Abstract and Introduction
Abstract
Objectives: To provide a global, up-to-date picture of the prevalence, treatment, and outcomes of Candida bloodstream infections in intensive care unit patients and compare Candida with bacterial bloodstream infection.
Design: A retrospective analysis of the Extended Prevalence of Infection in the ICU Study (EPIC II). Demographic, physiological, infection-related and therapeutic data were collected. Patients were grouped as having Candida, Gram-positive, Gram-negative, and combined Candida/bacterial bloodstream infection. Outcome data were assessed at intensive care unit and hospital discharge.
Setting: EPIC II included 1265 intensive care units in 76 countries.
Patients: Patients in participating intensive care units on study day.
Interventions: None.
Measurement and Main Results: Of the 14,414 patients in EPIC II, 99 patients had Candida bloodstream infections for a prevalence of 6.9 per 1000 patients. Sixty-one patients had candidemia alone and 38 patients had combined bloodstream infections. Candida albicans (n = 70) was the predominant species. Primary therapy included monotherapy with fluconazole (n = 39), caspofungin (n = 16), and a polyene-based product (n = 12). Combination therapy was infrequently used (n = 10). Compared with patients with Gram-positive (n = 420) and Gram-negative (n = 264) bloodstream infections, patients with candidemia were more likely to have solid tumors (p < .05) and appeared to have been in an intensive care unit longer (14 days [range, 5–25 days], 8 days [range, 3–20 days], and 10 days [range, 2–23 days], respectively), but this difference was not statistically significant. Severity of illness and organ dysfunction scores were similar between groups. Patients with Candida bloodstream infections, compared with patients with Gram-positive and Gram-negative bloodstream infections, had the greatest crude intensive care unit mortality rates (42.6%, 25.3%, and 29.1%, respectively) and longer intensive care unit lengths of stay (median [interquartile range]) (33 days [18–44], 20 days [9–43], and 21 days [8–46], respectively); however, these differences were not statistically significant.
Conclusion: Candidemia remains a significant problem in intensive care units patients. In the EPIC II population, Candida albicans was the most common organism and fluconazole remained the predominant antifungal agent used. Candida bloodstream infections are associated with high intensive care unit and hospital mortality rates and resource use.
Introduction
Candida bloodstream infections (BSIs) and other forms of invasive candidiasis are the most common invasive fungal infections among hospitalized patients. In the United States, infections resulting from Candida BSI are currently the fourth leading cause of nosocomial BSIs among hospitalized patients and third among intensive care unit (ICU) patients. Invasive Candida infections are an increasingly problematic in ICU patients as a result of the high crude mortality, ranging from 35% to 67%. Additionally, invasive candidiasis is also associated with significant cost and healthcare use. The increased length of stay in the hospital and the ICU are major contributors to the economic burden of Candida BSI with estimated cost associated with an episode of candidemia between $25,000 and $55,000.
Fluconazole remains an effective systemic antifungal agent for treatment for Candida BSI and patients with Candida BSI appear to benefit from early fluconazole therapy. However, the 2009 Infectious Disease Society of America (IDSA) treatment guidelines favor the use of an echinocandin for primary therapy of candidemia in patients who are moderately ill to severely ill and recommend fluconazole for patients who are less critically ill, in part based on the results of recent clinical trials of echinocandins in patients with candidemia and invasive candidiasis.
Understanding the current epidemiology of Candida BSI in critically ill patients may impact the choice of initial therapy. Significant regional and geographic differences exist in the incidence of the different Candida species. In some series, non-albicans Candida species account for the approximately half of all Candida BSIs. Candida glabrata is generally the second most commonly isolated pathogen in North America but occurs less frequently in other regions.
The Extended Prevalence of Infection in Intensive Care study (EPIC II) was conducted to provide an up-to-date picture of the extent and patterns of infection in ICUs throughout the world. We report the prevalence, epidemiology, treatment choices, and outcomes of Candida BSI in a worldwide sample of ICU patients. Also, patients with Candida BSIs were compared with patients with bacterial BSI and combined BSIs.