988. Is There Value of Infectious Diseases Consultation in Candidemia? A Single Center Retrospective Review From 2016-2019

Background Candidemia is the second most common cause of healthcare-associated bloodstream infections in the US with mortality of approximately 25%. Studies demonstrate lower candidemia mortality with infectious diseases consultation (IDC). We evaluated effects of IDC on mortality and guideline-adherence at our institution to determine if mandatory IDC was warranted. Methods We retrospectively reviewed adults hospitalized with candidemia (≥ 1 blood culture positive for Candida) between 1/1/2016-12/31/2019. Exclusion criteria included age < 19 years, polymicrobial blood culture, or death or hospice within 48 hours. Primary outcome was all-cause 30-day mortality. Secondary outcomes included guideline-adherence and treatment choice. Guideline-adherence was assessed with a modified EQUAL Candida score (Table 1). Descriptive statistics were performed. Table 1. Original vs Modified EQUAL Candida Score Abbreviations. CVC: central venous catheter, BCx: blood culture Results Of 187 patients reviewed, 92 episodes of candidemia with 94 species of Candida were included. Patient characteristics are shown in Table 2. Central venous catheters (CVCs) were present in 66 (71.7%) patients and were the most common infection source (N=38 [41.3%]) followed by intra-abdominal (N=23 [25%]). The most isolated species were Candida glabrata (40/94 [42.6%]) and C. albicans/dublienensis (35/94 [37.2%]). 30-day mortality was 21.7%. IDC was performed in 84 (91.3%) cases. Outcomes are in Table 3. Mortality was not different between IDC vs no IDC (18 [21.4%] vs 2 [25%]); other comparisons were numerically different but not significant: repeat blood culture (98.8% vs 87.5%), echocardiography (70.2% vs 50%), CVC removal (91.7% vs 83.3%), and initial treatment echinocandin (67.9% vs 50%). All patients received antifungal therapy. IDC resulted in more ophthalmology consultations (77.4% vs 12.5%, p< 0.01). Mean modified EQUAL Candida score was higher with IDC (17.4 vs 13.9, p< 0.01). Table 2. Patient Characteristics Abbreviations. TPN: total parenteral nutrition, ICU: intensive care unit, AIDS: acquired immunodeficiency syndrome Table 3. Outcomes Abbreviations. NS: non-significant, CVC: central venous catheter Conclusion IDC was common in candidemic patients and not associated with significant differences in outcomes. Current antimicrobial stewardship and consultation practices at our center do not warrant mandated IDC for candidemia. Disclosures Trevor C. Van Schooneveld, MD, FACP, BioFire (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Insmed (Individual(s) Involved: Self): Scientific Research Study Investigator; Merck (Individual(s) Involved: Self): Scientific Research Study Investigator; Rebiotix (Individual(s) Involved: Self): Scientific Research Study Investigator

Epidemiological Trends of Candidemia and the Impact of Adherence to the Candidemia Guideline: Six-Year Single-Center Experience

This study aimed to investigate the epidemiology of candidemia and evaluate the impact of adherence to the candidemia guideline defined by the European Confederation of Medical Mycology Quality of Clinical Candidemia Management (EQUAL) Candida score. Adult candidemia patients ≥ 19 years diagnosed at a tertiary care hospital in the Republic of Korea from 2013 to 2018 were enrolled (period 1 2013–2015, period 2 2016–2018). There was a total of 223 patients. The annual incidence of candidemia increased from 0.43 to 1.33 cases per 1000 admissions between 2013 and 2018, p < 0.001. A significant increase of fluconazole-resistant C. parapsilosis candidemia was noted in period 2 (35.3%) when compared to period 1 (0.0%), p = 0.020. The 30-day mortality rate was not different between period 1 and 2 (43.5% vs. 48.1%, p = 0.527). Multivariate analysis revealed that a Charlson comorbidity index score ≥ 4, neutropenia, duration of hospital stay ≥ 21 days before candidemia diagnosis, septic shock, mycological failure, and EQUAL Candida score < 15 were significantly associated with 30-day mortality. An increase in the incidence of candidemia and fluconazole resistance in the non-albicans Candida species over time was observed. Disease severity, comorbidities, and lower adherence to the candidemia guideline were associated with mortality.

Predicting Candida Infection in Pediatric Intensive Care Unit using Candida Score in a Low-Resource Setting

Candida infection was previously thought to be rare in intensive care. With the increased use of broad-spectrum antibiotics, the incidence of candida infection increased significantly. Case-control study was done in patients ≤18 years of age treated for 3 days or more in Pediatric Intensive Care Unit (PICU) Dr. Sardjito General Hospital, Yogyakarta from January 2014 to December 2016. Overall, 43 children were included in this study as a case group with positive candida culture and 43 children as a control group with no candida culture. Cut off point of candida score is ≥3 from our subjects. The area under curve (AUC) value for cut off ≥3 was moderate (0,72). Candida score ≥3 has an odd ratio (OR) 6.8 (95% CI 2.4-18.6) with P < .05. All of confounding factors in candida infection have no association with P > .05. Candida score can be used as predictor of candida infection in PICU.

Development and validation of a candidemia risk prediction (CanDETEC) model among patients with malignancy (Preprint)

BACKGROUND Appropriate empirical treatment for candidemia is associated with reduced mortality. However, timely diagnosis of candidemia for septic patients remains poor. OBJECTIVE This study aimed to use machine learning algorithms to develop and validate a candidemia prediction model for cancer patients. METHODS This single-center retrospective study used the cancer registry of a tertiary academic hospital. Adult patients with diagnosed malignancies from January 2010 to December 2018 were included. Our study outcome was the prediction of candidemia events. A stratified under-sampling method was used to extract control groups for algorithm learning. Multiple models were developed through a combination of four variable groups and five algorithms (auto-machine learning, deep neural network, gradient boosting, and logistic regression and random forest). The model with the highest area under the receiver operating characteristics (AUROC) was selected as the Candida species detection (CanDETEC) model and compared with the performance indexes of the candida score. RESULTS Among the 273,380 blood culture from 186,404 registered cancer patients, 501 candidemia events and 2000 controls were identified. The AUROC of the developed models varied from 0.771 to 0.889. The random forest model was selected CanDETEC model (AUROC = 0.889, 95% confidence interval: 0.888-0.889). It showed better performance than the candida score (AUROC = 0.677). CONCLUSIONS The CanDETEC model could predict candidemia in cancer patients with high discriminative power. This algorithm could be used for the timely diagnosis and appropriate empirical treatment of candidemia.

The Utilization Pattern of Caspofungin in an Educational Hospital

Background: Caspofungin is prescribed for the systemic treatment of fungal infections and its correct prescription pattern is an issue of importance. Hence in this study Caspofungin utilization and the frequency rate of medication errors were investigated at a training hospital in a developing country. Methods: This cross-sectional study enrolled 43 consecutive patients receiving Caspofungin in Firoozgar Hospital, Tehran, Iran from March to September 2017. Results: The prescription frequency was higher in Intensive Care Unit by a rate of 58.1%. Infectious disease specialists were responsible for Caspofungin prescription only in 11 cases (25.5%). The cause of Caspofungin prescription was unknown in 18.6% of cases; but empiric treatment for febrile neutropenia and ICU patients with Candida Score > 2.5 were the most known causes. The drug administration in 11 cases (25.6%) occurred in less than one hour. The indication of treatment was incorrect in 12 out of 43 cases (28%). On the first day of the treatment a dose of both 70 mg and 50 mg was prescribed, which was higher than the appropriate dose and also it was lower than the optimal dose in five cases (83.7%). The mean treatment duration was 10.88 ± 5.35 days ranging from 2 to 24 days. The duration of treatment was correct in 20 cases (46.5%) and incorrect for 23 patients (53.5%). Conclusion: In comparison with the Sanford and IDSA Guidelines there are multiple discordances in our setting, such as inappropriate duration, continuation, and indications. Hence these should be announced to the physicians for taking further caution in the aforementioned cases, and it is advisable to consult with infectious diseases specialists for the administration of anti-fungal drugs. J Pharm Care 2019; 7(3): 57-61.

Antifungals patterns in critical patients with candidiasis in the intensive care units at Sanglah General Hospital 2019

Introduction: The prompt initiation of appropriate antifungal therapy is essential in controlling invasive candidiasis and improving the prognosis in critical patients undergoing treatment in the Intensive Care Unit. Candida Score can assess patients at risk of candidiasis and is expected to assist clinicians in starting antifungal therapy in patients suspected Candidiasis. The purpose of this study was to determine the pattern of antifungal administration in critically ill patients with candidiasis in the Intensive Care Unit at Sanglah General Hospital. Patients and Methods: The design of this study is a cross-sectional descriptive study involving critically ill patients who were under treatment in Intensive Care Unit of Sanglah General Hospital from Januari to June 2019. The patients included in this study were patients who were ≥ 18 years old and under treatment in ICU for at least 7 days. Results: There are 64 patients undergoing treatment in the Intensive Care Unit. From 64 patients, 6 pasien had CS = 0, 29 patients had CS = 1, 13 patients had CS = 2, 11 patients had CS = 3, 5 patients had CS = 4, and no patients had CS = 5. Eleven patients received empirical antifungal therapy. All empirical antifungal therapies use the Triazole group. Conclusion: In this study was found that 11 of 16 patients with a CS value of ≥ 2.5 were given empirical antifungal therapy, while 48 patients with a CS value of <2.5 were not given empirical antifungal therapy. Keywords: Invasive Candidiasis, Candida Score, Empirical Antifungal Therapy.

Evaluation of the updated “Candida score” with sepsis 3.0 criteria in critically ill patients

BackgroundThe Candida score proposed in 2009 was calculated on the definition of “severe sepsis”, which was removed in the Sepsis 3.0 definition. This study investigated the clinical relevance of Candida score with the updated sepsis 3.0 definition (CS-3.0) instead of severe sepsis (CS-2009) in the new admitted critically ill patients.MethodWe performed a retrospective analysis on a single‑center public database. All patients with ICU stay≥72 hours were included in this study. The Candida score was calculated based on the data collected on ICU admission. The incidence of invasive candidiasis was determined and its relationship with the CS-2009 and CS-3.0 was studied.ResultsA total of 17,666 patients were identified after screening 58,976 hospital admissions, and 436 cases (2.5%) were diagnosed with invasive candidiasis. In the infection group, the number of patients who met the Sepsis 3.0 criteria was greater than the number of patients with severe sepsis (81.2% vs. 78.4%, p<0.005). The area under curve of the CS-2009 was 0.789 (95% CI 0.765-0.813) and the CS-3.0 was 0.804 (95% CI 0.782-0.827). ConclusionOur study confirmed the clinical relevance and comparative superiority of the updated Candida score model, using the Sepsis 3.0 definition, compared with the classic sepsis/severe sepsis model, in assessment of critically ill patients. Considering the clinical importance of organ dysfunction in ICI, the sepsis 3.0 should be used as the basis for prediction of invasive candidiasis.