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| |  High Mortality Rate From Septic Shock From []Candida[] Infection Due to Delay in Antimicrobial Therapy: Presented at CCCF By Pam Harrison TORONTO, CANADA -- November 5, 2007 -- A large part of the high mortality rate associated with septic shock in patients with Candida infections can be attributed to a significant delay in initiation of appropriate antimicrobial therapy, according to findings from the Cooperative Antimicrobial therapy of Septic Shock (CATSS) study. In their study, Faisal Siddiqui, MD, Fellow in Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada, and colleagues analysed survival in 433 patients with septic shock due to bacterial infections or candidiasis based on the time it took to administer effective antimicrobial therapy. Dr. Siddiqui presented the study results here at the Critical Care Canada Forum (CCCF). For their study, the researchers divided time to initiation of effective antimicrobial therapy from onset of hypotension into several different time frames: from 0 to 2 hours; 2 to 6 hours; 6 to 12 hours; 12 to 24 hours; 24 to 72 hours; and over 72 hours. Ninety-nine patients died without ever receiving effective therapy, while 36 patients received effective antimicrobial therapy before the onset of septic shock. The remaining 308 patients were subject to univariate and multivariate analysis. On univariate analysis, time to appropriate intervention was strongly associated with survival through to hospital discharge in both the bacterial infection and the candidiasis groups, as was the Acute Physiology and Chronic Health Evaluation (APACHE) score, according to the researchers. "Highly significant, delay-dependent increases in mortality [P <.0001] were seen in both groups," Dr. Siddiqui reported. However, there were marked differences in the distribution of delay between those with bacterial shock and those with candiasis shock. For example, when appropriate antimicrobial therapy was initiated within 0 to 2 hours of hypotension, in-hospital survival rates for both groups approached 80%. In-hospital survival rates were also similar for both groups when antimicrobial therapy was initiated between 2 and 6 hours after hypotension onset. Separation in survival rates between those with bacterial shock and those with candidiasis shock started to occur when treatment was initiated between 6 and 12 hours after onset of hypotension, where only about 20% of patients with candidiasis shock survived until hospital discharge versus about double that for those with bacterial shock. A similar pattern was seen between the two groups when treatment was initiated 12 to 24 hours after hypotension onset, where survival rates, although low, were still about double those for bacterial shock versus those with candidiasis shock. Survival rates were 10% and less for both groups when treatment was initiated 24 hours and more after hypotension onset. However, the median duration of time before appropriate antimicrobial therapy was initiated was 35.2 hours for those with candidiasis shock versus 5.5 hours for those with bacterial shock. Therefore, patients with Candida infections were far less likely to receive early initiation of appropriate antimicrobial therapy than those with bacterial shock. "We all know that with bacterial sepsis, the earlier we initiate therapy, the better," Dr. Siddiqui said in an interview. The problem with Candida-associated septic shock is that physicians tend not to think of fungal causes "right off the bat," he added. Therefore, antifungal therapy is delayed for 24 to 72 hours in the majority of patients with Candida. "We know that we should consider fungal sepsis early in patients who are immunocompromised as well as those who have been hospitalised for a long period of time," Dr. Siddiqui said. "But maybe we should also be considering antifungal therapy early in any patient with septic shock with the understanding that we would stop therapy if there was no sign of fungal infection after initial cultures were done." As the investigators note, mortality for Candida-associated septic shock exceeds 80% compared with approximately 50% for bacterial shock.
[Presentation title: The High Mortality of Candida Septic Shock is Explained by Excessive Delays in Initiation of Antifungal Therapy.]
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