Early Removal of Central Venous Catheter in Patients with Candidemia Does Not Improve Outcome: Analysis of 842 Patients from 2 Randomized Clinical Trials

• Published in: Clinical infectious diseases 2010-08, Vol.51 (3), p.295-303
• Main Authors: Nucci, Marcio, Anaissie, Elias, Betts, Robert F., Dupont, Bertrand F., Wu, Chunzhang, Buell, Donald N., Kovanda, Laura, Lortholary, Olivier
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Antifungal Agents - therapeutic use; Antifungals; ARTICLES AND COMMENTARIES; Biological and medical sciences; Blood; Blood - microbiology; Candidemia; Candidiasis - drug therapy; Candidiasis - therapy; Catheter-Related Infections - drug therapy; Catheter-Related Infections - therapy; Catheters; Central venous catheterization; Clinical trials; Double-Blind Method; Female; Fungemia - drug therapy; Fungemia - therapy; Health outcomes; Human mycoses; Humans; Infections; Infectious diseases; Male; Medical diagnosis; Medical sciences; Medical treatment; Middle Aged; Multivariate analysis; Mycology; Mycoses; Mycotic sepsis; Neutropenia; Prospective Studies; Recommendations; Survival Analysis; Time Factors; Treatment Outcome
• ISSN: 1058-4838; 1537-6591
• DOI: 10.1086/653935

Background. Patients with candidemia frequently have a central venous catheter (CVC) in place, and its early removal is considered the standard of care. Methods. We performed a subgroup analysis of 2 phase III, multicenter, double-blind, randomized, controlled trials of candidemia to examine the effects of early CVC removal (within 24 or 48 h after treatment initiation) on the outcomes of 842 patients with candidemia. Inclusion criteria were candidemia, age >16 years, CVC at diagnosis, and receipt of ≥1 dose of the study drug. Six outcomes were evaluated: treatment success, rates of persistent and recurrent candidemia, time to mycological eradication, and survival at 28 and 42 days. Univariate and multivariate analyses were performed, controlling for potential confounders. Results. In univariate analysis, early CVC removal did not improve time to mycological eradication or rates of persistent or recurrent candidemia but was associated with better treatment success and survival. These benefits were lost in multivariate analysis, which failed to show any beneficial effect of early CVC removal on all 6 outcomes and identified Acute Physiology and Chronic Health Evaluation II score, older age, and persistent neutropenia as the most significant variables. Our findings were consistent across all outcomes and time points (removal within 24 or 48 h and survival at 28 and 42 days). The median time to eradication of candidemia was similar between the 2 study groups. Conclusions. In this cohort of 842 adults with candidemia followed up prospectively, early CVC removal was not associated with any clinical benefit. These findings suggest an evidence-based re-evaluation of current treatment recommendations.