Effect of infectious disease consultation on mortality and treatment of patients with candida bloodstream infections: a retrospective, cohort study.

BACKGROUND: Candida bloodstream infection is associated with high mortality. Infectious disease consultation improves outcomes in several infections, including Staphylococcus aureus and cryptococcosis, as well as multidrug-resistant organisms. We aimed to examine the association between infectious disease consultation and differences in management with mortality in candida bloodstream infections.
METHODS: In this retrospective, single-centre cohort study, we reviewed the medical charts of all patients admitted to Barnes-Jewish Hospital (St Louis, MO, USA), a tertiary referral centre, aged 18 years or older with candida bloodstream infection from 2002 to 2015. We collected data for demographics, comorbidities, predisposing factors, all-cause mortality, antifungal use, central-line removal, and ophthalmological and echocardiographic evaluation to assess 90-day all-cause mortality between individuals with and without an infectious disease consultation. For the survival analysis we used Cox proportional hazards model with inverse weighting by propensity score to assess the effects of infectious disease consultation on mortality and differences in management.
FINDINGS: Between Jan 1, 2002, and Dec 31, 2015, of 1794 patients assessed for eligibility, we analysed 1691 patients with candida bloodstream infection; 776 (45·9%) who had an infectious disease consultation and 915 (54·1%) who did not have an infectious disease consultation. All 1691 patients were included in the analysis. None were missing data. Most underlying comorbidities were evenly distributed between groups. 90-day mortality was lower in the infectious disease consultation group than in patients who did not receive an infectious disease consultation (29% [222/776] vs 51% [468/915]; p<0·0001). In the model with inverse weighting by the propensity score, infectious disease consultation was associated with a hazard ratio of 0·81 (95% CI 0·73-0·91; p<0·0001) for mortality. In the consultation group, median duration of antifungal therapy was longer (18 [IQR 14-35] vs 14 [6-20] days; p<0·0001) and central-line removal (587 [76%] of 776 vs 538 [59%] of 915; p<0·0001), echocardiography use (442 [57%] of 776 vs 305 [33%] of 915; p<0·0001), and ophthalmological examination (412 [53%] of 776 vs 160 [17%] of 915; p<0·0001) were more frequently done. Fewer patients in the infectious disease consultation group were not treated (13 [2%] of 776 vs 128 [14%] of 915; p<0·0001).
INTERPRETATION: Patients with candida bloodstream infection receiving an infectious disease consultation have lower mortality. This finding might be attributable to these individuals receiving a higher number of non-pharmacological, evidence-based interventions and lower amounts of non-treatment. These data suggest that an infectious disease consultation should be an integral part of clinical care of patients with candida bloodstream infection. FUNDING: Astellas Global Development Pharma, Washington University Institute of Clinical and Translational Sciences, and the Agency for Healthcare Research and Quality.