Delaying the Empiric Treatment of <i>Candida</i> Bloodstream Infection until Positive Blood Culture Results Are Obtained: a Potential Risk Factor for Hospital Mortality

TLDR

Fungal bloodstream infections carry high mortality and healthcare costs, yet the impact of delaying empiric antifungal therapy until culture results are available remains unclear. The study aims to reduce such delays by promoting rapid diagnostics or targeted empiric antifungal use in high‑risk patients. A retrospective cohort of 157 Candida bloodstream infection cases at Barnes‑Jewish Hospital was analyzed using automated medical records and pharmacy data, with treatment initiation times categorized and logistic regression applied to identify mortality determinants. Of the 157 patients, 31.8% died; 134 received empiric antifungal therapy after culture results, most between 24–48 h, and a 12‑hour delay after a positive culture was independently associated with increased hospital mortality (adjusted odds ratio 2.09).

Abstract

Fungal bloodstream infections are associated with significant patient mortality and health care costs. Nevertheless, the relationship between a delay of the initial empiric antifungal treatment until blood culture results are known and the clinical outcome is not well established. A retrospective cohort analysis with automated patient medical records and the pharmacy database at Barnes-Jewish Hospital was conducted. One hundred fifty-seven patients with a Candida bloodstream infection were identified over a 4-year period (January 2001 through December 2004). Fifty (31.8%) patients died during hospitalization. One hundred thirty-four patients had empiric antifungal treatment begun after the results of fungal cultures were known. From the time that the first blood sample for culture that was positive was drawn, 9 (5.7%) patients received antifungal treatment within 12 h, 10 (6.4%) patients received antifungal treatment between 12 and 24 h, 86 (54.8%) patients received antifungal treatment between 24 and 48 h, and 52 (33.1%) patients received antifungal treatment after 48 h. Multiple logistic regression analysis identified Acute Physiology and Chronic Health Evaluation II scores (one-point increments) (adjusted odds ratio [AOR], 1.24; 95% confidence interval [CI], 1.18 to 1.31; P < 0.001), prior antibiotic treatment (AOR, 4.05; 95% CI, 2.14 to 7.65; P = 0.028), and administration of antifungal treatment 12 h after having the first positive blood sample for culture (AOR, 2.09; 95% CI, 1.53 to 2.84; P = 0.018) as independent determinants of hospital mortality. Administration of empiric antifungal treatment 12 h after a positive blood sample for culture is drawn is common among patients with Candida bloodstream infections and is associated with greater hospital mortality. Delayed treatment of Candida bloodstream infections could be minimized by the development of more rapid diagnostic techniques for the identification of Candida bloodstream infections. Alternatively, increased use of empiric antifungal treatment in selected patients at high risk for fungal bloodstream infection could also reduce delays in treatment.