No survival benefit associated with antifungal therapy for respiratory Candida spp.: a single-center retrospective cohort study

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Abstract Background Candida spp. are often recovered from respiratory cultures and usually interpreted as colonization. Whether species identity adds prognostic information or identifies patients more likely to benefit from antifungal therapy remains uncertain. Methods We performed a single-center retrospective cohort study of hospitalized adults with respiratory Candida spp. from 2018 through 2023, excluding same-admission candidemia. Mortality was assessed through 30 and 90 days. Species and mortality associations were estimated with multivariable Cox models. Antifungal therapy was evaluated as a post-culture time-dependent exposure and in stabilized inverse-probability-weighted analyses. Results Among 548 patients (median age, 66 years; 54.9% male; 33.4% non-Hispanic Black; 33.6% Hispanic), 78.3% required mechanical ventilation, 72.3% received vasopressors, and 30-day mortality was 27.0%. C. albicans accounted for 478 isolates (87.2%), C. glabrata for 18 (3.3%), and other non-albicans Candida spp. for 52 (9.5%). Compared with C. albicans, C. glabrata was associated with higher 30-day mortality (adjusted hazard ratio [aHR], 2.19; 95% confidence interval [CI], 1.05-4.56) and 90-day mortality (aHR, 2.18; 95% CI, 1.11-4.27). Antifungal therapy was not associated with lower 30-day mortality in time-dependent analysis (aHR, 1.25; 95% CI, 0.80-1.95) or weighted analysis (HR, 1.06; 95% CI, 0.64-1.75); 90-day analyses were also null. Conclusions Respiratory Candida spp. identified severe illness. C. glabrata identified a small high-mortality subgroup, but systemic antifungal therapy was not associated with improved survival, supporting caution against treating respiratory culture positivity alone.