Background: Invasive candidiasis (IC) is the most common invasive fungal disease in patients admitted to critical care and is associated with high mortality rates. Diagnosis can be delayed by the poor sensitivity of culture-based methods, leading to unnecessary use of empirical antifungal therapy (EAFT). The fungal biomarker (1-3)-b-d-glucan (BDG) has been shown to aid in the diagnosis of IC in critical care and has been incorporated into antifungal stewardship (AFS) programmes.Aim: To describe our experience using a diagnostics-driven AFS programme incorporating the fungal biomarker BDG, analyse its impact on antifungal therapy (AFT), and gain an improved understanding of the epidemiology of IC in our critical care unit (CrCU).Methods: An AFS care pathway incorporating BDG was introduced in the CrCU in St James's Hospital, Dublin. Following an educational programme, compliance with the pathway was prospectively audited between December 1st, 2017 and July 31st, 2018.Results and Conclusion: One hundred and nine AFT episodes were included, of which 95 (87%) had a BDG sent. Of those with BDG results available at the time of decision-making, 38 (63%) were managed in accordance with the care pathway. In compliant episodes without IC, median EAFT duration was 5.5 days [IQR 4-7] and no increase in mortality or subsequent IC was observed. Although adopting a diagnostics-driven approach was found to be useful in the cohort of patients with BDG results available, the use of once-weekly BDG testing did not result in an observed reduction in the consumption of anidulafungin, highlighting an important limitation of this approach.& COPY; 2020 The Authors. Published by Elsevier Ltd on behalf of The Healthcare Infection Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

All courses of fidaxomicin use in the study hospital were reviewed. It was used for first recurrence (six times), second recurrence (eight times) and one case of third recurrence. One patients received fidaxomicin as first-line treatment. Eight patients initially responded to therapy; of these, three patients were asymptomatic at 90 days, three patients remained asymptomatic at 30 days, and two patients had recurrences five and nine days after stopping therapy. Four patients failed to respond; of these, two patients required faecal transplantation and one patient required a colectomy. Two patients deteriorated and two patients died. Fidaxomicin was well tolerated. These findings suggest that the utility of fidaxomicin at this stage of infection is unclear.

Enoch et al. discussed their experience with fidaxomicin in the treatment of recurrent C. difficile infection (rCDI) [ [1] Enoch D.A. Santos R. Phillips C.J. Micallef C. Murphy M. Aliyu S.H. et al. Real-world use of fidaxomicin in a large UK tertiary hospital: how effective is it for treating recurrent disease?. J Hosp Infect. 2018; 100: 142-146 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar ]. International evidence-based guidelines recommend fidaxomicin therapy for initial episode and for first recurrence, whereas their centre has approved its use for second recurrence [ 2 Debast S.B. Bauer M.P. Kuijper E.J. European Society of Clinical Microbiology and Infectious Diseases update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2014; 20: 1-26 Abstract Full Text Full Text PDF PubMed Scopus (915) Google Scholar , 3 McDonald L.C. Gerding D.N. Johnson S. Bakken J.S. Carroll K.C. Coffin S.E. et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018; 66: 987-994 Crossref PubMed Scopus (517) Google Scholar ]. However, the authors did not include data on the rCDI rate, stating only that 10.6% had more than one positive toxin result. Real-world use of fidaxomicin in a large UK tertiary hospital: how effective is it for treating recurrent disease?Journal of Hospital InfectionVol. 100Issue 2PreviewAll courses of fidaxomicin use in the study hospital were reviewed. It was used for first recurrence (six times), second recurrence (eight times) and one case of third recurrence. One patients received fidaxomicin as first-line treatment. Eight patients initially responded to therapy; of these, three patients were asymptomatic at 90 days, three patients remained asymptomatic at 30 days, and two patients had recurrences five and nine days after stopping therapy. Four patients failed to respond; of these, two patients required faecal transplantation and one patient required a colectomy. Full-Text PDF