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Intensive Care Antifungal Stewardship Programme Based on T2Candida PCR and Candida Mannan Antigen: A Prospective
Jannik Helweg-Larsen1, Morten Steensen2, Finn Møller Pedersen3
1Department of Infectious Diseases, Rigshospitalet, 2100 Copenhagen, Denmark.
Abstract:
Non-culture-based biomarkers may improve diagnosis and antifungal treatment (AFT) of invasive candidiasis (IC). We evaluated an antifungal stewardship programme (AFSP) in a prospective intensive care unit (ICU) study, which included T2Candida and Candida mannan antigen (MAg) screening of patients with sepsis and a high risk of IC. Patients with non-neutropenic sepsis and a high risk of IC from two large tertiary ICUs were prospectively included, during a one-year period. IC was classified as proven, likely, possible or unlikely. The AFSP, diagnostic values of T2Candida and MAg, and the consumption of antifungals were evaluated. An amount of 219 patients with 504 T2Candida/MAg samples were included. IC was classified as proven in 29 (13.2%), likely in 7 (3.2%) and possible in 10 (5.5%) patients. Sensitivity/specificity/PPV/NPV values, comparing proven/likely versus unlikely IC, were 47%/100%/94%/90% for BC alone, 50%/97%/75%/90% for T2Candida alone, and 39%/96%/67%/88% for MAg alone. For the combination of T2Candida/MAg taken ≤3 days after AFT initiation, sensitivity/specificity/PPV/NPV was 70%/90%/63%/93%. T2Candida/MAg contributed to early (<3 days) AFT initiation in 13%, early AFT discontinuation in 25% and abstaining from AFT in 24% of patients. No reduction in overall use of AFT during the study period compared with the previous year was observed. An AFSP based on T2Candida and MAg screening contributed to a reduction of unnecessary treatment, but not overall AFT use. The diagnostic performance of T2Candida was lower than previously reported, but increased if T2Candida was combined with MAg.
Insights
Non-culture-based biomarkers like T2Candida and mannan antigen improve diagnosis and antifungal treatment for invasive candidiasis. Combining these tests reduced unnecessary antifungal use in sepsis patients, though overall consumption remained unchanged.
Area of Science:
- Infectious Diseases
- Clinical Microbiology
- Critical Care Medicine
Background:
- Invasive candidiasis (IC) diagnosis and antifungal treatment (AFT) can be improved by non-culture-based biomarkers.
- Antifungal stewardship programs (AFSP) aim to optimize antifungal use, especially in high-risk patients.
- T2Candida and Candida mannan antigen (MAg) are emerging biomarkers for IC detection.
Purpose of the Study:
- To evaluate an antifungal stewardship program (AFSP) incorporating T2Candida and MAg screening in intensive care unit (ICU) patients.
- To assess the diagnostic performance of T2Candida and MAg, individually and in combination, for invasive candidiasis.
- To determine the impact of this AFSP on antifungal consumption and treatment decisions.
Main Methods:
- Prospective study in two tertiary ICUs over one year, including 219 non-neutropenic sepsis patients at high risk for IC.
- Collected 504 T2Candida and MAg samples for parallel testing.
- Evaluated AFSP impact on AFT initiation, discontinuation, and antifungal consumption, comparing biomarker performance against proven/likely IC.
Main Results:
- Invasive candidiasis was proven in 13.2% of patients. T2Candida/MAg combination showed improved sensitivity (70%) and specificity (90%) when tested within 3 days of AFT initiation.
- The combined biomarkers contributed to early AFT initiation (13%), early discontinuation (25%), and avoiding AFT (24%).
- While unnecessary treatment was reduced, overall antifungal use did not decrease compared to the previous year. T2Candida performance was lower than reported but improved with MAg.
Conclusions:
- An AFSP utilizing T2Candida and MAg screening can reduce unnecessary antifungal exposure in high-risk ICU patients.
- Combining T2Candida and MAg enhances diagnostic performance for invasive candidiasis.
- Further optimization is needed to impact overall antifungal consumption despite improved stewardship.
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