More than a quarter of adult patients with chronic liver disease admitted to the intensive care unit (ICU) for treatment of candidemia developed septic shock, according to results of a retrospective observational study published in Infectious Diseases.

Investigators analyzed data on adult patients with candidemia who were admitted to the ICU of a tertiary care medical center between 2009 and 2018. Patients who had received treatment with an antifungal agent for 3 days or more were included, and demographic and clinical factors were compared between those who did and did not develop septic shock during their ICU stay.

The investigators also developed a predictive model of 30-day mortality using a receiver operating characteristic (ROC) curve based on mortality risk factor scores for each patient. The ideal threshold score identified from the ROC curve was 7, and investigators divided patients into 3 groups according to mortality risk factor scores: group A (<7 points), group B (7-13 points), and group C (≥14 points).


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Of the 126 patients with candidemia included in the final analysis, 32 (25.4%) developed septic shock and 94 (74.6%) did not develop septic shock. The median patient age was 70 (interquartile range, 61-77) years, and 59.5% were men. The most common Candidia species isolated from patients with candidemia was C. albicans (46.0%).

The investigators found an independent association between patients with chronic liver disease and an increased risk for septic shock (odds ratio [OR], 3.372; 95% CI, 1.057-10.057; P =.040). Urinary tract-related candidemia was less common in patients with vs without septic shock (0% vs 13.8%; P =.038). There were no significant differences noted between the groups in regard to age, sex, Charlson comorbidity index scores, comorbidities, clinical conditions, fluconazole-resistant Candida species, abdominal source of candidemia infection, central venous catheter management, or length of ICU stay.

Although no significant differences in effectiveness or duration of antifungal treatment were noted between the groups, patients treated with fluconazole were more likely to develop septic shock (P =.035) and those without septic shock were more likely to have been treated with echinocandins (P =.024). In addition, the rates of clinical and mycological response were significantly decreased in patients with septic shock (P <.001 and P =.022, respectively), and 30-day mortality rates were significantly increased compared with those without septic shock (59.4% vs 27.7%; P =.001).

Among patients with candidemia included in the analysis, 45 (35.7%) died and 81 survived at 30 days, with no difference observed in the type of antifungal agent used. The factors found to be associated with a significantly increased mortality risk were malignancy, hemodialysis, mycological failure, and septic shock; chronic liver disease had a borderline significant association with an increased mortality risk (OR, 3.605; 95% CI, 0.913-14.227; P =.067). Patients who died were significantly more likely to have septic shock secondary to candidemia and mycological failure (P =.001 and P <.001, respectively).

The predictive model for 30-day mortality showed significantly different mortality rates among the 3 groups (P <.001): 10.7% (group A), 65.6% (group B), and 84.2% (group C).

The study was limited by its single-center setting, relatively small sample size, and unintentional selection bias due to its retrospective design.

“Our prediction model of 30-day mortality would be useful in assessing the probability of 30-day mortality among patients [with candidemia treated] in the ICU,” the investigators concluded.

Reference

Suh JW, Kim MJ, Kim JH. Risk factors of septic shock development and thirty-day mortality with a predictive model in adult candidemia patients in intensive care units. Infect Dis (Lond). Published online July 30, 2021. doi:10.1080/23744235.2021.1959052