title: Systemic antifungal therapy for proven or suspected invasive candidiasis: the AmarCAND 2 study.
abstract: BACKGROUND
  In the context of recent guidelines on invasive candidiasis (IC), how French intensive care units (ICUs) are managing IC?
  
  
  METHODS
  This is a prospective observational multicenter cohort study. During 1 year (2012-2013), 87 French ICUs enrolled consecutive patients with suspected or proven IC (SIC or PIC) and receiving systemic antifungal therapy (SAT). Data were collected up to 28 days after inclusion.
  
  
  RESULTS
  We studied 835 patients, 291 with PIC and 544 with SIC. At SAT initiation, patients with SIC were significantly more severe (SAPS II 50.1 ± 18.7 vs. 46.2 ± 18.0). Severe sepsis or septic shock prompted to initiate empiric SAT in 70 % of SIC. Within 4 days in median, the initial SAT was modified in 49 % of patients with PIC vs. 33 % patients with SIC. Modifications were most often motivated by mycological results, and de-escalation was the most frequent change. Regarding compliance to IC management guidelines, echinocandin was used for 182 (62.5 %) patients with PIC, and 287 (52.7 %) of those with SIC; central venous catheter was removed in 87 (54.3 %) of patients with candidaemia, and 43 of the remaining patients received echinocandin; and de-escalation was undertaken after 5 days of SAT in 142 patients, after 10 days in 13 patients. As 20.6 % of SIC were secondarily documented, 403/835 (48 %) patients had finally a proven IC. Candida albicans was the main pathogen (65.3 %), then Candida glabrata (15.9 %). The 28-day mortality rates were 40.0 % in candidaemia, 25.4 % in cIAI, and 26.7 % in deep-seated candidiasis. In the overall population of patients with proven IC, four independent prognostic factors were identified: immunosuppression (Odds Ratio (OR) = 1.977: 1.03-3.794 95 % confidence interval (CI), p = 0.04), age (OR = 1.035; 1.017-1.053 95 % CI; p < 0.001), SAPS >46 on ICU admission (OR = 2.894; 1.81-4.626 95 % CI; p < 0.001), and surgery just before or during ICU stay (OR = 0.473; 0.29-0.77 95 % CI; p < 0.001).
  
  
  CONCLUSIONS
  When SAT is initiated in French ICUs, the IC is ultimately proven for 48 % of patients. Empiric SAT is initiated in severely ill ICU patients. The initial SAT is often adapted, with de-escalation to fluconazole when possible. Mortality rate remains high.
authors.affiliation: Medical ICU, Chatilliez Hospital, Tourcoing, France. oleroy@ch-tourcoing.fr.
authors.forename: Olivier
authors.initials: O
authors.lastname: Leroy
authors.affiliation: U823, Grenoble 1 University, La Tronche, France.
authors.forename: Sébastien
authors.initials: S
authors.lastname: Bailly
authors.affiliation: Mycology, Rennes University Hospital, Rennes, France.
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Gangneux
authors.affiliation: Medical ICU, Cochin University Hospital, Paris, France.
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Mira
authors.affiliation: Bio Statistics Unit, Lille University Hospital, Lille, France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Devos
authors.affiliation: Surgical ICU, Amiens University Hospital, Amiens, France.
authors.forename: Hervé
authors.initials: H
authors.lastname: Dupont
authors.affiliation: Anesthesiology and Critical Care Medicine, Bichat-Claude Bernard University Hospital, Paris, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Montravers
authors.affiliation: Medical-surgical ICU, Montpellier University Hospital, Montpellier, France.
authors.forename: Pierre-François
authors.initials: PF
authors.lastname: Perrigault
authors.affiliation: Perioperative Medicine Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France.
authors.forename: Jean-Michel
authors.initials: JM
authors.lastname: Constantin
authors.affiliation: Unité de Pharmaco-épidémiologie et Maladies Infectieuses, Institut Pasteur, Paris, France.
authors.forename: Didier
authors.initials: D
authors.lastname: Guillemot
authors.affiliation: Medical ICU, Saint-Louis University Hospital, Paris, France.
authors.forename: Elie
authors.initials: E
authors.lastname: Azoulay
authors.affiliation: Necker Pasteur Center for Infectious Diseases, Necker Enfants-Malades Hospital, Paris, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Lortholary
authors.affiliation: Medical Affairs, MSD France, Courbevoie, France.
authors.forename: Caroline
authors.initials: C
authors.lastname: Bensoussan
authors.affiliation: Medical ICU, Bichat-Claude Bernard University Hospital, Paris, France.
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Timsit
keywords: Candida; Candidaemia; Candidiasis; Cohort study; Critically ill; Intensive care