%0 Journal Article
%A Moreno-Garcia, E.
%A Puerta-Alcalde, P.
%A Gariup, G.
%A Fernandez-Ruiz, M.
%A Lopez Cortes, L. E.
%A Cuervo, G.
%A Salavert, M.
%A Merino, P.
%A Machado, M.
%A Guinea, J.
%A Garcia-Rodriguez, J.
%A Garnacho-Montero, J.
%A Cardozo, C.
%A Peman, J.
%A Montejo, M.
%A Fortun, J.
%A Almirante, B.
%A Castro, C.
%A Rodriguez-Bano, J.
%A Aguado, J. M.
%A Martinez, J. A.
%A Carratala, J.
%A Soriano, A.
%A Garcia-Vidal, C.
%A Project GEMICOMED SEIMC
%T Early Stepdown From Echinocandin to Fluconazole Treatment in Candidemia: A Post Hoc Analysis of Three Cohort Studies
%D 2021
%@ 2328-8957
%U https://hdl.handle.net/10668/27322
%X Background. There are no clear criteria for antifungal de-escalation after initial empirical treatments. We hypothesized that early de-escalation (ED) (within 5 days) to fluconazole is safe in fluconazole-susceptible candidemia with controlled source of infection.Methods. This is a multicenter post hoc study that included consecutive patients from 3 prospective candidemia cohorts (20072016). The impact of ED and factors associated with mortality were assessed.Results. Of 1023 candidemia episodes, 235 met inclusion criteria. Of these, 54 (23%) were classified as the ED group and 181 (77%) were classified as the non-ED group. ED was more common in catheter-related candidemia (51.9% vs 31.5%; P = .006) and episodes caused by Candida parapsilosis, yet it was less frequent in patients in the intensive care unit (24.1% vs 39.2%; P = .043), infections caused by Nakaseomyces glabrata (0% vs 9.9%; P = .016), and candidemia from an unknown source (24.1% vs 47%; P = .003). In the ED and non-ED groups, 30-day mortality was 11.1% and 29.8% (P = .006), respectively. Chronic obstructive pulmonary disease (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.48-10.61), Pitt score > 2 (OR, 4.39; 95% CI, 1.94-9.20), unknown source of candidemia (OR, 2.59; 95% CI, 1.14-5.86), candidemia caused by Candida albicans (OR, 3.92; 95% CI, 1.48-10.61), and prior surgery (OR, 0.29; 95% CI, 0.08-0.97) were independent predictors of mortality. Similar results were found when a propensity score for receiving ED was incorporated into the model. ED had no significant impact on mortality (OR, 0.50; 95% CI, 0.16-1.53).Conclusions. Early de-escalation is a safe strategy in patients with candidemia caused by fluconazole-susceptible strains with controlled source of bloodstream infection and hemodynamic stability. These results are important to apply antifungal stewardship strategies.
%K antifungal
%K candidemia
%K de-escalation
%K invasive candidiasis
%K outcome
%K Critically-ill patients
%K De-escalation
%K Down therapy
%K Antifungal
%K Susceptibility
%K Candidaemia
%K Management
%K Guideline
%K Mortality
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