Early empiric antifungals not associated with improved survival in ICU candidemia

Researchers pooled patient-level data from two prospective worldwide observational cohorts, EUROBACT-1 and EUROBACT-2, to assess whether early adequate empiric antifungal therapy was associated with 28-day mortality in adults with candidemia. The secondary analysis included 272 ICU patients from 158 centers. Early therapy was defined as adequate antifungal treatment within two days after blood culture collection; propensity-score weighting was used to adjust the mortality analysis.

Of 110 patients receiving early adequate therapy, 45 (40.9%) died within 28 days, compared with 60 of 162 (37.0%) who did not receive early adequate therapy. Overall mortality was 38.6%. The weighted hazard ratio was 1.23 (95% CI 0.82–1.83; p=0.314), indicating no statistically significant association. Findings were consistent across subgroups defined by cohort, Candida species, and hypotension, and in a sensitivity analysis accounting for center effects.

The authors argue for more targeted empiric antifungal treatment and better identification of patients most likely to benefit from immediate therapy. However, this observational analysis cannot establish causality or demonstrate equivalence between treatment strategies. The confidence interval remains compatible with both benefit and harm, and the findings should not be interpreted as evidence that delaying antifungal therapy is safe.