Expert review of anti-infective therapy · 2026
Breakthrough candidemia during prophylactic or empirical antifungal therapy: antifungal exposure, in vitro activity, and association of early treatment modification with mortality.
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Suarez-Urquiza Pedro, Velasco-Marrodán Marcos, Favier Patricio, Frasquet-Artes Juan, Ángeles-Ferre María, Moreno Ignacio, Tasias María, Calabuig-Muñoz Eva, Gordon-Sahuquillo Mónica, Pemán Javier, Muñoz-Brell Paula, Castaño-Garcia María, Castaño-Aroca María Jesús, Gómez María Dolores, Ruiz-Gaitán Alba
Аннотация
BACKGROUND: Breakthrough candidemia (BrC) occurs during systemic antifungal therapy, but its determinants, relationship with in vitro resistance, and optimal management remain unclear.
RESEARCH DESIGN AND METHODS: Retrospective matched case-case study at a 900-bed tertiary-care center (2012-2026) including 713 first candidemia episodes (92 BrC, defined as candidemia after ≥ 72 hours of antifungal exposure; 621 non-BrC). MICs were compared with same-species non-breakthrough isolates. BrC cases were matched 1:1 on age, location and period. The main outcome was 30-day mortality; antifungal therapy modification was evaluated in a 5-day landmark analysis.
RESULTS: BrC accounted for 12.9% of episodes, arising a median of 8 days into therapy, mostly during echinocandin exposure (73.9%). Of 88 isolates tested against the administered agent, 2 (2.3%) were resistant, 2 (2.3%) non-wild-type and 4 (4.5%) intermediate, and no statistically significant MIC difference was detected across 37 species-antifungal comparisons. Parenteral nutrition and non-C. albicans species were independently associated with BrC. BrC was associated with higher 30-day mortality (aOR 2.00; 95% CI 1.04-3.88). Among day-5 survivors, therapy modification was associated with lower mortality (aOR 0.17; 0.05-0.51; exploratory).
CONCLUSIONS: BrC mainly occurs during echinocandin therapy, rarely involves isolates resistant to the administered agent, and identifies a high-risk group warranting early therapeutic reassessment.
RESEARCH DESIGN AND METHODS: Retrospective matched case-case study at a 900-bed tertiary-care center (2012-2026) including 713 first candidemia episodes (92 BrC, defined as candidemia after ≥ 72 hours of antifungal exposure; 621 non-BrC). MICs were compared with same-species non-breakthrough isolates. BrC cases were matched 1:1 on age, location and period. The main outcome was 30-day mortality; antifungal therapy modification was evaluated in a 5-day landmark analysis.
RESULTS: BrC accounted for 12.9% of episodes, arising a median of 8 days into therapy, mostly during echinocandin exposure (73.9%). Of 88 isolates tested against the administered agent, 2 (2.3%) were resistant, 2 (2.3%) non-wild-type and 4 (4.5%) intermediate, and no statistically significant MIC difference was detected across 37 species-antifungal comparisons. Parenteral nutrition and non-C. albicans species were independently associated with BrC. BrC was associated with higher 30-day mortality (aOR 2.00; 95% CI 1.04-3.88). Among day-5 survivors, therapy modification was associated with lower mortality (aOR 0.17; 0.05-0.51; exploratory).
CONCLUSIONS: BrC mainly occurs during echinocandin therapy, rarely involves isolates resistant to the administered agent, and identifies a high-risk group warranting early therapeutic reassessment.