Download An audit of the management of invasive candidaemia

Medical Microbiology audit template
Date of
completion
(To be inserted when completed)
Name of lead
author/
participants
(To be inserted)
Specialty
Medical Microbiology
Title
An audit of the management of invasive candidaemia
Background
Candidaemia is increasing in incidence, and attributable mortality is >20%.
Proposed standards of care for patients with invasive fungal infections were
produced by the British Society for Medical Mycology (BSMM) in 20031 and
audited nationally.2 Updates of Clinical Practice Guidelines for the Management of
Candidiasis3 and Intravascular Catheter-Related Infection4 were produced by the
Infectious Diseases Society of America in 2009.
The most recent guidelines (publication imminent) are the ESCMID candidiasis
guidelines.5 Standards for this audit template have been derived from these
various publications, but it should be noted that the management of complications
of candidaemia, such as ocular candidiasis (occurring in up to 16%)6 or
endocarditis (>8%),5 are not specifically addressed.
Aim and
objectives
To examine whether the correct specimens are taken for laboratory processing
and to see how management of candidaemia correlates with guidelines.
Standards
and criteria
Criteria range: 100% compliance is probably unreasonable, given the evidence
base could be stronger. However >85% should be achievable and explanation of
variance would help inform practice. Where appropriate, there should be
documentation in the case notes that explains any variance.
Identification of the Candida spp from blood cultures or invasive devices should
be performed.3-5
Sensitivity testing of the Candida spp from blood cultures or invasive devices
should be performed.3 -5
Patients with candidaemia should have lines removed within 48 hours of
diagnosis. 4,5
Patients should be treated systemically with an anti-fungal agent at an
appropriate dose.5
Ocular candidiasis should be considered in candidaema.5, 6
Endocarditis should be considered in candidaemia.5
At least one blood culture per day should be taken, until the culture results are
negative.5
Transition/step-down therapy should be appropriate (timing and doses).5
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Duration of treatment should be in line with recommendations: 14 days after the
end of candidaemia for uncomplicated cases.5
Therapeutic drug monitoring is recommended with voriconazole or
posaconazole.5
Method
Sample selection: The last 20 patients with candidaemia.
Data to be collected on proforma (see below).
Results
(To be completed by the author)
The results of this audit show the following % compliance with the standards:
% compliance
Identification of the Candida spp from blood cultures or
invasive devices was performed
Sensitivity testing of the Candida spp from blood cultures or
invasive devices was performed
Patients with candidaemia should have lines removed within
48 hours of diagnosis
Patients treated systemically with an anti-fungal agent at an
appropriate dose
Ocular candidiasis was considered
Endocarditis was considered
At least one blood culture per day was taken until the culture
results came back negative
Transition/step-down therapy: appropriate timing and doses
Duration of treatment was in line with recommendations: 14
days after the end of candidaemia for uncomplicated cases5
Therapeutic drug monitoring was performed for those treated
with voriconazole or posaconazole
Commentary:
Conclusion
(To be completed by the author)
Recommendations for
improvement
Present the result with recommendations, actions and responsibilities for action
and a timescale for implementation. Assign a person/s responsible to do the work
within a timeframe.
Some suggestions:


highlight areas of practice that are different
present findings.
Action plan
(To be completed by the author – see attached action plan proforma)
Re-audit date
(To be completed by the author)
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References
1. Denning DW, Kibbler CC, Barnes RA, British Society for Medical Mycology.
British Society for Medical Mycology proposed standards of care for patients
with invasive fungal infections. Lancet Infect Dis 2003;3:230–240.
2. Schelenz S, Barnes RA, Kibbler CC. Jones BL, Denning DW. Standards of
care for patients with invasive fungal infections within the United Kingdom: a
national audit. J Infect 2009;58:145–153.
3. Pappas PG, Kauffman DCA, Andes D, Benjamin DK Jr, Calandra TF,
Edwards JE Jr et al. Clinical practice guidelines for the management of
candidiasis: 2009 update by the Infectious Diseases Society of America. Clin
Infect Dis 2009;48:503–535.
4. Mermel LA, Allon M, Bouza E, Craven DE , Flynn P, O'Grady NP et al. Clinical
practice guidelines for the diagnosis and management of intravascular
catheter-related infection: 2009 Update by the Infectious Diseases Society of
America. Clin Infect Dis 2009;49:1–45.
5. Corneley OA, Bassetti M ,Calandra T, Garbino J, Kullberg B-J, Lortholary O et
al. ESCMID guideline for the diagnosis and management of candida diseases
2012, Non-neutropenic adults. Clin Microbiol Infect Dis [in press].
doi 10:1111/1469-0691.12039.
6. Oude Lashof AM, Rothova A, Sobel JD, Ruhnke M, Pappas PG, Viscoli C et
al. Ocular manifestations of candidemia. Clin Infect Dis 2011;53:262–268.
7. Local hospital guidelines in use.
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Data collection proforma for treatment of invasive candidaemia
Patient name:
Hospital number:
Date of birth:
Consultant:
1
2
Yes No
3 If no, was there
documentation to
explain the
variance?
Yes/No plus freetext comment
4 Compliant with
guideline based on
Yes from column 1 or
an appropriate
explanation from
column 3. Yes/No
Identification of the Candida spp
from blood cultures or invasive
devices was performed
Candida other than C albicans
should be tested for sensitivity to
antifungal agents
Patients with candidaemia should
have their central line removed
within 48 hours of diagnosis
and be treated systemically with
an anti-fungal agent at an
appropriate dose
Patients with candidaemia were
treated systemically with an antifungal agent at an appropriate
dose
Ocular candidiasis was considered
Endocarditis was considered
Transition/step-down therapy:
timing and doses were appropriate
Duration of treatment was in line
with recommendations: 14 days
after the end of candidaemia for
uncomplicated cases
Voroiconazole or posaconazole
serum levels checked if prescribed
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Audit action plan
An audit of the management of invasive candidaemia
Audit
recommendation
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Objective
Action
Timescale Barriers
and
constraints
5
Outcome
Monitoring
V5