Comparative effectiveness of echinocandins versus fluconazole therapy for the treatment of adult candidaemia due to Candida parapsilosis : a retrospective observational cohort study of the Mycoses Study Group (MSG-12): Table 1.

Abstract

Objectives: A polymorphism in the gene encoding b-1,3-glucan synthase, the target of the echinocandin class of antifungals, results in increased in vitro MICs of the echinocandins. This has resulted in controversy surrounding use of the echinocandins for treatment of Candida parapsilosis candidaemia. We aimed to compare 30 day mortality in adults with C. parapsilosis candidaemia treated with echinocandins versus fluconazole.Methods: This is a retrospective observational cohort study. We used the Premier Perspective Database to identify adult patients with C. parapsilosis candidaemia treated with only fluconazole or only an echinocandin as definitive therapy. The primary outcome was 30 day mortality. Propensity scores were derived to estimate the probability the patient would have received either an echinocandin or fluconazole. Inverse probability of treatment weighting (IPTW) was used in a weighted logistic regression to calculate odds of 30 day mortality.Results: There were 307 unique patients with C. parapsilosis candidaemia. One hundred and twenty-six (41%) received fluconazole and 181 (59%) received an echinocandin. Age, gender, race, year of admission, need for ICU resources in the week prior to candidaemia onset, and receipt of vasopressors on the day of candidaemia onset were included in the propensity score model used to calculate inverse probability of treatment weights. Weighted logistic regression demonstrated no difference in 30 day mortality between patients receiving an echinocandin as compared with fluconazole (OR 0.82, 95% CI 0.33 -2.07).Conclusions: Our result supports the 2016 IDSA invasive candidiasis guidelines, which no longer clearly favour treatment with fluconazole over an echinocandin for C. parapsilosis candidaemia.

An Azole-Resistant Candida parapsilosis Outbreak: Clonal Persistence in the Intensive Care Unit of a Brazilian Teaching Hospital

“…Echinocandins have been recommended as first-line treatment for candidemia by the main clinical guidelines (Cornely et al, 2012; Pappas et al, 2016), including fungemia by C. parapsilosis . Indeed, similar 30-days mortality rates have been observed between echinocandin- and fluconazole-treated patients with fungemia by this species (Fernández-Ruiz et al, 2014; Chiotos et al, 2016). On the other hand, C. parapsilosis isolates demonstrate innately high MICs for echinocandins (Garcia-Effron et al, 2008), which led to EUCAST to classify isolates with MICs below 2 mg/L as intermediate, instead of susceptible as recommended by the CLSI (Meletiadis et al, 2016).…”

Fungicidal versus fungistatic therapy of invasive Candida infection in non-neutropenic adults: a meta-analysis

“…It is also supported by recent retrospective analyses (Chiotos et al 2016). However, the superior therapeutic success rate (despite the absence of an ultimate survival benefit) with amphotericin B in randomised trials is a novel observation (Figure 1).…”

The Quiet and Underappreciated Rise of Drug-Resistant Invasive Fungal Pathogens

“…A naturally occurring polymorphism in HS1 of FKS1 (P660A) in C . parapsilosis results in elevated echinocandin MIC values in this species [ 189 ], yet an effect on the drug–target interaction seems weak and the infected candidemia patients treated with echinocandins show a favorable clinical outcome compared to those treated with FLZ [ 190 , 191 ]. Interestingly, despite the identification of clinical echinocandin-resistant C .…”