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Dellai F, Pagotto A, Sbrana F, Ripoli A, Danieli G, Colombo A, D'Elia D, Geminiani M, Giuliano S, Sartor A, Tascini C. The Impact of Epidemiological Trends and Guideline Adherence on Candidemia-Associated Mortality: A 14-Year Study in Northeastern Italy. J Fungi (Basel) 2025; 11:400. [PMID: 40422734 DOI: 10.3390/jof11050400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2025] [Revised: 05/08/2025] [Accepted: 05/10/2025] [Indexed: 05/28/2025] Open
Abstract
Invasive candidiasis represents a major global health concern, with incidence and mortality rates expected to rise due to medical advancements and unavoidable risk factors. This retrospective, multicentric study was conducted in eight hospitals in a northeastern Italian region, enrolling adult patients diagnosed with candidemia from 1 January 2018 to 31 December 2022. Epidemiological trends and clinical characteristics were analyzed and compared to those from a prior regional study (2009-2011), allowing a fourteen-year comparative evaluation. A shift in species distribution was observed, with a decline in Candida albicans (from 65.7% to 57.8%) and a rise in non-albicans species, particularly the Candida parapsilosis complex (from 16.1% to 18.2%). Guideline adherence was assessed applying the EQUAL Candida score; scores ≥ than 11.5 were independently associated with improved in-hospital survival (HR 3.51, p < 0.001). Among individual score components, empiric echinocandin therapy and central venous catheter removal correlated with better outcomes. Centers with routine infectious disease (ID) consultations showed higher survival and adherence, reinforcing the value of specialist involvement. These findings support local epidemiological and management practice surveillance program adoption to address context-specific gaps, promote the adoption of best practices in Candida BSI management-as expanded ID specialist consultations and education programs-and, ultimately, reduce candidemia-related mortality rates.
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Affiliation(s)
- Fabiana Dellai
- Department of Medicine (DMED), University of Udine, 33100 Udine, Italy
| | - Alberto Pagotto
- Infectious Diseases Division, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy
| | - Francesco Sbrana
- Lipoapheresis Unit and Reference Center for Inherited Dyslipidemias, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
| | - Andrea Ripoli
- Lipoapheresis Unit and Reference Center for Inherited Dyslipidemias, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
| | | | - Alberto Colombo
- Microbiology Unit, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy
| | - Denise D'Elia
- Department of Medicine (DMED), University of Udine, 33100 Udine, Italy
| | - Monica Geminiani
- Department of Medicine (DMED), University of Udine, 33100 Udine, Italy
| | - Simone Giuliano
- Infectious Diseases Division, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy
| | - Assunta Sartor
- Microbiology Unit, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy
| | - Carlo Tascini
- Department of Medicine (DMED), University of Udine, 33100 Udine, Italy
- Infectious Diseases Division, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy
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Caniff KE, Al Musawa M, Judd C, Shupp M, Veve MP, Alangaden G, Claeys KC, Scipione MR, Walsh TJ, Rybak MJ. Evaluating antimicrobial stewardship strategies in candidemia: a novel desirability of outcome ranking (DOOR) analysis comparing blood culture versus T2Candida diagnostic approaches. J Clin Microbiol 2025; 63:e0004325. [PMID: 40214232 PMCID: PMC12077142 DOI: 10.1128/jcm.00043-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2025] [Accepted: 03/05/2025] [Indexed: 05/15/2025] Open
Abstract
The T2Candida Panel (T2 Biosystems, Lexington, MA) is a rapid diagnostic test that detects Candida from whole blood within 3-5 hours. We developed and applied a desirability of outcome ranking (DOOR) analysis to investigate if an antimicrobial stewardship program (ASP) strategy centered on T2Candida diagnosis is associated with improved outcomes compared to an ASP strategy that relies on conventional blood culture diagnosis in critically ill patients with candidemia. This is a retrospective, observational cohort of patients with candidemia identified ≤72 h of intensive care unit admission at two medical centers in Detroit, MI (one T2Candida site and one blood culture site) from 2016 to 2023. Management strategies for candidemia were compared using an original DOOR analysis with inverse probability of treatment weighting (IPTW) to account for confounding. Two hundred patients were included, 100 from each site. Baseline illness severity, race, and Candida species varied between groups; however, source control procedures, echocardiogram, and ophthalmologic exam occurred at similar frequencies. T2Candida/ASP was associated with faster median (interquartile range [IQR]) detection of candidemia (7.0 [5.0-10.75] h vs 45.5 h [34.25-68.75], P < 0.001) and timelier median (IQR) initiation of directed antifungal therapy (6.0 [0-11.0] h vs 49.0 [34.0-77.0] h, P < 0.001). T2Candida/ASP patients had a 58.0% probability of achieving an overall better outcome compared to those managed with blood culture/ASP (95% confidence interval: 50.4-65.2%) in IPTW-adjusted DOOR analysis. An ASP strategy incorporating T2Candida was associated with an overall better patient outcome compared to patients managed via conventional blood culture diagnosis.IMPORTANCECandida species are a significant cause of bloodstream infections in critically ill patients. Conventional diagnostic methods, such as blood cultures, have poor sensitivity and delayed results. The T2Candida Panel is a diagnostic tool that rapidly detects Candida directly from the blood in 3-5 h, enabling faster initiation of antifungal therapy. Antimicrobial stewardship programs (ASPs) optimize the management of bloodstream infections and may benefit from incorporating T2Candida to improve patient outcomes. This study examined whether an ASP intervention based on T2Candida diagnosis, compared to one relying on traditional blood culture methods, could improve outcomes in candidemia using a desirability of outcome ranking (DOOR) analysis. The DOOR method provides a comprehensive evaluation by integrating multiple outcomes into a single end point, which is ideal given the complexity of patients with candidemia. The T2Candida/ASP intervention resulted in an overall better patient outcome, considering infectious complications, treatment failure, and all-cause mortality.
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Affiliation(s)
- Kaylee E. Caniff
- Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, Michigan, USA
| | - Mohammed Al Musawa
- Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, Michigan, USA
| | - Chloe Judd
- Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, Michigan, USA
| | - Macy Shupp
- Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, Michigan, USA
| | - Michael P. Veve
- Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, Michigan, USA
- Henry Ford Health System, Detroit, Michigan, USA
| | | | | | - Marco R. Scipione
- Department of Pharmacy Services, Detroit Receiving Hospital, Detroit Medical Center, Detroit, Michigan, USA
| | - Thomas J. Walsh
- Center for Innovative Therapeutics and Diagnostics, Richmond, Virginia, USA
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael J. Rybak
- Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, Michigan, USA
- Wayne State University School of Medicine, Detroit, Michigan, USA
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Procacci C, Marras L, Maurmo L, Vivanet G, Scalone L, Bertolino G. Antifungal Stewardship in Invasive Fungal Infections, a Systematic Review. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2025; 1476:49-68. [PMID: 38337088 DOI: 10.1007/5584_2024_798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Invasive fungal infections (IFI) are a group of life-threatening diseases associated with significant morbidity, mortality and high healthcare costs. Some modern management programs known as AFS (antifungal stewardship programs) have now been developed. The purpose of this systematic review is to evaluate the different declinations of antifungal stewardship programs (AFPs). METHODS Articles were systematically reviewed using the PRISMA checklist 2020. EMBASE and MEDLINE/PubMED were searched using the term "antifungal stewardship" (2012-2022 data) on 2 January 2023. Eligible studies were those that described an AFS and included an intervention, performance evaluation and outcome measures. RESULTS A total of 22/796 studies were included. Approximately two-thirds (16) were published between 2018 and 2022. 16 (72.7%) stated a minimal complete AFS team. 12 (54.5%) adopted a non-compulsory AFS approach, 6(27.3%) had an Educational AFS and 4(18.2%) a compulsory AFS. Cost analyses of 12 studies showed a decrease for 7 (31.8%) compared to an increase for 5 (22.7%). In terms of outcomes, 18 studies showed a lower (10;45.5%) or the same (8;36.4%) pre-post intervention mortality rate. CONCLUSION AFS programs seem to be related to lower costs and better outcomes and should thus be implemented in tandem with antimicrobial stewardship programs.
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Affiliation(s)
- Cataldo Procacci
- Pharmaceutical Department, ASL BAT, Barletta - Adria - Trani, Italy
| | | | - Leonarda Maurmo
- School of Specialization in Hospital Pharmacy, University of Bari "Aldo Moro", Bari, Italy
| | - Grazia Vivanet
- Unity of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Giacomo Bertolino
- Pharmaceutical Department, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
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Klingspor HT, Hällgren A. Factors influencing outcomes in candidemia: A retrospective study of patients in a Swedish county. Mycoses 2024; 67:e13758. [PMID: 38932675 DOI: 10.1111/myc.13758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 06/13/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Candidemia is a diverse condition and associated with a broad spectrum of clinical presentation. As mortality is high, timely diagnosis of candidemia and start of correct therapeutic treatment are essential. OBJECTIVES To investigate characteristics and factors influencing outcomes for patients with candidemia in a Swedish setting. METHOD All positive blood cultures for any Candida species in Östergötland County from 2012 to 2016 were screened. Medical records of patients fulfilling all inclusion criteria and no exclusion criteria were retrospectively reviewed to obtain data on risk factors, diagnostic and therapeutic procedures and at what wards candidemia was diagnosed. Univariate logistic regression and multivariable regression analysis were used to obtain odds ratio to determine risk factors for 30-day all-cause mortality associated with candidemia. A p-value <.05 was considered statistically significant. RESULTS Of all analysed risk factors, increasing age, renal failure with haemodialysis, immunosuppressant treatment, and severity of the infection (i.e. if septic shock was present) were significantly associated with 30-day mortality in univariate analysis (p < .05). Removal of a central venous catheter or an infectious diseases consultant was associated with a significantly lower odds ratio for death at 30 days (p < .05). With multivariable analysis, age, time to start of treatment and infectious disease consultant remained significant (p < .05). CONCLUSION In conclusion, this study provides an update of the epidemiology and outcomes of candidemia in a Swedish setting, highlighting that patients with candidemia are present at various departments and indicates the importance of an infectious disease consultant when candidemia is present.
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Affiliation(s)
- Hanna Thorold Klingspor
- Department of Infectious Diseases in Östergötland and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Anita Hällgren
- Department of Infectious Diseases in Östergötland and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Speight CC, Williamson JE, Ebied AM, Medaris LA, McCurdy L, Hammer KL. Impact of Infectious Diseases Consultation in Patients With Candidemia at a Multisite Health Care System With Established Antimicrobial Stewardship and Telemedicine Services. Open Forum Infect Dis 2023; 10:ofad388. [PMID: 37555131 PMCID: PMC10405132 DOI: 10.1093/ofid/ofad388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/18/2023] [Indexed: 08/10/2023] Open
Abstract
Background Infectious diseases consultation improves outcomes in patients with candidemia, although some facilities lack access to consultation. This multisite health care system study compared in-hospital mortality in patients with candidemia across 3 groups-those who received on-site consultation, telemedicine consultation, or no consultation. All patients were reviewed by an antimicrobial stewardship pharmacist. Methods A retrospective observational cohort study was performed of adult hospitalized patients with candidemia from January 2018 to October 2021. The primary outcome was in-hospital mortality. Secondary outcomes included receipt and duration of antifungals, removal of central venous lines if present, ophthalmologic examination, echocardiography, and determination of infection source. Results A total of 265 patients were evaluated: 187 in the on-site consultation group, 49 in the telemedicine consultation group, and 29 in the nonconsultation group. Although in-hospital mortality did not differ significantly between the on-site and nonconsultation groups, it was significantly lower in the telemedicine group when compared with the nonconsultation group (10.2% vs 34.5%, P = .009). Patients who received on-site or telemedicine consultation had significantly more antifungal therapy initiated, appropriate therapy duration, central lines removed, and echocardiography performed, as well as fewer unknown candidemia sources, vs those in the nonconsultation group. Conclusions This is the first study of a multisite health care system providing telemedicine services to evaluate the impact of infectious diseases consultation on candidemia mortality. These findings suggest that when on-site consultation is unavailable, infectious diseases telemedicine consultation and antimicrobial stewardship can improve outcomes and should be considered for all patients with candidemia at resource-limited sites.
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Affiliation(s)
- Carly C Speight
- Department of Pharmacy, Atrium Health Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Julie E Williamson
- Antimicrobial Support Network, Atrium Health Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Alex M Ebied
- Department of Medical Affairs, Celltrion USA, Jersey City, New Jersey, USA
| | - Leigh Ann Medaris
- Division of Infectious Diseases, Department of Medicine, Atrium Health Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Lewis McCurdy
- Division of Infectious Diseases, Department of Medicine, Atrium Health Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Katie L Hammer
- Antimicrobial Support Network, Atrium Health Carolinas Medical Center, Charlotte, North Carolina, USA
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