Research in context
Evidence before this study
Candida is a substantial cause of morbidity and mortality. Overall, candida now represents the second most common cause of health-care-associated bloodstream infection in the USA, as well as the most common fungal bloodstream infection. In a preliminary systematic review, we searched MEDLINE and Embase from Jan 1, 1967, to May 8, 2019, using the search terms “candidemia” or “candida blood stream infection” and “infectious diseases consultation”. We limited the search to studies in adults aged 18 years and older, with no language restrictions. This search identified six studies in which the effect of an infectious disease consultation was evaluated in patients with candidaemia. Currently, the published literature is limited to small cohorts of candida bloodstream infection, with limited insights into management differences. Even so, these studies support the inclusion of infectious disease expertise in the diagnosis and treatment of candida bloodstream infection. Candida bloodstream infection attributable mortality is reported to range between 15–47%, but with appropriate therapy, these rates can be reduced by almost half. Infectious disease consultations have been found to positively affect mortality outcomes in patients with several bloodstream infections, including Staphylococcus aureus, cryptococcus, and multidrug-resistant organisms. Increased adherence to disease management drawn from evidence-based recommendations benefits patients with these bloodstream infections.
Added value of this study
To our knowledge, this is the largest cohort of patients with candida bloodstream infection examining the association between infectious disease consultation and mortality, as well as the most detailed assessment of bloodstream infection management done thus far. We established a 19% survival benefit that persists long-term, which is associated with infectious disease consultation after extensively controlling for patient factors and disease severity using propensity score modelling. Previous cohort studies were too small to allow a robust statistical approach to control for potential confounders. This is the first study to include an extensive number of known risk factors to account for confounding by indication with propensity score modelling and to document extensive differences in management. We showed that increased frequency of interventions often recommended by infectious disease specialists, including central-line removal, echocardiography for detection of endocarditis, more consistent recognition of positive blood cultures, and prolonged duration of antifungal therapy explain the decrease in mortality associated with infectious disease consultation.
Implications of all the available evidence
Our findings show that patients with candida bloodstream infection who received an infectious disease consultation had significantly decreased 90-day mortality through use of evidence-based interventions. The results of this study, combined with others examining bloodstream infection, illustrate that infectious disease consultation significantly lowers the risk of mortality among patients with bloodstream infection. This effect is consistently derived from better adherence to evidence-based standards of treatment. An infectious disease consultation is appropriate, even preferred, for patients with candida bloodstream infection, considering the often variable presentation and complex management of these patients. We highlight the benefit of this consultation for candida bloodstream infection, contributing to the literature supporting its use for patients with bloodstream infection.