Biomarker-driven strategy for early discontinuation of empirical antifungal treatment in critically ill patients: the role of (1-3)-β-D-glucan using Wako® test.

BACKGROUND

(1,3)-β-D-Glucan (BDG) testing with Fungitell® assay has been shown to support antifungal stewardship by shortening empirical antifungal therapy in critically ill patients; however, data on Wako® assay are lacking.

METHODS

Prospective, non-randomized study conducted over 15 months in a tertiary care hospital. Critically ill patients receiving empirical echinocandin therapy with a BDG measurement within 48 h were included. Patients were stratified by Candida score (low risk <3, high risk ≥3) and initial BDG result and followed for 30 days after discontinuation or death. The primary endpoint was early echinocandin discontinuation and total antifungal duration. Secondary endpoints included mortality, invasive candidiasis (IC) within 30 days, length of stay and antifungal consumption.

RESULTS

Ninety patients were included. Among low-risk patients (n = 27), 81.5% (22/27) had negative BDG; antifungal therapy was discontinued early in 77.3% (17/22) of BDG-negative versus 20% (1/5) of BDG-positive cases, with no IC diagnosed. Among high-risk patients (n = 63), 58.7% (37/63) had negative BDG; therapy was discontinued in 75.7% (28/37). In high-risk patients with positive BDG (n = 26), there were 3 IC (11.5%); in all cases, the antifungal was maintained. Early discontinuation was more frequent in BDG-negative patients (77.2% versus 19.2%; P < 0.001), resulting in shorter echinocandin (2 versus 4 days; P = 0.004) and total antifungal therapy (3 versus 8 days;P < 0.001), without differences in mortality or subsequent IC. Echinocandin costs decreased by ∼50%.

CONCLUSIONS

BDG-guided management using Wako® assay increased early antifungal discontinuation and reduced echinocandin exposure. BDG should be used cautiously as an adjunctive tool, particularly in high-risk patients, due to potential false negatives.