Patterns of Systemic Antifungal Initiation Across Ordinary, COVID-19, and Earthquake-Affected ICU Cohorts: A Retrospective Single-Center Study

Background: Systemic antifungal treatment in intensive care units (ICUs) is frequently initiated before microbiological confirmation. Earthquake-affected ICUs provide an important setting for examining antifungal decision-making under sudden patient surges and disrupted care processes. We compared initiation patterns across ordinary pre-pandemic, COVID-19, and earthquake-affected ICU cohorts. Methods: This retrospective single-center study included 566 adults receiving systemic antifungal therapy for suspected or blood-culture-confirmed Candida bloodstream infection: 256 ordinary pre-pandemic, 150 COVID-19, and 160 earthquake-affected patients. Initiation was classified as empirical, culture-guided, or same-day indeterminate using the recorded ICU days of treatment initiation and blood culture positivity. Initial antifungal class, documented infectious diseases consultation, and total treatment duration were compared. Thirty-day all-cause mortality after antifungal initiation was a secondary exploratory outcome. Results: Initiation patterns differed across cohorts (p < 0.001; Cramer’s V = 0.449). Empirical initiation occurred in 15.6%, 85.3%, and 69.4% of ordinary, COVID-19, and earthquake-affected patients, respectively. Echinocandins accounted for 96.0% of initial therapy in the COVID-19 cohort. Infectious diseases consultation was documented in 80.5%, 66.7%, and 19.4%, respectively. Median treatment durations were 8 (interquartile range, 6–10), 8 (4–14), and 6 (5–7) days (p < 0.001). After excluding 63 same-day cases, empirical initiation was not significantly associated with mortality after adjustment (adjusted odds ratio, 0.891; 95% confidence interval, 0.522–1.519; p = 0.671). Alternative same-day classifications also yielded nonsignificant associations. Conclusions: Recorded antifungal initiation timing and treatment patterns differed across the three ICU cohorts. These descriptive findings do not establish causal effects of healthcare context, treatment appropriateness, or equivalence between initiation approaches.