Clinical outcome of critically ill cirrhotic patients with invasive candidiasis

ARTICLE REVIEW

Cirrhosis-associated immune dysfunction strongly increases the risk of severe infections occurrence in such patients’ category, including invasive candidiasis. However few data are available from the literature on this topic. The author of this retrospective, multicentre, international study investigated the risk factors and the outcome of a large cohort of cirrhotic patients with candidemia and intra-abdominal candidiasis (IAC).

Over a two-year period, a total of 241 cirrhotic patients (26% with a MELD score >): 169 were affected by candidemia and 72 by IAC. The latter mainly consisted in peritonitis (63.9%), while biliary tract infections, pancreatitis and others were less common. The large majority of infections were acquired in hospital (86.3%) and ICU (50.2%), with a septic shock rate of 34.9%. Candida albicans was the most common species (54.4%), followed by C. glabrata (14.5%) and C. parapsilosis (14.1%). However, 20 patients had mixed Candida spp. infection and 50.6% had a concomitant bacterial infection. More than 8% of the patients received an adequate initial antifungal treatment, mostly with echinocandins: significant levels of azole resistance (15.8% to fluconazole, 7.9% to voriconazole) emerged in susceptibility tests. However, only 60% of such cases received an appropriate antifungal treatment within 24 hours based on suspicion of invasive candidiasis  and collection of microbiological samples. Furthermore, adequate source control was performed in about half of patients, again mostly within 24 hours after culture positivity.

A global mortality rate of 35.3 % was observed: 40.2% in patients with candidaemia and 23.6% in those with IAC. Multivariable logistic regression analysis confirmed that candidaemia (OR 2.2, 95% CI 1.2-4.5) and septic shock (OR 3.2, 95% CI 1.7-6) were independent predictors of 30 day mortality. Conversely, adequate antifungal treatment (OR 0.4, 95% CI 0.3-0.9) was associated with survival.

Conclusions

• Despite the intrinsic limitations of a retrospective, multicentre, observational investigation on a heterogeneous population, this study clearly shows that invasive candidiasis is associated with high mortality, also in the specific population of cirrhotic patients.
• This study also underlines the importance of prompt adequate antifungal treatment to reduce the detrimental clinical impact of such infections.
• Further investigations into risk factors for Candida infections related to the severity of cirrhosis, as well as study into epidemiological shifts and resistance patterns in the Candida species, are necessitated.

Article review prepared and submitted by Temistocle Taccheri (EJRC), Simone Carelli (EJRC), and Gennaro De Pascale (NEXT Communication Committee).

Reference

Bassetti M. et al. Clinical characteristics and predictors of mortality in cirrhotic patients with candidemia and intra-abdominal candidiasis: a multicenter study. Intensive Care Medicine, Original; April 2017, Volume 43, Issue 4, pp 509–518; First Online: 07 March 2017. DOI: 10.1007/s00134-017-4717-0