Kevin W. Garey

Time to Initiation of Fluconazole Therapy Impacts Mortality in Patients with Candidemia: A Multi-Institutional Study

BACKGROUND Inadequate antimicrobial treatment is an independent determinant of hospital mortality, and fungal bloodstream infections are among the types of infection with the highest rates of inappropriate initial treatment. Because of significant potential for reducing high mortality rates, we sought to assess the impact of delayed treatment across multiple study sites. The goals our analyses were to establish the frequency and duration of delayed antifungal treatment and to evaluate the relationship between treatment delay and mortality. METHODS We conducted a retrospective cohort study of patients with candidemia from 4 medical centers who were prescribed fluconazole. Time to initiation of fluconazole therapy was calculated by subtracting the date on which fluconazole therapy was initiated from the culture date of the first blood sample positive for yeast. RESULTS A total of 230 patients (51% male; mean age +/- standard deviation, 56 +/- 17 years) were identified; 192 of these had not been given prior treatment with fluconazole. Patients most commonly had nonsurgical hospital admission (162 patients [70%]) with a central line catheter (193 [84%]), diabetes (68 [30%]), or cancer (54 [24%]). Candida species causing infection included Candida albicans (129 patients [56%]), Candida glabrata (38 [16%]), Candida parapsilosis (25 [11%]), or Candida tropicalis (15 [7%]). The number of days to the initiation of antifungal treatment was 0 (92 patients [40%]), 1 (38 [17%]), 2 (33 [14%]) or > or = 3 (29 [12%]). Mortality rates were lowest for patients who began therapy on day 0 (14 patients [15%]) followed by patients who began on day 1 (9 [24%]), day 2 (12 [37%]), or day > or = 3 (12 [41%]) (P = .0009 for trend). Multivariate logistic regression was used to calculate independent predictors of mortality, which include increased time until fluconazole initiation (odds ratio, 1.42; P < .05) and Acute Physiology and Chronic Health Evaluation II score (1-point increments; odds ratio, 1.13; P < .05). CONCLUSION A delay in the initiation of fluconazole therapy in hospitalized patients with candidemia significantly impacted mortality. New methods to avoid delays in appropriate antifungal therapy, such as rapid diagnostic tests or identification of unique risk factors, are needed.

Economic healthcare costs of Clostridium difficile infection: a systematic review.

Clostridium difficile infection (CDI) is the leading cause of infectious diarrhoea in hospitalised patients. CDI increases patient healthcare costs due to extended hospitalisation, re-hospitalisation, laboratory tests and medications. However, the economic costs of CDI on healthcare systems remain uncertain. The purpose of this study was to perform a systematic review to summarise available studies aimed at defining the economic healthcare costs of CDI. We conducted a literature search for peer-reviewed studies that investigated costs associated with CDI (1980 to present). Thirteen studies met inclusion and exclusion criteria. CDI costs in 2008 US dollars were calculated using the consumer price index. The total and incremental costs for primary and recurrent CDI were estimated. Of the 13, 10 were from the USA and one each from Canada, UK, and Ireland. In US-based studies incremental cost estimates ranged from

T2 magnetic resonance assay for the rapid diagnosis of candidemia in whole blood: A clinical trial

2,871 to

Association of Fluconazole Area under the Concentration-Time Curve/MIC and Dose/MIC Ratios with Mortality in Nonneutropenic Patients with Candidemia

4,846 per case for primary CDI and from

Prevalence, Resistance Mechanisms, and Susceptibility of Multidrug-Resistant Bloodstream Isolates of Pseudomonas aeruginosa

13,655 to

Outcomes of Bacteremia due to Pseudomonas aeruginosa with Reduced Susceptibility to Piperacillin-Tazobactam: Implications on the Appropriateness of the Resistance Breakpoint

18,067 per case for recurrent CDI. US-based studies in special populations (subjects with irritable bowel disease, surgical inpatients, and patients treated in the intensive care unit) showed an incremental cost range from

A randomized, double-blind, placebo-controlled pilot study to assess the ability of rifaximin to prevent recurrent diarrhoea in patients with Clostridium difficile infection

6,242 to

Rifaximin in treatment of recurrent Clostridium difficile-associated diarrhea: an uncontrolled pilot study.

90,664. Non-US-based studies showed an estimated incremental cost of

Case-control study of the relationship between MRSA bacteremia with a vancomycin MIC of 2 μg/mL and risk factors, costs, and outcomes in inpatients undergoing hemodialysis

5,243 to

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)

8,570 per case for primary CDI and