title: Empirical and targeted therapy of candidemia with fluconazole versus echinocandins: a propensity score-derived analysis of a population-based, multicentre prospective cohort.
abstract: We compared the clinical efficacy of fluconazole and echinocandins in the treatment of candidemia in real practice. The CANDIPOP study is a prospective, population-based cohort study on candidemia carried out between May 2010 and April 2011 in 29 Spanish hospitals. Using strict inclusion criteria, we separately compared the impact of empirical and targeted therapy with fluconazole or echinocandins on 30-day mortality. Cox regression, including a propensity score (PS) for receiving echinocandins, stratified analysis on the PS quartiles and PS-based matched analyses, were performed. The empirical and targeted therapy cohorts comprised 316 and 421 cases, respectively; 30-day mortality was 18.7% with fluconazole and 33.9% with echinocandins (p 0.02) in the empirical therapy group and 19.8% with fluconazole and 27.7% with echinocandins (p 0.06) in the targeted therapy group. Multivariate Cox regression analysis including PS showed that empirical therapy with fluconazole was associated with better prognosis (adjusted hazard ratio 0.38; 95% confidence interval 0.17-0.81; p 0.01); no differences were found within each PS quartile or in cases matched according to PS. Targeted therapy with fluconazole did not show a significant association with mortality in the Cox regression analysis (adjusted hazard ratio 0.77; 95% confidence interval 0.41-1.46; p 0.63), in the PS quartiles or in PS-matched cases. The results were similar among patients with severe sepsis and septic shock. Empirical or targeted treatment with fluconazole was not associated with increased 30-day mortality compared to echinocandins among adults with candidemia.
authors.affiliation: Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío - IBiS, Sevilla, Spain.
authors.forename: L E
authors.initials: LE
authors.lastname: López-Cortés
authors.affiliation: Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: B
authors.initials: B
authors.lastname: Almirante
authors.affiliation: Department of Micology, Spanish National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Cuenca-Estrella
authors.affiliation: Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Garnacho-Montero
authors.affiliation: Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
authors.forename: B
authors.initials: B
authors.lastname: Padilla
authors.affiliation: Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Puig-Asensio
authors.affiliation: Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: I
authors.initials: I
authors.lastname: Ruiz-Camps
authors.affiliation: Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío - IBiS, Sevilla, Spain; Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain. Electronic address: jesusrb@us.es.
authors.forename: J
authors.initials: J
authors.lastname: Rodríguez-Baño
mesh_terms: D000368:Aged; D000935:Antifungal Agents / Q000494:pharmacology / Q000627:therapeutic use*; D058387:Candidemia / Q000188:drug therapy* / Q000453:epidemiology / Q000382:microbiology* / Q000401:mortality; D015897:Comorbidity; D054714:Echinocandins / Q000494:pharmacology / Q000627:therapeutic use*; D005260:Female; D015725:Fluconazole / Q000494:pharmacology / Q000627:therapeutic use*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009026:Mortality; D011159:Population Surveillance; D057216:Propensity Score; D016016:Proportional Hazards Models; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents; D054714:Echinocandins; D015725:Fluconazole
keywords: Bloodstream infection; Candidemia; Echinocandins; Empirical therapy; Targeted therapy