Background Ocular candidiasis is a known complication of candidemia. Given the poor ocular penetration of echinocandins, there is some concern that the increasing use of echinocandins may portend an increased incidence of ophthalmic complications. We examined the changing trends in antifungal prescribing patterns and the incidence of ophthalmic complications following candidemia. Methods Patients with blood cultures positive for Candida species between January, 2014 and June, 2020 who underwent screening fundoscopic examination by an ophthalmologist were analysed. Chi squared analysis was used to compare antifungal prescriptions and ocular exam findings before and after 2016. Trend analysis was also performed to assess temporal changes in prescribing practices and eye exam findings. Results There were 226 candidemia cases during the study period of which 129 (57.1%) underwent screening eye exams. From 2014-2015, 24/37 (64.5%) patients received eye-penetrating antifungals compared to 36/92 (39.1%) from 2016-2020 (p=0.008). Overall 30/129 (23.3%) patients had abnormal eye exams with the prevalence of abnormal findings being 7/37 (18.9%) before 2016 compared to 23/92 (25%, p= 0.46) thereafter. A trend analysis revealed an increase in abnormal eye findings over the study period (p=0.008). Of the 30 patients who had abnormal eye exams, nine (30%) had a change in systemic antifungal therapy from echinocandins to eye-penetrating antifungals. Echinocandin use was associated with abnormal eye findings Conclusion Prescription of eye-penetrating antifungals for candidemia has trended down since 2016. This was associated with a concomitant increase in abnormal findings on screening fundoscopy. Abnormal eye exams were not uncommon throughout our study period
Background The incidence of Candida bloodstream infections has risen over the last several decades. Complications of candidemia include endogenous fungal endophthalmitis which can result in devastating outcomes including vision loss. In 2015, the IDSA guidelines were updated to recommend echinocandins as initial therapy for candidemia. Given the poor ocular penetration of echinocandins there has been some concern this change may portend an increased incidence of ocular complications in candidemic patients. We sought to examine whether patients who received empiric echinocandin therapy developed higher rates of ophthalmic complications of candidemia. Methods We identified patients in our healthcare system who had blood cultures positive for Candida species and a completed ophthalmology consult between January 1, 2014 and April 30, 2019. Chi-squared analysis was used to compare antifungal prescribing patterns before and after release of the updated IDSA guidelines. We assessed whether the switch to empiric echinocandin therapy as directed by the guidelines was associated with higher rates of abnormal eye exams. Results 47 patients treated before the guideline change were compared to 57 patients treated after the guideline change. There was no significant difference in age, gender, or comorbid diabetes and hypertension between the groups. Before the guideline change, 24/47 (51%) of patients received eye-penetrating antifungals. This decreased to 21/57 after the updated guideline (37%, p=0.21). The percentage of patients with positive eye exams was nearly equal before and after the updated guidelines, 10/47 (21%) before vs 13/57 (22%) after (p=1). After the guideline change, 7/21 (33%) of the patients treated with penetrating antifungals had positive eye exams vs 6/36 (16%) who received echinocandins (p=0.19). Conclusion Echinocandins are known to have poor ocular penetration yet our data demonstrate no change in the incidence of ophthalmic complications of candidemia after the 2016 guideline endorsed echinocandins as empiric therapy. The prevalence of positive eye exams throughout our study period was 22%, suggesting ongoing utility for these exams. Ongoing investigation is necessary to confirm and further study these findings. Disclosures All Authors: No reported disclosures
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