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Utilización de Intervenciones de Cuidados Intensivos en Pacientes Críticamente Enfermos con Candidemia versus
Mary North Jones1,2, Masayuki Nigo1,3,4, Stefano Casarin5,6,7
1Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, TX.
Insights
Los pacientes críticamente enfermos que requieren recursos de la unidad de cuidados intensivos (UCI) tienen un mayor riesgo de candidemia, un tipo de infección del torrente sanguíneo. La terapia antifúngica empírica puede ser beneficiosa para estos pacientes de UCI de alto riesgo.
Área de la Ciencia:
- Enfermedades Infecciosas
- Medicina de Cuidados Críticos
Sus antecedentes:
- Las especies de Candida son una causa común de infecciones del torrente sanguíneo (ITS) en las unidades de cuidados intensivos (UCI).
- Las guías actuales carecen de recomendaciones sólidas para iniciar la terapia antifúngica empírica en pacientes de UCI con ITS sospechada.
Objetivo del estudio:
- Comparar las características de los pacientes con candidemia de inicio en UCI versus bacteriemia.
- Identificar los factores de riesgo de mortalidad en estos pacientes.
- Determinar si la candidemia es un factor de riesgo independiente de muerte en pacientes de UCI.
Principales métodos:
- Estudio de cohorte retrospectivo de pacientes de UCI con ITS de un sistema hospitalario en Houston, Texas (2016-2023).
- Validación utilizando la cohorte disponible públicamente Medical Information Mart for Intensive Care (MIMIC)-IV.
- Análisis de regresión multivariante para evaluar la candidemia como factor de riesgo independiente de mortalidad, ajustando por intervenciones de UCI y parámetros basales.
Principales resultados:
- De 1509 pacientes en la cohorte principal, el 19,2% tuvo candidemia y el 80,8% tuvo bacteriemia.
- Los pacientes con candidemia mostraron una mayor utilización de ventilación mecánica invasiva, vasopresores y terapia de reemplazo renal continua.
- Si bien la candidemia no se asoció de forma independiente con la mortalidad en la cohorte principal, sí lo hizo en la cohorte MIMIC-IV.
Conclusiones:
- Los pacientes con alta utilización de recursos de UCI enfrentan un mayor riesgo de candidemia.
- Se sugiere la consideración de la terapia antifúngica empírica para pacientes de UCI que requieren atención de altos recursos al iniciar antibióticos empíricos.
Objectives:
Candida species are one of the most common causes of ICU-onset bloodstream infection (BSI). Yet, there is no robust guidance on when to initiate empiric antifungals for ICU patients suspected of BSI. We compared patients with ICU-onset candidemia vs. ICU-onset bacteremia to determine which patients may benefit from empiric antifungals.
Design:
We compared characteristics between patients with bacteremia vs. candidemia at time of culture. We determined risk factors for death and constructed a multivariable regression to determine if candidemia is an independent risk factor for death.
Setting/Patients:
We included ICU patients from a hospital system in Houston, Texas (n = 8 hospitals) with a BSI from 2016 to 2023 and validated our findings using ICU patients with a BSI in the publicly available Medical Information Mart for Intensive Care (MIMIC)-IV cohort.
Interventions:
None.
Measurements And Main Results:
Of 1509 total patients in our primary cohort, 290 (19.2%) had candidemia and 1219 (80.8%) had bacteremia. Patients with candidemia were more likely to be on invasive mechanical ventilation (72.8% vs. 52.8%; p < 0.001), vasopressors (39.3% vs. 24.0%; p < 0.001), and continuous renal replacement therapy (15.2% vs. 9.4%; p = 0.006) at the time of culture. They contracted infection later in ICU stay than bacteremia patients (7.2 vs. 5.0 d; p < 0.001) and were more likely to die within 30 days of culture (unadjusted odds ratio [OR], 1.62; 95% CI, 1.25-2.09). After adjusting for ICU interventions (invasive mechanical ventilation, vasopressors, and continuous renal replacement therapy) and baseline parameters, candidemia was not independently associated with mortality compared with bacteremia in our primary cohort (OR, 1.21; 95% CI, 0.92-1.60) but was in the MIMIC-IV cohort (OR, 1.48; 95% CI, 1.003-2.17).
Conclusions:
Patients with significant ICU resource utilization are at increased risk for candidemia. Our data suggest that when initiating empiric antibiotics in patients requiring high-resource ICU care, empiric antifungal therapy should be considered.
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