Title : Improving candidaemia management through guideline compliance and structured electronic documentation: A multi-centre review
Abstract:
Background: Candidaemia remains a significant global cause of morbidity and mortality, with case fatality rates reported between 30–60%. Effective management requires both timely antifungal therapy and systematic investigation for potential complications, including endocarditis, endophthalmitis, and deep-seated organ involvement. International guidelines consistently emphasise the need for routine fundoscopy, echocardiography, repeat blood cultures to confirm clearance, and a minimum of 14 days of antifungal therapy following the first negative blood culture. Despite these well-established recommendations, real-world adherence varies considerably across healthcare systems. Additionally, the influence of electronic health records (EHRs) and documentation quality on candidaemia management pathways has not been well explored, despite increasing global reliance on digital systems.
Objectives: This study aimed to evaluate compliance with key international candidaemia management standards across a large multi-site hospital network, examine how documentation quality influences clinical follow-through, identify system-level barriers to completing recommended investigations and treatment, and propose a scalable EHR-based model to improve candidaemia care in diverse health settings.
Methods: A comprehensive review of 54 candidaemia episodes between 2021–2024 was undertaken within a multi-site healthcare organisation. Cases were identified via laboratory information systems and cross-referenced with EHR clinical documentation. Duplicate cultures from the same admission were excluded. Each episode was assessed against international standards relating to fundoscopy, echocardiography, repeat blood cultures, appropriateness of antifungal therapy, and treatment duration. Documentation completeness and structure were evaluated, and associations between documentation and adherence were analysed statistically. A structured EHR candidaemia note template was subsequently developed to improve clarity of management plans and to emphasise key guideline elements, particularly treatment duration and investigation requirements.
Results: Echocardiography compliance was 68.5% (37/54), while fundoscopy compliance reached 74% (40/54). Reasons for missed investigations included early patient deterioration, palliative decision-making, premature discharge before arrangements could be completed, and undocumented outpatient follow-up plans. Guideline-appropriate antifungal therapy was delivered in >95% of episodes, although occasional deviations in treatment duration were observed, typically associated with absent documentation of the 14-day post- clearance rule.
Structured EHR documentation demonstrated a strong, statistically significant association with completion of key investigations and correct treatment duration, including echocardiography (p < 2×10?¹?), fundoscopy (p < 2×10?¹?), and appropriate 14-day therapy (p = 1.7×10??). In contrast, informal communication methods such as email or messaging platforms were linked to inconsistent follow-through and greater uncertainty around clinical plans.
Conclusion: Although antifungal prescribing practices demonstrated high adherence to guideline standards, documentation variability had a clear and measurable impact on investigation completion and treatment duration. These findings highlight the central role of structured EHR documentation in supporting reliable delivery of complex, multi-step infectious disease pathways such as candidaemia care.
Implications for Global Practice: Introducing a standardised, guideline-aligned EHR candidaemia template represents a scalable, low-resource intervention applicable across diverse healthcare systems. Such tools may enhance communication, reduce missed investigations, strengthen antimicrobial stewardship, and promote safer, more consistent management of candidaemia worldwide.
