In the JournalsPerspective

ID consultation lowers mortality in patients with candidemia

ANdrej Spec, MD
Andrej Spec

Infectious disease consultation was associated with lower mortality among patients with candida bloodstream infections during a recent 14-year period at one St. Louis hospital, according to results from a retrospective study.

“Many people have previously reported similar effects in small studies, and the pushback has always been about confounding in retrospective data. So, we undertook to analyze the data in such a way that it accounted for any possible confounders, given that a randomized controlled trial would be unethical,” Andrej Spec, MD, MSCI, assistant professor of medicine and associate director of the Infectious Disease Clinical Research Unit at Washington University School of Medicine in St. Louis, told Infectious Disease News.

Spec and colleagues reviewed the charts of patients admitted to Barnes-Jewish Hospital in St. Louis with candida bloodstream infections between Jan. 1, 2002, and Dec. 31, 2015. According to the study, they used a Cox proportional hazards model to assess the effects of infectious disease consultation on mortality.

“We limited the study to patients that survived more than 24 hours after the discovery of the infection and eliminated the highest and lowest risk tails of the data in order to minimize the confounding,” Spec explained. “This way we can feel comfortable increasing the involvement of infectious disease physicians in the care of patients with candidemia in order to reduce mortality.”

The researchers analyzed 1,691 patients with candida bloodstream infection, of which 45.9% had an infectious disease consultation and 54.1% did not. According to the study, 90-day mortality was lower among the infectious disease consultation group (29%) compared with patients who did not receive an infectious disease consultation (51%). Additional data showed that among the group that received infectious disease consultation, median duration of antifungal therapy was longer (18 days vs. 14 days) and central-line removal (76% vs. 59%), echocardiography use (57% vs. 33%), and ophthalmological examination (53% vs. 17%) were more frequently done, the researchers reported. In addition, fewer patients in the consultation group went untreated (2% vs. 14%).

According to Spec, the “topline result” is that, after extensive adjustment, infectious disease consultation was associated with a 19% survival benefit (HR = 0.81; 95% CI, 0.73-0.91) — a “dramatic effect,” he said.

“This difference is associated with more stringent implementation of interventions that have been associated with improved mortality in studies, such as removal of central lines, and ensuring that all patients are given therapy once candidemia is identified, even if they appear well,” he said. “Every patient with a candida in the blood should be treated, and they should be treated by an infectious disease physician.” – by Caitlyn Stulpin

Disclosures: Spec reports no relevant financial disclosures.

ANdrej Spec, MD
Andrej Spec

Infectious disease consultation was associated with lower mortality among patients with candida bloodstream infections during a recent 14-year period at one St. Louis hospital, according to results from a retrospective study.

“Many people have previously reported similar effects in small studies, and the pushback has always been about confounding in retrospective data. So, we undertook to analyze the data in such a way that it accounted for any possible confounders, given that a randomized controlled trial would be unethical,” Andrej Spec, MD, MSCI, assistant professor of medicine and associate director of the Infectious Disease Clinical Research Unit at Washington University School of Medicine in St. Louis, told Infectious Disease News.

Spec and colleagues reviewed the charts of patients admitted to Barnes-Jewish Hospital in St. Louis with candida bloodstream infections between Jan. 1, 2002, and Dec. 31, 2015. According to the study, they used a Cox proportional hazards model to assess the effects of infectious disease consultation on mortality.

“We limited the study to patients that survived more than 24 hours after the discovery of the infection and eliminated the highest and lowest risk tails of the data in order to minimize the confounding,” Spec explained. “This way we can feel comfortable increasing the involvement of infectious disease physicians in the care of patients with candidemia in order to reduce mortality.”

The researchers analyzed 1,691 patients with candida bloodstream infection, of which 45.9% had an infectious disease consultation and 54.1% did not. According to the study, 90-day mortality was lower among the infectious disease consultation group (29%) compared with patients who did not receive an infectious disease consultation (51%). Additional data showed that among the group that received infectious disease consultation, median duration of antifungal therapy was longer (18 days vs. 14 days) and central-line removal (76% vs. 59%), echocardiography use (57% vs. 33%), and ophthalmological examination (53% vs. 17%) were more frequently done, the researchers reported. In addition, fewer patients in the consultation group went untreated (2% vs. 14%).

According to Spec, the “topline result” is that, after extensive adjustment, infectious disease consultation was associated with a 19% survival benefit (HR = 0.81; 95% CI, 0.73-0.91) — a “dramatic effect,” he said.

“This difference is associated with more stringent implementation of interventions that have been associated with improved mortality in studies, such as removal of central lines, and ensuring that all patients are given therapy once candidemia is identified, even if they appear well,” he said. “Every patient with a candida in the blood should be treated, and they should be treated by an infectious disease physician.” – by Caitlyn Stulpin

Disclosures: Spec reports no relevant financial disclosures.

    Perspective
    Cornelius (Neil) J. Clancy

    Cornelius (Neil) J. Clancy

    This study by Carlos Mejia-Chew, Andrej Spec and colleagues is most important for showing, yet again, that care by ID physicians improves the treatment and outcomes of patients with life-threatening infections. The investigators’ findings that ID consultation was associated with significantly lower 90-day mortality and greater adherence to evidence-based therapeutic interventions among patients with Candida bloodstream infections can be added to a large body of data demonstrating superior outcomes of infections by various fungi, bacteria, antimicrobial-resistant pathogens and HIV. The results here corroborate those from earlier, smaller studies of ID consultation for Candida infections, using a much larger patient cohort and rigorous statistical analyses. As the financial unsustainability of the U.S. health care system forces inevitable reforms in the not-too-distant future, it is hoped that studies like this will guide rational policy, budgetary and reimbursement decisions. ID professionals save lives and do so at a large scale in a cost-efficient manner.

    • Cornelius (Neil) J. Clancy, MD
    • Associate professor of medicine
      Director, XDR pathogen lab and mycology program
      University of Pittsburgh

    Disclosures: Clancy reports no relevant financial disclosures.

    Perspective
    Susan C. Bleasdale

    Susan C. Bleasdale

    This is an important study because this looks at a large patient population — over 1,600 patients from 2002 to 2016, comparing those who received an infectious disease consult and those who did not. The study showed that there was a significant survival benefit, a decrease in mortality risk of over 19%, which is a significant move forward to highlight the importance of infectious disease consults in the care of patients. There have been other studies showing other facets of care that we provide in infectious disease, so this is one more study showing our contribution to quality care.

    Also, I think it is very important highlight to the value of infectious disease physicians, especially in the environment we are in now where we need to show how we can contribute to improve quality care. In general, as infectious disease physicians, we must continually try to provide justification of how we contribute to care. Now, with Medicare and Medicaid trying to contain budgets as our health care population is aging, there is always work to be done to preserve our funds. It is important to highlight the quality of care that ID physicians contribute to complex patients, and this is just one more piece of evidence of our quality and value in the health care system.

    • Susan C. Bleasdale, MD
    • Medical director for infection prevention and antimicrobial stewardship
      University of Illinois at Chicago
      Chair, Clinical Affairs Committee
      Infectious Diseases Society of America

    Disclosures: Bleasdale reports no relevant financial disclosures.