Physician's Compliance to Clinical Practice Guidelines and Outcomes of Patients With Invasive Candidiasis in a University Hospital in Thailand.

Abstract

Introduction: Invasive candidiasis is a life-threatening fungal infection associated with high mortality rates. Adherence to clinical practice guidelines (CPG) has been shown to improve patient outcomes. This study aimed to evaluate physician compliance with CPG following the implementation of care bundles and locally developed CPG and to assess the impact of CPG implementation on patient mortality.

Methods: This quasi-experimental study utilised a historical cohort control design. Candidemia patients treated at Siriraj Hospital in Bangkok, Thailand, from November 2021 to April 2024 were enrolled. A prospective cohort group received CPG for invasive candidiasis, modified from ESCMID recommendations, covering eight facets. Education care bundles, including clinical policy, training, infographic sheets, leaflets and SMS alerts, were also implemented. Each CPG item was scored as 0, 1 or 2, representing non-compliance, partial compliance and full compliance, respectively. A total compliance score below eight indicates poor compliance. Physician compliance and 30-day mortality rates were analysed.

Results: A total of 112 patients were included in the study: 56 in the historical control group and 56 in the prospective intervention group. Both groups exhibited similar baseline characteristics and risk factors for candidemia. Following the implementation of the CPG and care bundles, physician compliance significantly improved across several metrics. Notable increases were observed in: initiating anti-fungal therapy within 24 h (OR = 6.00, 95% CI [2.41-14.96], p < 0.001), receipt of appropriate anti-fungal therapy, specifically with echinocandins or amphotericin B (OR = 9.17, 95% CI [1.11-75.96], p = 0.03), catheter removal or source control within 48 h (OR = 37.17, 95% CI [4.68-295.39], p < 0.001), obtaining blood cultures at least every other day (OR = 19.15, 95% CI [7.35-49.86],p < 0.001), continuing anti-fungal therapy for at least 14 days after the first negative culture (OR = 3.30, 95% CI [1.42-7.67], p = 0.005), conducting echocardiography (0% vs. 16.1%, p = 0.003), performing fundoscopy (OR = 5.24, 95% CI [1.79-15.30], p = 0.001). There was a significant improvement in compliance scores, with ≥ 8 being more prevalent in the intervention group compared to controls (OR = 5.39, 95% CI [1.98-14.69], p < 0.001). The mean compliance score was 8 ± 2 in the control group and 11 ± 2 in the intervention group (p < 0.001). Additionally, the all-cause 30-day mortality rate decreased significantly from 55.4% in the control group to 35.7% in the intervention group (OR = 0.45, 95% CI [0.21-0.96], p = 0.04).

Conclusions: The implementation of CPG and care bundles for invasive candidiasis significantly enhanced physician compliance and improved patient survival. These findings support the continued adoption of CPG and care bundles in the management of invasive candidiasis.