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Overtreatment of Asymptomatic Candiduria among Hospitalized Patients: a Multi-institutional Study
David M Jacobs1, Thomas J Dilworth2, Nicholas D Beyda3
1University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA dmjacobs@buffalo.edu.
Abstract:
Candiduria is common in hospitalized patients, and asymptomatic candiduria contributes to antifungal overuse. The guidelines for management of asymptomatic candiduria do not recommend antifungal use, but rather the elimination of predisposing factors. It is unknown whether these recommendations are being followed. The primary objective of this study was to characterize candiduria management among hospitalized patients. This was a retrospective cohort study of a random sample of 305 hospitalized patients with candiduria at four U.S. medical centers from January 2010 to December 2013. Patients were classified as asymptomatic or symptomatic based on established criteria, and data were collected by chart review. Infectious Diseases Society of America (IDSA) treatment guideline adherence and its association with clinical outcomes, including candiduria recurrence (short- and long-term) and 30-day readmission, were assessed. Eighty percent of patients were classified as having asymptomatic candiduria. Overall, 143 (47%) patients were not managed according to recommended guidelines, including 105/243 (43%) in the asymptomatic candiduria group and 38/62 (61%) in the symptomatic group (P = 0.01). Discordance among asymptomatic patients was driven by overtreatment with an antifungal (98/105 [93%]). Thirty-three percent of patients with asymptomatic candiduria not managed according to the guidelines were treated for over 7 days, and 5% received over 14 days of therapy. Fluconazole was the most commonly used empirical antifungal among asymptomatic candiduria patients (96%), followed by micafungin (4%). Asymptomatic candiduria patients not managed according to the guidelines had a trend toward higher 30-day readmission (35% versus 26%, P = 0.27). Inappropriate management of candiduria among hospitalized patients was high, leading to overtreatment with antifungal therapy.
Insights
Hospitalized patients often receive unnecessary antifungal treatment for asymptomatic candiduria, contradicting guidelines. This overtreatment, particularly with fluconazole, contributes to overuse and potential adverse outcomes.
Area of Science:
- Infectious Diseases
- Clinical Pharmacy
- Hospital Epidemiology
Background:
- Candiduria is prevalent in hospitalized patients, frequently leading to inappropriate antifungal use, especially in asymptomatic cases.
- Current Infectious Diseases Society of America (IDSA) guidelines advocate for managing asymptomatic candiduria by addressing predisposing factors, not antifungal treatment.
- Adherence to these guidelines for candiduria management in hospitals remains largely uncharacterized.
Purpose of the Study:
- To evaluate the adherence to IDSA guidelines for candiduria management in hospitalized patients.
- To assess the association between guideline adherence and clinical outcomes, including recurrence and readmission.
- To identify patterns of antifungal use in both symptomatic and asymptomatic candiduria cases.
Main Methods:
- A retrospective cohort study analyzed data from 305 hospitalized patients with candiduria across four U.S. medical centers (2010-2013).
- Patients were categorized as asymptomatic or symptomatic based on established criteria.
- Chart reviews were conducted to collect data on management practices, guideline adherence, and clinical outcomes like recurrence and 30-day readmission.
Main Results:
- Eighty percent of patients presented with asymptomatic candiduria.
- Nearly half of all patients (47%) received management inconsistent with IDSA guidelines.
- Overtreatment with antifungals was common in asymptomatic candiduria (43% of cases), with 93% of these receiving inappropriate antifungal therapy, often for extended durations (over 7 days for 33%). Fluconazole was the predominant agent used.
Conclusions:
- Inappropriate management of candiduria, characterized by overtreatment of asymptomatic cases, is alarmingly high in hospitalized patients.
- This widespread deviation from established guidelines contributes significantly to unnecessary antifungal exposure.
- Further interventions are needed to promote guideline adherence and curb antifungal overuse in candiduria management.
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