Prosthetic valve Candida spp. endocarditis: new insights into long term prognosis - the ESCAPE study

Abstract

Background

Prosthetic valve endocarditis caused by Candida spp. (PVE-C) is rare and devastating, with international guidelines based on expert recommendations consisting in the combination of surgery and subsequent azole treatment.

Methods

PVE-C collected in Spain and France between 2001 and 2015 were retrospectively analyzed with a focus on management and outcome.

Results

Forty-six cases were followed up for a median of 9 months. Twenty-two (48%) patients had a past history of endocarditis; 30 (65%) cases were nosocomial or healthcare-related, 9 (20%) patients were intravenous drug users. "Induction" therapy mainly consisted in a liposomal amphotericin B-based (n=21) or an echinocandin-based therapy (n=13). Overall, 19 (41%) patients were operated. Patients less than 66 years old and without cardiac failure more likely underwent cardiac surgery (aOR [95% IC] = 6.80 [1.59-29.13]) and 10.92 [1.15-104.06], respectively). Surgery was not associated with better survival at 6 months. Patients who received liposomal amphotericin B alone had a better 6-month survival than those who received an echinocandin alone (aOR [95%CI] =13.52 [1.03-838.10]). "Maintenance" fluconazole therapy, prescribed in 21 patients for a median duration of 13 months [range 2-84] led to minor adverse effects.

Conclusion

During PVE-C, liposomal amphotericin B "induction" treatment improves survival. A medical treatment followed by "maintenance" long-term fluconazole may be the best treatment option for frail patients.