Echinocandins Compared to Fluconazole for Candidemia of a Urinary Tract Source: A Propensity Score Analysis

• Published in: Clinical infectious diseases 2017-05, Vol.64 (10), p.1374-1379
• Main Authors: Cuervo, Guillermo, Garcia-Vidal, Carolina, Puig-Asensio, Mireia, Vena, Antonio, Meije, Yolanda, Fernández-Ruiz, Mario, González-Barberá, Eva, Blanco-Vidal, Maria José, Manzur, Adriana, Cardozo, Celia, Gudiol, Carlota, Montejo, José Miguel, Pemán, Javier, Ayats, Josefina, Aguado, Jose María, Muñoz, Patricia, Marco, Francesc, Almirante, Benito, Carratalà, Jordi
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Antifungal agents; Antifungal Agents - administration & dosage; Antifungal Agents - therapeutic use; ARTICLES AND COMMENTARIES; Candida albicans - drug effects; Candida albicans - isolation & purification; Candida glabrata - drug effects; Candida glabrata - isolation & purification; Candidemia; Candidemia - drug therapy; Candidemia - microbiology; Candidemia - mortality; Candiduria; Cohort Studies; Comorbidity; Confidence intervals; Echinocandins; Echinocandins - administration & dosage; Echinocandins - therapeutic use; Epidemiology; Failure analysis; Female; Fluconazole; Fluconazole - administration & dosage; Fluconazole - therapeutic use; Fungal infections; Humans; Kidneys; Male; Microbial Sensitivity Tests; Middle Aged; Multivariate Analysis; Patients; Prescription drugs; Propensity Score; Regression analysis; Renal failure; Renal Insufficiency - microbiology; Surgery; Therapy; Treatment Outcome; Urinary tract; Urinary Tract Infections - drug therapy; Urinary Tract Infections - microbiology
• ISSN: 1058-4838; 1537-6591
• DOI: 10.1093/cid/cix033

Background. Whether echinocandins could be used to treat candidemia of a urinary tract source (CUTS) is unknown. We aimed to provide current epidemiological information of CUTS and to compare echinocandin to fluconazole treatment on CUTS outcomes. Methods. A multicenter study of adult patients with candidemia was conducted in 9 hospitals. CUTS was defined as a candidemia with concomitant candiduria by the same organism associated with significant urological comorbidity. The primary outcome assessed was clinical failure (defined by 7-day mortality or persistent candidemia) in patients treated with either an echinocandin or fluconazole. A propensity score was calculated and then entered into a regression model. Results. Of 2176 episodes of candidemia, 128 were CUTS (5.88%). Most CUTS cases were caused by Candida albicans (52.7%), followed by Candida glabrata (25.6%) and Candida tropicalis (16.3%). Clinical failure occurred in 7 patients (20%) treated with an echinocandin and in 15 (17.1%) treated with fluconazole (P = .730). Acute renal failure (adjusted odds ratio [AOR], 3.01; 95% confidence interval [CI], 1.01–8.91; P = .047) was the only independent factor associated with clinical failure, whereas early urinary tract drainage procedures (surgical, percutaneous, or endoscopic) were identified as protective (AOR, 0.08; 95% CI, .02–.31; P < .001). Neither univariate nor multivariate analysis showed that echinocandin therapy altered the risk of clinical failure. Conclusions. Initial echinocandin therapy was not associated with clinical failure in patients with CUTS. Notably, acute renal failure predicted worse outcomes and performing an early urologic procedure was a protective measure.