Antifungal treatment (AFT) for proven or probable invasive candidiasis (IC) is common in critically ill immunocompromised patients. Early AFT de-escalation appears safe in unselected ICU patients, but has not been studied specifically amongst immunocompromised hosts.

This retrospective study was conducted in 19 ICUs in France between January 2019 and December 2024. All immunocompromised patients hospitalized in ICU for ≥5 days and treated with antifungals for a first proven or probable episode of IC were included. Early AFT de-escalation was defined as either spectrum reduction, i.e., a switch from an initial echinocandin or liposomal amphotericin B to fluconazole, or complete discontinuation of the initial antifungal, occurring within 5 days (day 1–5) of treatment initiation. The primary objective was to determine the incidence of early AFT de-escalation (censored at day 28 after initiation of AFT).

242 patients were analysed (median age 64 years, 64% males). Most patients ( n= 175, 72.3%) were treated empirically or pre-emptively for probable IC. Early AFT de-escalation occurred in 92 patients (38%, 95% confidence interval [CI] 31.9%–44.2%). AFT de-escalation consisted of spectrum reduction in 35.9%, and AFT discontinuation in 64.1% of cases. There was no difference in ICU mortality, ICU length-of-stay and the number of ventilator-free days between patients with and without AFT de-escalation. AFT was re-initiated within 7 days of de-escalation in 6 of the 92 patients (6.5%) who had undergone early AFT de-escalation.

Early AFT de-escalation occurred in 38% of critically ill immunocompromised patients, and was not associated with adverse prognostic outcomes.