Abstract
Replacement of fluconazole by echinocandins as the first-line therapy for yeast-related fungemia could have an impact on both the mortality rate and the epidemiology of yeast species responsible for candidemia. We analyzed the individual clinical and microbiological data collected through the active surveillance program on yeast fungemia (YEASTS program, 2004–2016, Paris area, France) within 14 University Hospitals. The cohort included 3,092 patients [male:female ratio: 1.56; median age 61.0 years (IQR: 23.8)]. The mean mortality rate within 30 days was 38.5% (1,103/2,868) and significantly higher in intensive care units (690/1,358, 50.8%) than outside (413/1,510, 27.4%, p < 0.0001) without significant change over time. The yeast species distribution [Candida albicans (n = 1,614, 48.0%), Candida glabrata (n = 607, 18.1%), Candida parapsilosis (n = 390, 11.6%), Candida tropicalis (n = 299, 8.9%), Candida krusei (n = 96, 2.9%), rare species (n = 357, 10.6%)], minimal inhibitory concentration distribution, and the distribution between the patient populations (hematological malignancies, solid tumors, without malignancy) did not change either while the proportion of patients ≥60-years increased from 48.7% (91/187) in 2004 to 56.8% (133/234) in 2017 (p = 0.0002). Fluconazole as first-line therapy dramatically decreased (64.4% in 2004 to 27.7% in 2017, p < 0.0001) with a corresponding increase in echinocandins (11.6% in 2004 to 57.8% in 2017, p < 0.0001). Survival rates did not differ according to the first antifungal therapy. The progressive replacement of fluconazole by echinocandins as the first-line antifungal therapy was not associated with change in global mortality, regardless of species involved and antifungal susceptibility profiles. Other factors remain to be uncovered to improve the prognosis of yeast fungemia.
Highlights
Candidiasis is associated with mortality as high as 40%, acknowledging that patients with this condition usually present several entangled risk factors impacting the prognosis [1]
The current analysis concerns all episodes of yeast fungemia diagnosed in all ages, notified by the 14 university hospitals which sustainably participated from January 2004 to December 2017
The global mortality reported here in the YEASTS program is in the same order as recently reported in a meta-analysis of European studies, between 37 and 38% [17]
Summary
Candidiasis is associated with mortality as high as 40%, acknowledging that patients with this condition usually present several entangled risk factors impacting the prognosis [1]. One the reasons usually advocated is the limited spectrum of activity of fluconazole and the resistance or decreased susceptibility to fluconazole of some Candida species. The possible shift toward non-albicans Candida species and the emergence of resistance to antifungal drugs pose a serious potential health threat considering the poor prognosis of candidiasis and the limited number of systemic antifungal drugs available [1, 13]. It is of utmost interest to evaluate the impact of such therapeutic recommendations on both the epidemiology of the different species and the associated mortality rate
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