744. Antifungal De-escalation Strategy in ICU Patients: Clinical Success and Cost Savings

BACKGROUND: The incidence of Candida spp infections in critically ill patients is increasing. Initial broad-spectrum empiric antifungal agents (e.g., echinocandins), followed by immediate switching to fluconazole if isolates are fluconazole sensitive could be a low-cost de-escalation strategy. The aim of this study was to evaluate the budget impact of the de-escalation strategy using fungostatin in ICU patients and clinical effectiveness. METHODS: This prospective study was conducted in a 30-bed mixed ICU, from January 2015 through January 2017. Critically ill patients with invasive candidiasis were placed on initial empiric broad-spectrum antifungal agents either on echinocandins or liposomal amphoteric B. De-escalation to fungostatin strategy at day 3 vs. patients without de-escalation were compared. Clinical characteristics and the presence of clinical success by the eighth-day of treatment and 28-day outcome were evaluated. Clinical success was defined as the complete eradication of Candida spp. in blood cultures. Economic outcomes included budget impact was also evaluated. RESULTS: Forty-seven ICU patients with documented invasive candidemia enrolled and received empiric broad-spectrum antifungal agents with either echinocandins or liposomal amphotericin B. Of those, 22 (47%) were eligible for de-escalation at day 3 to fungostatin based on susceptibility test for fungi. Specific Candida species isolated in the de-escalation group were C. albicans (14, 64%), and non-C. albicans (8, 36%). Interestingly 6/22 (27%) invasive candidemia de-escalated cases relapsed by day 8 of initiation of the empiric therapy, vs. 2/25 (8%) of the control group (P = 0.12). Survival rates at day 28 were not statistically significant among the two groups [15/22 (68%) vs. 11/25 (44%), P = 0.12]. The budget impact of using de-escalation was greater, producing cost savings of €3,200 per patient but did not translate into significant clinical and mycological success. CONCLUSION: Critically ill patients who had received empiric antifungal therapy for documented candidemia and underwent de-escalation from echinocandins or liposomal ambisome B to fungostatin had a potential economic cost–benefit but did not associate with significantly improved clinical success rates. DISCLOSURES: All authors: No reported disclosures.