Early de-escalation of antifungal treatment to fluconazole within 5 days of initial empirical treatment appears safe in clinically stable adults with candidemia due to fluconazole-susceptible strains, according to research results published in Open Forum infectious Diseases.

A team of investigators conducted a retrospective, multicenter, post-hoc study including patients from 3 prospective candidemia cohorts to determine whether early de-escalation to fluconazole was safe in patients who had reached hemodynamic stability following echinocandin empirical treatment for fluconazole-susceptible candidemia.

Of the 1023 documented episodes of candidemia, 235 met eligibility criteria; 54 episodes occurred in the early de-escalation cohort and 181 episodes occurred in the cohort that did not undergo early de-escalation. Among patients in the early de-escalation group, the median time to de-escalation was 3.5 days.


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Early de-escalation occurred less frequently among patients who developed candidemia in the intensive care unit (P =.043) but more frequently among patients who had catheter-related candidemia (P =.006). Candidemia of an unknown source (P =.003) or infections caused by Nakaesomyces glabrata were also linked to less likelihood of early de-escalation (P =.016).

The 30-day mortality rate was 11.1% in the early de-escalation group and 29.8% in the group that did not experience early de-escalation (P =.006). The overall 30-day mortality was 25.5%. The effect of exact days until de-escalation on mortality was not significant in the early de-escalation group (P =.665).

Independent predictors of mortality included chronic obstructive pulmonary disease, Pitt score greater than 2, an unknown source of candidemia, and candidemia due to Candida albicans. Prior surgery was found to be protective.

Despite propensity score adjustments, lack of confounding factors cannot be assumed. The investigators also noted that, “these results are only acceptable in a selected group of patients” and that “these results should be confirmed in a randomized clinical trial.”

Disclosure: Some study author(s) declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

Reference

Moreno-García E, Puerta-Alcalde P, Gariup G, et al; for the Project from GEMICOMED (SEIMC). Early stepdown from echinocandin to fluconazole treatment in candidemia. A post-hoc analysis of three cohort studies. Open Forum Infect Dis. Published online May 16, 2021. doi:10.1093/ofid/ofab250