• Anne-Lise Bienvenu, Pierre Pradat, Claude Guerin, Frederic Aubrun, Jean-Luc Fellahi, Arnaud Friggeri, Céline Guichon, Romain Hernu, Jean Menotti, Céline Monard, Sylvie Paulus, Thomas Rimmele, Vincent Piriou, Christian Chidiac, Laurent Argaud, and Gilles Leboucher.
• Service Pharmacie, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France; Service d'Hématologie, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France; ICBMS CNRS 5246, Campus Lyon-Tech La Doua, Université de Lyon, Lyon, France. Electronic address: anne-lise.bienvenu@chu-lyon.fr.
• Int. J. Infect. Dis. 2020 Apr 1; 93: 15-21.

BackgroundCandidemia is a major cause of mortality in the intensive care unit (ICU). According to the Infectious Diseases Society of America (IDSA), an echinocandin is recommended as initial therapy and fluconazole as an alternative. In a context of echinocandin resistance development, the question arising is whether azoles are a suitable alternative to echinocandins for the treatment of candidemia in critically ill patients.MethodsA 3-year (2015-2017) retrospective multicentric cohort study was conducted. Adult patients with a diagnosis of candidemia during the ICU stay and treated with echinocandins or azoles were included. Demographic, clinical data, mycological data, and antifungal treatments were collected. Kaplan-Meier survival analysis, univariate analysis, and a multivariate logistic regression analysis using a propensity score with the inverse probability of treatment weighting method were performed.FindingsSeventy-nine patients (n = 79) were analyzed. Treatment success, as well as survival on day 90 (Kaplan-Meier survival analysis, log rank test, p = 0.542), were comparable between patients who received echinocandins (caspofungin (n = 47)) or azoles (fluconazole (n = 29) or voriconazole (n = 3)). A multivariable analysis demonstrated that higher SOFA score on the day of candidemia diagnosis and absence of adequate Candida source control were independently associated with a greater risk of 90-day mortality, whereas azoles treatment was not associated with an excess 90-day mortality.InterpretationThis study confirms that the use of azoles recommended for candidemia, mostly fluconazole, as a first-line therapy is a reasonable alternative to caspofungin for ICU patients in our institution. This needs to be included in local guidelines through antifungal stewardship programs.Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.

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