Fungicidals vs. Fungistatics: No Difference in 30-day Mortality for Pediatric Candidemia

PHILADELPHIA, PA—What is the definitive therapy for pediatric candidemia: a fungicidal or a fungistatic agent? Limited data suggest both can be considered, a retrospective study concluded at IDWeek 2014.

Neika Vendetti, MPH, of the Division of Infectious Diseases, Center for Pediatric Clinical Effectiveness, the Children’s Hospital of Philadelphia, Philadelphia, PA, and colleagues sought to answer this question because “patient-level review of adult clinical trial data concluded that echinocandin therapy for treatment of candidemia was associated with a decreased mortality rate.” However, there is limited data regarding options of systemic antifungals for pediatrics. 

The investigators compared the effectiveness of fungicidal versus fungistatic agents as definitive therapy for pediatric candidemia on 30-day all-cause mortality in patients aged 6 months–18 years diagnosed between 2000 and 2012. Candidemia onset was defined as “the day the first microbiologic evidence of candidemia (report of yeast from a positive blood culture) was available to the clinician.” 

“Amphotericin products and echinocandins were categorized as fungicidal and fluconazole as fungistatic,” Vendetti noted. “Candidemic patients were included in the final data analysis if they received the same antifungal agent for 2 consecutive days following candidemia onset.”

They used a propensity score model to generate inverse probability weights for receiving a fungicidal agent that were then included in a weighted logistic regression model to compare 30-day mortality among patients who had received fungicidal versus fungistatic agents.

Among 203 children with candidemia who received the same antifungal agent for 2 consecutive days after culture was known to be positive, 151 (74.4%) received either amphotericin (n=134) or caspofungin (n=17); 52 (25.6%) received fluconazole.

Overall, 18 (8.9%) patients died within 30 days. In the weighted logistic regression model, no statistically significant difference in mortality between patients who started on a fungicidal agent verus fungistatic therapy was observed (OR 2.19; 95% CI 0.42–11.48).

“The results should be interpreted with caution given the small sample size and resultant wide confidence intervals,” Vendetti noted. “Larger pediatric cohort studies are needed to further compare antifungal therapeutic options and outcomes.”