The objectives of this study were to contrast risk factors, microbiology, and outcomes in patients with
invasive candidiasis treated in an intensive care unit (ICU) with those in patients with
invasive candidiasis treated outside an ICU and to describe therapeutic results with
caspofungin in ICU patients.
MATERIALS AND METHODS: We retrospectively identified patients with documented
invasive candidiasis who received their first dose of the study
drug in the ICU as part of a double-blind randomized trial. Participants were not stratified at entry by their ICU status. Patients received
caspofungin (50 mg/d after a 70-mg loading dose) or conventional
amphotericin B (0.6-1.0 mg/kg per day) for 10 to 14 days. A favorable response required resolution of signs and symptoms as well as eradication of Candida pathogens.
RESULTS: Of the 224 patients, 97 (43%) received their first dose of the study
drug in the ICU. Most patients had well-recognized risk factors for
invasive candidiasis, including broad-spectrum
antibiotics,
central venous catheters, and hyperalimentation. Recent surgery was more common whereas
malignancy,
neutropenia, and immunosuppression were less common among ICU patients than among non-ICU patients.
Candidemia was demonstrated in 81% of ICU patients and in 84% of non-ICU patients. Favorable response rates in the ICU patients vs the non-ICU patients were 68% (95% confidence interval [CI] = 53%, 82%) vs 77% (95% CI = 67%, 87%) for
caspofungin and 56% (95% CI = 43%, 69%) vs 67% (95% CI = 55%, 79%) for
amphotericin B. After accounting for differences in APACHE (Acute Physiology and Chronic Health Evaluation) II score,
neutropenia status, and geographic region, we found that patients initiating the study
therapy in an ICU were still more likely to die than patients initiating study
therapy outside an ICU. For ICU patients, all-cause mortality rates were 45% (95% CI = 30%, 60%) for
caspofungin recipients and 40% (95% CI = 28%, 53%) for
amphotericin B recipients, whereas
candidiasis-attributable mortality rates were 5% (95% CI = 0%, 12%) for
caspofungin recipients and 11% (95% CI = 3%, 19%) for
amphotericin B recipients. Overall,
drug-related adverse events were reported less often among the ICU patients than among the non-ICU patients.
CONCLUSIONS: