Cited by 152Antifungal resistance and susceptibilityFungal Infections and StudiesInfective Endocarditis Diagnosis and Management

Guideline adherence and survival of patients with candidaemia in Europe: results from the ECMM Candida III multinational European observational cohort study

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Hoenigl, Martin, Salmanton-García, Jon, Egger, Matthias, Gangneux, Jean-Pierre, Bicanic, Tihana, Arikan-Akdagli, Sevtap, Alastruey-Izquierdo, Ana, Klimko, Nikolai +85 more·2023·The Lancet Infectious Diseases

Abstract

BACKGROUND The European Confederation of Medical Mycology (ECMM) collected data on epidemiology, risk factors, treatment, and outcomes of patients with culture-proven candidaemia across Europe to assess how adherence to guideline recommendations is associated with outcomes. METHODS In this observational cohort study, 64 participating hospitals located in 20 European countries, with the number of eligible hospitals per country determined by population size, included the first ten consecutive adults with culture-proven candidaemia after July 1, 2018, and entered data into the ECMM Candida Registry (FungiScope CandiReg). We assessed ECMM Quality of Clinical Candidaemia Management (EQUAL Candida) scores reflecting adherence to recommendations of the European Society of Clinical Microbiology and Infectious Diseases and the Infectious Diseases Society of America guidelines. FINDINGS 632 patients with candidaemia were included from 64 institutions. Overall 90-day mortality was 43% (265/617), and increasing age, intensive care unit admission, point increases in the Charlson comorbidity index score, and Candida tropicalis as causative pathogen were independent baseline predictors of mortality in Cox regression analysis. EQUAL Candida score remained an independent predictor of mortality in the multivariable Cox regression analyses after adjusting for the baseline predictors, even after restricting the analysis to patients who survived for more than 7 days after diagnosis (adjusted hazard ratio 1·08 [95% CI 1·04-1·11; p<0·0001] in patients with a central venous catheter and 1·09 [1·05-1·13; p<0·0001] in those without one, per one score point decrease). Median duration of hospital stay was 15 days (IQR 4-30) after diagnosis of candidaemia and was extended specifically for completion of parenteral therapy in 100 (16%) of 621 patients. Initial echinocandin treatment was associated with lower overall mortality and longer duration of hospital stay among survivors than treatment with other antifungals. INTERPRETATION Although overall mortality in patients with candidaemia was high, our study indicates that adherence to clinical guideline recommendations, reflected by higher EQUAL Candida scores, might increase survival. New antifungals, with similar activity as current echinocandins but with longer half-lives or oral bioavailability, are needed to reduce duration of hospital stay. FUNDING Scynexis.

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  • There has been a clear worldwide trend of decreasing proportions of C. albicans as the causative pathogen of invasive candidiasis or candidemia.

    “Independent of these geographic variations, there has been a clear worldwide trend of decreasing proportions of C. albicans as the causative pathogen.”

    From Epidemiology of Invasive Candidiasis (2024) · cites this paper as [56]

    The Discussion refers to an increase in Candida species other than C. albicans, which supports the direction of the claimed shift. The Results report species proportions from a European cohort, but the paper does not establish a clear worldwide trend over time. (LLM, conf=0.84)

    Experimental — accuracy not yet measured
  • In the European Confederation of Medical Mycology Candida studies, the proportion of C. albicans causing candidemia decreased from 56.4% in 1997-1999, to 54% in 2006-2008, to 46.2% in 2018, with corresponding increases in non-albicans species.

    “While that decreasing trend is ubiquitous, with the series of multicenter European Confederation of Medical Mycology (ECMM) Candida studies showing the proportion of C. albicans causing candidemia decreased from 56.4% in 1997–1999,57 to 54% in 2006–2008,58 to 46.2% in 201856 with corresponding increases in non-albicans species (Table 1), there are important geographic differences.”

    From Epidemiology of Invasive Candidiasis (2024) · cites this paper as [56]

    The Results report that C. albicans caused 287 of 621 cases, or 46.2% when calculated from the reported counts. The Study design says centres entered data between July 2018 and March 2022, so this is not a proportion measured solely in 2018. The earlier percentages have separate citations in the citing sentence. (LLM, conf=0.85)

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  • Summarizing all of Europe, the increase in the proportion of C. glabrata between 2006-2008 (13.8%) and 2018 (21.4%) has been striking.

    “Summarizing all of Europe together, the increase in the proportion of C. glabrata between 2006–2008 (13.8%)58 to 2018 (21.4%)56 has been striking.”

    From Epidemiology of Invasive Candidiasis (2024) · cites this paper as [56]

    The Results report C. glabrata in 133 of 621 patients (21%), equivalent to 21.4%, across the European cohort. But the Study design says centres entered data from July 2018 through March 2022, so this is not a proportion measured for 2018 alone. The 2006–2008 figure is attached to a different citation and is not assessed here. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

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  1. [33]33. Salmanton-García J, Hoenigl M, Gagneux J-P, et al. The current state of laboratory mycology in Europe: a European Confederation of Medical Mycology survey. Lancet Microbe 2023; 4: e47-56.

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Authors
Hoenigl, M., Salmanton-García, J., Egger, M., Gangneux, J.-P., Bicanic, T., Arikan-Akdagli, S., Alastruey-Izquierdo, A., Klimko, N., Barac, A., Özenci, V., Meijer, E. F. J., Khanna, N., Bassetti, M., Rautemaa-Richardson, R., Lagrou, K., Adam, K.-M., Akalin, E. H., Akova, M., Arsic Arsenijevic, V., Aujayeb, A., Blennow, O., Bretagne, S., Danion, F., Denis, B., de Jonge, N. A., Desoubeaux, G., Drgona, L., Erben, N., Gori, A., García Rodríguez, J., Garcia-Vidal, C., Giacobbe, D. R., Goodman, A. L., Hamal, P., Hammarström, H., Toscano, C., Lanternier, F., Lass-Flörl, C., Lockhart, D. E. A., Longval, T., Loughlin, L., Matos, T., Mikulska, M., Narayanan, M., Martín-Pérez, S., Prattes, J., Rogers, B., Rahimli, L., Ruiz, M., Roilides, E., Samarkos, M., Scharmann, U., Sili, U., Sipahi, O. R., Sivakova, A., Steinmann, J., Trauth, J., Turhan, O., Van Praet, J., Vena, A., White, P. L., Willinger, B., Tortorano, A. M., Arendrup, M. C., Koehler, P., Cornely, O. A., Tumbarello, M., Talento, A. F., Ruiz, A. C., Racil, Z., Stoma, I., Calbacho, M., Van Wijngaerden, E., Henriques, J., Jordan, H., Ferroni, V., Ozyurt, O. K., Milacek, C., Krause, R., Zurl, C., Backx, M., Li, A., Seufert, R., Tomazin, R., Blankenheim, Y., Dávila-Valls, J., García-Clemente, P., Freiberger, T., Buil, J., Meis, J. F., Akyol, D., Guegan, H., & Logan, C.
Affiliations
  • Medical University of Graz (AT)
  • Inserm (FR)
  • St George's, University of London (GB)
  • University of Belgrade (RS)
  • Karolinska University Hospital (SE)
  • Radboud University Nijmegen (NL)
  • University Hospital of Basel (CH)
  • Ospedale Policlinico San Martino (IT)
  • Universitair Ziekenhuis Leuven (BE)
  • Hacettepe University (TR)
  • Northumbria Healthcare NHS Foundation Trust (GB)
  • Assistance Publique – Hôpitaux de Paris (FR)
  • Hôpitaux Universitaires de Strasbourg (FR)
  • Eskişehir Osmangazi University (TR)
  • University of Milan (IT)
  • St Thomas' Hospital (GB)
  • Palacký University Olomouc (CZ)
  • University of Gothenburg (SE)
  • Hospital de Egas Moniz (PT)
  • Hôpital Necker-Enfants Malades (FR)
  • University of Aberdeen (GB)
  • Centre Hospitalier de Versailles (FR)
  • Belfast Health and Social Care Trust (GB)
  • University of Ljubljana (SI)
  • Newcastle upon Tyne Hospitals NHS Foundation Trust (GB)
  • University of Cologne (DE)
  • University Hospitals of Leicester NHS Trust (GB)
  • Aristotle University of Thessaloniki (GR)
  • National and Kapodistrian University of Athens (GR)
  • Essen University Hospital (DE)
  • Marmara University (TR)
  • Nuremberg Hospital (DE)
  • Justus-Liebig-Universität Gießen (DE)
  • Public Health Wales (GB)
  • Medical University of Vienna (AT)
  • Statens Serum Institut (DK)
  • Centre Hospitalier Universitaire de Tours (FR)
  • Université de Strasbourg (FR)
Corresponding author
Hoenigl, Martin
Venue
The Lancet Infectious Diseases
Publisher
Elsevier BV
Published
2023-06
Volume
23
Issue
6
Pages
751-761
ISSN
1473-3099 (ISSN-L)
OpenAlex
W4320896711
Cited by
152
References
33
Citations by year
2026: 38 · 2025: 48 · 2024: 42 · 2023: 23
FWCI
31.08
Type
journal article
Language
en
Open access
Locations
  • The Lancet Infectious Diseases (publishedVersion)
  • PubMed (publishedVersion)
  • Research at the University of Copenhagen (University of Copenhagen) (publishedVersion, cc-by-nc-nd)
  • Research Explorer (The University of Manchester) (publishedVersion, cc-by)
  • St George's Online Research Archive (St George's University of London) (acceptedVersion)
  • HAL (submittedVersion, cc-by-nc)
  • DIGITAL.CSIC (Spanish National Research Council (CSIC)) (submittedVersion, cc-by-nc-nd)
  • UCL Discovery (University College London) (submittedVersion)
  • Radboud Repository (Radboud University) (submittedVersion)
  • Bursa Uludag University - AVESIS (submittedVersion)
  • Ghent University Academic Bibliography (Ghent University) (submittedVersion)
  • Universitätsbibliographie, Universität Duisburg-Essen (submittedVersion)
  • CINECA IRIS Institutial Research Information System (University of Genoa) (submittedVersion)
  • Lirias (submittedVersion, cc-by-nc)
  • Dspace Repository (Marmara Üniversitesi) (submittedVersion, other-oa)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (submittedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
  • Newcastle University ePrints (Newcastle Univesity)
Funders
  • National Science Foundation
  • Bristol-Myers Squibb
  • Eli Lilly and Company
  • Pfizer
  • AstraZeneca
  • Sanofi
  • Gilead Sciences
  • Teva Pharmaceutical Industries
  • Medpace
  • Chiesi Farmaceutici
  • HELIOS Kliniken
  • Cidara Therapeutics
  • ViiV Healthcare
  • Mylan
  • Melinta Therapeutics
  • Amplyx
  • Entasis Therapeutics
  • Nabriva Therapeutics
  • Seres Therapeutics
  • Deutsche Forschungsgemeinschaft
  • Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (51NF40_180541))
  • Bundesministerium für Bildung und Forschung
  • Astellas Pharma
  • Shionogi
  • Ludwig-Maximilians-Universität München
  • Angelini Pharma
  • Swedish Orphan Biovitrum
  • Tillotts Pharma
  • Da Volterra
  • Allergan
  • Medical Research Council (MC_UU_00004/05)
Topics
  • Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
  • Health Sciences › Medicine › Epidemiology › Fungal Infections and Studies
  • Health Sciences › Medicine › Epidemiology › Infective Endocarditis Diagnosis and Management
Keywords
candidemia, guideline adherence, antifungal therapy, echinocandins, mortality, Candida tropicalis, central venous catheters, length of hospital stay, antifungal resistance, quality of care, mortality risk factors, observational cohort, antifungal therapy duration
MeSH terms
Adult, Antifungal Agents, Candida, Europe, Humans, Cohort Studies, Guideline Adherence, Candidemia

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