Moreno-Garcia, E.Puerta-Alcalde, P.Gariup, G.Fernandez-Ruiz, M.Lopez Cortes, L. E.Cuervo, G.Salavert, M.Merino, P.Machado, M.Guinea, J.Garcia-Rodriguez, J.Garnacho-Montero, J.Cardozo, C.Peman, J.Montejo, M.Fortun, J.Almirante, B.Castro, C.Rodriguez-Bano, J.Aguado, J. M.Martinez, J. A.Carratala, J.Soriano, A.Garcia-Vidal, C.Project GEMICOMED SEIMC2025-01-072025-01-072021-05-162328-8957https://hdl.handle.net/10668/27322Background. 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.enAttribution-NonCommercial-NoDerivatives 4.0 Internationalhttp://creativecommons.org/licenses/by-nc-nd/4.0/antifungalcandidemiade-escalationinvasive candidiasisoutcomeCritically-ill patientsDe-escalationDown therapyAntifungalSusceptibilityCandidaemiaManagementGuidelineMortalityresearch article34104670open access10.1093/ofid/ofab250https://academic.oup.com/ofid/article-pdf/8/6/ofab250/43915337/ofab250.pdf715364900045