Antifungal Therapy in Candida Infective Endocarditis: A Comparison of Echinocandins and Other Treatment Regimens in a Nationwide Cohort Study

Abstract

Background Amphotericin B-based treatment has been the cornerstone of Candida infective endocarditis (CIE) treatment, but recent guidelines also recommend echinocandins. However, there are limited outcome data. The few studies performed report differing results. Our aim in this study was to compare the outcome with echinocandins to those of other antifungal strategies. Methods A CIE cohort was derived from the Swedish Registry of Infective Endocarditis for 1995–2019. In-hospital mortality or relapse was considered treatment failure. Results 51 episodes in 38 patients were treated with echinocandins (n = 21), amphotericin B-based therapy (n = 22), or azoles (n = 8). The proportions of treatment failure were 32%, 38%, and 62%, respectively (P =.35). Patients who received echinocandins were older and had a higher burden of comorbidities. The overall 1-year mortality rate from index hospitalization was 26%, with no significant differences between backbone therapies (P =.18). Because Candida parapsilosis IE was not treated with echinocandins, a subgroup analysis was performed of 33 episodes with C. non-parapsilosis that showed no significant differences between backbone therapies (P =.33). In a subgroup analysis of episodes treated with amphotericin B-based therapy, treatment failure was seen in 54% of 13 episodes caused by C. parapsilosis and 12% of 8 episodes caused by C. non-parapsilosis (P =.10). Conclusions No differences in in-hospital mortality, relapse rate, or 1-year mortality were seen in patients with echinocandin-based therapy compared with other CIE regimens, despite risk factors in the echinocandin group that would be expected to negatively bias outcome. Candida parapsilosis CIE appears to pose specific challenges in terms of optimal therapy.