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Elias Anaissie, Marcio Nucci, Far-reaching Conclusions Based on Weak and Missing Data, Clinical Infectious Diseases, Volume 55, Issue 6, 15 September 2012, Pages 890–893, https://doi.org/10.1093/cid/cis521
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Tothe Editor—Andes et al can be commended for their extensive analysis of outcome predictors for invasive candidiasis (IC). The authors pooled data from 7 randomized controlled trials (RCTs) of candidemia/IC [1] and selected 30-day all-cause mortality as the primary endpoint, with clinical cure serving as the secondary endpoint. Apache II score, removal of central venous catheter (CVC), and echinocandin therapy emerged as independent predictors of mortality and clinical cure [1] with the authors concluding that a treatment strategy of echinocandin and “CVC removal at any time” improves outcomes. We herein show that these recommendations are not supported by data. To test the IDSA recommendations that “early CVC removal” improved candidemia outcomes [2], we pooled data from the 2 most contemporary studies examined by Andes et al, included only the 842 subjects who fulfilled Infectious Diseases Society of America (IDSA) criteria (ie, presence of both candidemia and CVC), and tested the effect of “early removal” (within 24 or 48 hours after antifungal therapy) [3]. We emphasized candidemia-relevant endpoints (clinical cure, time to mycological eradication, and rates of recurrent/persistent candidemia) and examined 28- and 42-day survival. Despite applying strict IDSA-driven criteria to a well-defined infection (candidemia), we failed to identify benefits from early CVC removal for any of the predefined outcomes. Our remarkably consistent findings across all outcomes and both removal time points confirm the robustness of our analysis [3]. The striking differences between our findings [3] and those of Andes et al [1] are likely related to the following limitations in Andes et al's work:
