study, which included T2Candida and Candida mannan antigen (MAg) screening of patients with sepsis and a high risk of IC. Patients with non-neutropenic sepsis and a high risk of IC from two large tertiary ICUs were prospectively included, during a one-year period. IC was classified as proven, likely, possible or unlikely. The AFSP, diagnostic values of T2Candida and MAg, and the consumption of antifungals were evaluated. An amount of 219 patients with 504 T2Candida/MAg samples were included. IC was classified as proven in 29 (13.2%), likely in 7 (3.2%) and possible in 10 (5.5%) patients. Sensitivity/specificity/PPV/NPV values, comparing proven/likely versus unlikely IC, were 47%/100%/94%/90% for BC alone, 50%/97%/75%/90% for T2Candida alone, and 39%/96%/67%/88% for MAg alone. For the combination of T2Candida/MAg taken ≤3 days after AFT initiation, sensitivity/specificity/PPV/NPV was 70%/90%/63%/93%. T2Candida/MAg contributed to early (<3 days) AFT initiation in 13%, early AFT discontinuation in 25% and abstaining from AFT in 24% of patients. No reduction in overall use of AFT during the study period compared with the previous year was observed. An AFSP based on T2Candida and MAg screening contributed to a reduction of unnecessary treatment, but not overall AFT use. The diagnostic performance of T2Candida was lower than previously reported, but increased if T2Candida was combined with MAg.
Highlights
Invasive candidiasis (IC) comprises candidaemia and deep-seated tissue candidiasis [1,2]
We evaluated a new antifungal stewardship programme (AFSP) which included T2Candida magnetic resonance (T2MR) and Candida mannan antigen (MAg) screening in high-risk intensive care units (ICU) patients
Since several patients had possible abdominal IC, we examined the diagnostic performance with the inclusion of possible blood cultures (BC)-negative intra-abdominal candidiasis in the definition of true positives (n = 18)
Summary
Invasive candidiasis (IC) comprises candidaemia and deep-seated tissue candidiasis [1,2]. For high-risk ICU patients, randomized controlled trials of pre-emptive or empiric AFT have failed to demonstrate a survival benefit [4,5,6,7,8]. Implementation of systematic and more frequent diagnostic testing could increase the use of early pre-emptive echinocandin AFT. Unnecessary antifungal treatment may increase due to a higher awareness of IFI (outside the defined study patients or until a negative result was available) or as a result of false positive test results. The goal of AFSP is to increase the number of patients who receive early and appropriate therapy, not to reduce the overall cost and use of AFT. It is plausible that a setting with more frequent T2MR and MAg testing with strict adherence to the AFSP may even reduce the AF use through the earlier discontinuation of unnecessary therapy
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