247. Evaluation of the T2Candida Panel as an Antifungal Stewardship Tool in Transplant and Non-Transplant Patients at a Tertiary Care Center

Background

Invasive candidiasis (IC) has a mortality of >30% and likelihood of death increases 50% each day antifungal therapy (AF) is delayed. In patients with suspected IC early empiric AF improves outcomes but has the potential for overuse. Blood cultures (BC) detect ~50% of candidemia with a turn-around-time (TAT) of 2–5 days. T2Candida Panel (T2) an FDA-approved molecular diagnostic test, detects 5 Candida species directly in blood with specificity 99.4%, sensitivity 91.1%, and TAT of 3–5 hours. Our institutional guidelines permit the use of empiric AF in patients with suspected IC (Figure 1). We evaluated the utility of T2 as an AF stewardship tool to support these guidelines.

Methods

We reviewed patients that had T2 done January 2016 to May 2016 at Henry Ford Hospital, a 900-acute care bed teaching hospital in Detroit, MI. Patients with negative T2 [T2(−)] and negative concurrent BC [BC (−)] were evaluated. The primary endpoint was discontinuation (d/c) of AF after a T2 (−) result. Secondary endpoints were candidemia after d/c of AF and all-cause 30-day mortality. Comparative analyses were performed of transplant (txp) vs. non-transplant (non-txp) patients. Univariate analysis was done to determine the association of risk factors and outcomes. Multivariate regression using forward selection was used to model mortality risk. Time to d/c of AF were modeled using Kaplan–Meier estimators.

Results

500 consecutive patients with T2 (−) and BC (−) results were identified. Patients on AF for prophylaxis or treatment of fungal infection were excluded. 472 patients (93 txp patients) were included in the analyses. Characteristics of the txp and non-txp patients are in Table 1. Median TAT in hours (hr) of T2 was 6 (±2) vs. 123 (±25) for final BC (−) result. 264/472 (56%) patients were initiated on empiric AF. In patients with T2 (−) result, AF were d/c within 7 days in 97%; time to d/c of AF was 72 hr in 50% txp patients and 48 hr in 50% of non-txp patients respectively (Figure 2). No episodes of candidemia were diagnosed after d/c of AF. All-cause mortality was lower in txp patients (14%) vs. non-txp patients (34%) (P = 0.0002). Likelihood of mortality did not increase after d/c of AF (OR1.3, 95% CI 0.913–2.064).

Conclusion

T2 promotes d/c of empiric AF in txp and non-txp patients with suspected IC without a negative impact on clinical outcomes.

Disclosures

All authors: No reported disclosures.

Cutaneous cryptococcosis in solid organ transplant recipients

Clinical manifestations, treatment, and outcomes of cutaneous cryptococcosis in solid organ transplant (SOT) recipients are not fully defined. In a prospective cohort comprising 146 SOT recipients with cryptococcosis, we describe the presentation, antifungal therapy, and outcome of cutaneous cryptococcal disease. Cutaneous cryptococcosis was documented in 26/146 (17.8%) of the patients and manifested as nodular/mass (34.8%), maculopapule (30.4%), ulcer/pustule/abscess (30.4%), and cellulitis (30.4%) with 65.2% of the skin lesions occurred in the lower extremities. Localized disease developed in 30.8% (8/26), and disseminated disease in 69.2% (18/26) with involvement of the central nervous system (88.9%, 16/18), lung (33.3%, 6/18), or fungemia (55.6%, 10/18). Fluconazole (37.5%) was employed most often for localized and lipid formulations of amphotericin B (61.1%) for disseminated disease. Overall mortality at 90 days was 15.4% (4/26) with 16.7% in disseminated and 12.5% in localized disease (P = 0.78). SOT recipients who died were more likely to have renal failure (75.0% vs. 13.6%, P = 0.028), longer time to onset of disease after transplantation (87.5 vs. 22.6 months, P = 0.023), and abnormal mental status (75% vs. 13.6%, P = 0.028) than those who survived. Cutaneous cryptococcosis represents disseminated disease in most SOT recipients and preferentially involves the extremities. Outcomes with appropriate management were comparable between SOT recipients with localized and disseminated cryptococcosis.

Combination of Voriconazole and Caspofungin as Primary Therapy for Invasive Aspergillosis in Solid Organ Transplant Recipients: A Prospective, Multicenter, Observational Study

BACKGROUND

: The efficacy of the combination of voriconazole and caspofungin when used as primary therapy for invasive aspergillosis in organ transplant recipients has not been defined.

METHODS

: Transplant recipients who received voriconazole and caspofungin (n=40) as primary therapy for invasive aspergillosis (proven or probable) in a prospective multicenter study between 2003 and 2005 were compared to a control group comprising a cohort of consecutive transplant recipients between 1999 and 2002 who had received a lipid formulation of AmB as primary therapy (n=47). In vitro antifungal testing of Aspergillus isolates to combination therapy was correlated with clinical outcome.

RESULTS

: Survival at 90 days was 67.5% (27/40) in the cases, and 51% (24/47) in the control group (HR 0.58, 95% CI, 0.30-1.14, P=0.117). However, in transplant recipients with renal failure (adjusted HR 0.32, 95% CI: 0.12-0.85, P=0.022), and in those with A. fumigatus infection (adjusted HR 0.37, 95% CI: 0.16-0.84, P=0.019), combination therapy was independently associated with an improved 90-day survival in multivariate analysis. No correlation was found between in vitro antifungal interactions of the Aspergillus isolates to the combination of voriconazole and caspofungin and clinical outcome.

CONCLUSIONS

: Combination of voriconazole and caspofungin might be considered preferable therapy for subsets of organ transplant recipients with invasive aspergillosis, such as those with renal failure or A. fumigatus infection.

Late-onset invasive aspergillosis in organ transplant recipients in the current era

We assessed predictive factors and characteristics of patients with late-onset invasive aspergillosis in the current era of novel immunosuppressive agents. Forty transplant recipients with invasive aspergillosis were included in this prospective, observational study initiated in 2003 at our institutions. In 50% (20/40) of these patients, the infections were late-occurring. Receipt of sirolimus in conjunction with tacrolimus for refractory rejection or cardiac allograft vasculopathy (P=0.047) was significantly associated with late-onset infection. The use of depleting or non-depleting T or B-cell antibodies, either as induction or as antirejection therapy did not correlate with time to onset of invasive aspergillosis. Mortality at 90 days was 20% (4/20) for the patients with early-onset infection and 45% (9/20) for those with late-onset infection (P=0.17). Thus, nearly one-half of the Aspergillus infections in transplant recipients in the current era are late-occurring. These data have implications relevant for prophylactic strategies and guiding clinical management of transplant recipients presenting with pulmonary infiltrates.

Antifungal Management Practices and Evolution of Infection in Organ Transplant Recipients with Cryptococcus Neoformans Infection

BACKGROUND

Therapeutic practices for Cryptococcus neoformans infection in transplant recipients vary, particularly with regards to antifungal agent employed, and duration of therapy. The risk of relapse and time to recurrence is not known. We assessed antifungal treatment practices for cryptococcosis in a cohort of prospectively followed organ transplant recipients.

METHODS

The patients comprised 83 transplant recipients with cryptococcosis followed for a median of 2.1 and up to 5.2 years.

RESULTS

Patients with central nervous system infection (69% vs. 16%, P = 0.00001), disseminated infection (82.7% vs. 20%, P = 0.00001), and fungemia (29% vs. 8%, P = 0.046) were more likely to receive regimens containing amphotericin B than fluconazole as primary therapy. The use of fluconazole, on the other hand, was more likely for infection limited to the lungs (64% vs. 14%, P = 0.00002). Survival at 6 months tended to be lower in patients whose CSF cultures at 2 weeks were positive compared to those whose CSF cultures were negative (50% vs. 91%, P = 0.06). Maintenance therapy was employed in 68% (54/79) of the patients who survived >3 weeks. The median duration of maintenance therapy was 183 days; 55% received maintenance for > or = 6 months and 25% for >1 year. Relapse was documented in 1.3% (1/79) of the patients.

CONCLUSIONS

A majority of the organ transplant recipients with cryptococcosis receive maintenance antifungal therapy for 6 months with low risk of relapse. These data can assist in trials to assess the optimal therapeutic approach and duration of therapy for cryptococcosis in transplant recipients.