Traitements antifongiques des candidémies chez les patients non neutropéniques : évaluation des pratiques en réanimation

Abstract

Objective The authors had for objective to assess systemic antifungal treatment for candidemia in non-neutropenic patients, in intensive care units (ICU), and compare the results with French 2004 recommendations. Study design A retrospective multicenter study (nine ICU in two teaching hospitals) was made. Patients and method Thirty-eight non-neutropenic patients with at least one positive blood culture for Candida who had received systemic antifungal treatment were included between May 2004 and September 2007. Results Thirty-nine cases of candidemia were analyzed. The median age was 54.5 (21–80), the median SAPS II score at admission was 44 (20–79), the median duration of stay in ICU was 22.5 days (2–82), and the death rate was 45%. Candida albicans was identified in 69% of the cases. Eight percent of Candida sp. isolates were resistant or susceptible dose-dependent (S-DD) to fluconazole. Before identification, fluconazole, caspofungin, voriconazole, and amphotericin B were used in 74%, 15%, 5%, and 5% of cases respectively. After identification and antifungal susceptibility determination, fluconazole was used in 68% of cases, caspofungin in 24% of cases, any formulation of amphotericin B in 6% of cases, voriconazole in 3% of cases. The French recommendations were applied in 71% of cases before identification and in 68% of cases after identification and antifungal susceptibility determination. Conclusion The main causes of non-compliance to recommendations were the use of fluconazole in patients previously exposed to azole agents, the use of caspofungin in hemodynamically unstable patients, and the absence of therapeutic desescalade.