Excess Mortality, Hospital Stay, and Cost Due to Candidemia: A Case-Control Study Using Data From Population-Based Candidemia Surveillance

An observational study on the epidemiological and mycological profile of Candidemia in ICU patients

Background

This study aimed to analyze the epidemiological and mycological profile of candidemia in intensive care unit (ICU) patients attending a tertiary care teaching hospital in the Himalayan region of northern India.

Material/Methods

A 15-bed medico-surgical ICU and a 5-bed pediatric ICU. Ninety-one consecutively admitted ICU patients were screened for the presence of candidemia by performing blood cultures at periodic intervals.

Results

The recovered Candida isolates were speciated and subjected to antifungal susceptibility testing using standard procedures. Forty-one of the recruited patients (45%) were found to be candidemic, with the majority of patients being in the extremes of age (13 neonates and 15 >65 years of age). Four risk factors were found to be significantly associated with the occurrence of candidemia in our patients – a period of hospitalization exceeding 7 days (p=0.0008), previous use of antibiotics (p=0.001), presence of chronic renal failure (p=0.003), and ongoing cancer chemotherapy (p= 0.041). Ninety-six Candida isolates were recovered from the 41 culture-positive patients, with Candida albicans being the commonest isolate recovered (n=75, 78.1%), followed by Candida tropicalis (n=15, 16%), and Candida glabrata (n=6, 6.5%). Fluconazole resistance was observed among 26% of all Candida isolates and 17.3% of C. albicans isolates.

Conclusions

Contrary to the majority of recent reports, species shift towards non-albicans candidemia has not been observed in our center, though the prevalence of azole resistance is alarmingly high even among the C. albicans isolates.

Impact of yeast-bacteria coinfection on the detection of Candida sp. in an automated blood culture system

Invasive candidiasis remains a major cause of morbidity and mortality. It is now well known that an early diagnosis contributes to the patients' outcome. Blood cultures, which are the first-line test in case of bloodstream infection suspicion, can be carried out using fungus-selective medium (containing antibiotics) or standard microorganism medium allowing both bacterial and fungal growth. Some patients can suffer from polymicrobial sepsis involving bacteria and yeasts, so we decided to investigate in blood cultures the influence of the presence of bacteria on fungal development. Simulated blood cultures were performed using Candida albicans or C. glabrata coincubated with Escherichia coli or Staphylococcus aureus at different concentrations. The results showed that, in a standard microorganism medium, bacterial growth could hide the fungal development. Thus, in patients at risk of invasive candidiasis, the use of a specific fungal medium could improve the diagnosis and allow an earlier efficient antifungal treatment.

Multidisciplinary approach to the treatment of invasive fungal infections in adult patients. Prophylaxis, empirical, preemptive or targeted therapy, which is the best in the different hosts?

The high morbidity, mortality, and health care costs associated with invasive fungal infections, especially in the critical care setting and immunocompromised host, have made it an excellent target for prophylactic, empiric, and preemptive therapy interventions principally based on early identification of risk factors. Early diagnosis and treatment are associated with a better prognosis. In the last years there have been important developments in antifungal pharmacotherapy. An approach to the new diagnosis tools in the clinical mycology laboratory and an analysis of the use new antifungal agents and its application in different clinical situations has been made. Furthermore, an attempt of developing a state of the art in each clinical scenario (critically ill, hematological, and solid organ transplant patients) has been performed, trying to choose the best strategy for each clinical situation (prophylaxis, pre-emptive, empirical, or targeted therapy). The high mortality rates in these settings make mandatory the application of early de-escalation therapy in critically ill patients with fungal infection. In addition, the possibility of antifungal combination therapy might be considered in solid organ transplant and hematological patients.

Patient isolation measures for infants with candida colonization or infection for preventing or reducing transmission of candida in neonatal units

BACKGROUND

Candida is a common nosocomial infection and is associated with increased healthcare costs. In neonates, candida infection is associated with high mortality and morbidity and is transmitted by direct and indirect contact. Patient isolation measures, i.e. single room isolation or cohorting, are usually recommended for infections that spread by contact.

OBJECTIVES

To determine the effect of patient isolation measures (single room isolation and/or cohorting) for infants with candida colonization or infection as an adjunct to routine infection control measures on the transmission of candida to other infants in the neonatal unit.

SEARCH METHODS

Relevant trials in any language were searched in the following databases in July 2011: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2011), MEDLINE, BIOSIS, EMBASE and CINAHL. Proceedings of the Pediatric Academic Societies (from 1987) and ongoing trials were searched.

SELECTION CRITERIA

Types of studies: Cluster randomized trials (where clusters may be defined by hospital, ward, or other subunits of the hospital).

TYPES OF PARTICIPANTS

Neonatal units caring for infants colonized or infected with Candida. Types of interventions: A policy of patient isolation measures (single room isolation or cohorting of infants with Candida colonization or infection) compared to routine isolation measures.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Review Group (CNRG) were used to identify studies and to assess the methodological quality of eligible cluster-randomized trials. Infection rates and colonization rates were to be expressed as rate ratios for each trial and if appropriate for meta-analysis, the generic inverse variance method in RevMan was to be used.

MAIN RESULTS

No eligible trials were identified.

AUTHORS' CONCLUSIONS

The review found no evidence to either support or refute the use of patient isolation measures (single room isolation or cohorting) in neonates with candida colonization or infection.Despite the evidence for transmission of candida by contact and evidence of cross-infection by health care workers, no standard policy of patient isolation measures beyond routine infection control measures exists in the neonatal unit. There is an urgent need to research the role of patient isolation measures for preventing transmission of candida in the neonatal unit. Well designed trials randomizing clusters of units or hospitals to a type of patient isolation method intervention are needed.

Validation of 24-hour flucytosine MIC determination by comparison with 48-hour determination by the Clinical and Laboratory Standards Institute M27-A3 broth microdilution reference method

Flucytosine and itraconazole are the only antifungal agents for which the Clinical Laboratory and Standards Institute recommendations include MIC breakpoint readings at 48 h only. Here we show good essential and categorical agreement between the flucytosine MIC readings at 48 and 24 h for Candida species.

Epidemiology and antifungal susceptibility of bloodstream Candida isolates in Quebec: Report on 453 cases between 2003 and 2005

BACKGROUND

Between May 2003 and April 2005, a population-based surveillance of Candida bloodstream infections was conducted in Quebec. A total of 453 episodes of candidemia (464 yeast isolates) from 54 participating hospitals were studied.

RESULTS

The annual incidence rate was three per 100,000 population. Global hospital mortality was 38%. The most common predisposing factors were the presence of an intravascular catheter (80%), use of antibacterial therapy (67%), stay in an intensive care unit (49%), use of parenteral nutrition (32%) and intra-abdominal surgery (31%). Fluconazole alone or in association with other antifungals was used for treatment in over 80% of cases. Candida albicans comprised 62% of isolates, followed by Candida glabrata (17%), Candida parapsilosis (9%), Candida tropicalis (5%), Candida lusitaniae (3%) and Candida krusei (3%). Of the 288 C albicans isolates, seven (2%) were resistant to flucytosine, one to fluconazole and none to itraconazole or voriconazole. Of the 75 non-C albicans species isolates with reduced susceptibility to fluconazole (minimum inhibitory concentration [MIC] 16 mug/mL or greater), none were susceptible to itraconazole (MIC 0.12 mg/L or lower), whereas 71 (95%) were susceptible to voriconazole (MIC 1 mug/mL or lower). However, only five of 12 (42%) fluconazole-resistant isolates were susceptible to voriconazole. Posaconazole, ravuconazole and caspofungin displayed a broad spectrum of activity against these isolates, with MICs of 1 mg/L or lower in 56%, 92% and 100% of isolates, respectively. Overall, a correlation (r(2)>0.87) was observed among increasing fluconazole MICs and the geometric mean MICs of itraconazole, voriconazole, posaconazole and ravuconazole.

CONCLUSIONS

These surveillance results when compared with those of the 1993 to 1995 survey confirm little variation in the distribution of species causing invasive Candida infection over a 10-year period in Quebec, as well as the continuous excellent overall in vitro activity of fluconazole.

Evaluation of antifungal therapy in patients with candidaemia based on susceptibility testing results: implications for antimicrobial stewardship programmes

BACKGROUND

Definitive antifungal therapy is typically based on Candida species and clinical status, rather than susceptibility reports. Antifungal susceptibility testing is available, but the impact on treatment decisions is unknown. The purpose of this study was to assess antifungal therapy in hospitalized patients with candidaemia during the time period between the start of empirical therapy and after antifungal susceptibility testing reports are available.

METHODS

A retrospective study of 161 hospitalized patients with candidaemia was conducted. Patients who received fluconazole or an echinocandin were evaluated for changes in empirical antifungal therapy prior to and after susceptibility reporting.

RESULTS

One hundred and sixty-one patients aged 59 ± 16 years (male, 54%; Caucasian, 52%; APACHE II score ≥ 15, 48%; and intensive care unit, 50%) were identified, of whom 130 (81%) had fluconazole-susceptible candidaemia. Fifty-eight patients (36%) were initiated on fluconazole and 103 (64%) on an echinocandin. The mean time from culture to the susceptibility report was 5 ± 2 days. Prior to availability of the susceptibility report, 20 fluconazole-initiated patients (34%) were switched to an echinocandin, while 14 echinocandin-initiated patients (14%) were switched to fluconazole. Once a susceptibility report was available, 35 of 89 (39%) patients with fluconazole-susceptible candidaemia on an echinocandin were de-escalated to fluconazole. Eleven patients on fluconazole just prior to a susceptibility report were identified with a fluconazole-resistant Candida species.

CONCLUSIONS

Using antifungal susceptibility testing, patients given fluconazole with fluconazole-resistant Candida species were identified. Less than 40% of echinocandin-treated patients with fluconazole-susceptible organisms were de-escalated to fluconazole. Antifungal susceptibility testing may help to identify patients in need of clinical intervention.

[Update: invasive fungal infections: Diagnosis and treatment in surgical intensive care medicine]

Fungal infections are of great relevance in surgical intensive care and Candida species represent the predominant part of fungal pathogens. Invasive aspergillosis is also relevant especially in patients with chronic pulmonary diseases. It is crucial for therapy success to begin adequate antifungal treatment at an early stage of the disease. Risk stratification of individual patient symptoms is essential for therapy timing. In case of suspected or proven candida infection, fluconazole is the agent of choice when the patient is clinically stable and no azoles have been administrated in advance and the local epidemiology makes azol resistance unlikely. For clinically instable patients with organ dysfunction the echinocandins serve as primary therapy because of their broad spectrum and reasonable safety profile. Due to a relevant proportion of azole resistant Candida species, susceptibility testing should be done routinely. Depending on the species detected de-escalating to an azole is feasible if organ dysfunctions have resolved. An invasive aspergillosis is primarily treated with voriconazole.

[Incidence of central line-associated bloodstream infection in an intensive care unit]

BACKGROUND

Central line-associated bloodstream infection (CLABSI) is one of the most common nosocomial infections. The incidence is higher in paediatric patients than in adults, especially in those admitted to Intensive Care Units (ICU). CLABSI-related morbidity makes it a major health problem; therefore it is necessary to develop prevention strategies against it.

PATIENTS AND METHODS

An intervention study in a paediatric ICU (PICU) was performed, in order to assess the impact of the introduction of the program «Bacteraemia zero» in December 2007. This program aims to prevent CLABSI. Demographic data and variables related to hospitalisation and infection were collected from January to December 2007 (before the intervention) and from January to December 2008 (after the intervention), and were compared. In the first period, 497 patients were studied, and 495 in the second.

RESULTS

A reduction of 30.4% in the incidence of CLABSI (P=0.49) in the second year was observed (5.5 to 3.8 episodes per 1000 catheter-days). The CVC use ratio was 0.59 and 0.64, respectively. The most frequently isolated organism was coagulase-negative Staphylococcus spp.

CONCLUSIONS

The implementation of a «no bacteraemia» program, involving all staff in the PICU as well as the professionals in infection control, reduces the incidence of CLABSI.

Multicenter comparison of the Vitek 2 antifungal susceptibility test with the CLSI broth microdilution reference method for testing caspofungin, micafungin, and posaconazole against Candida spp

The performance of the automated Vitek 2 (bioMérieux, Inc., Marcy l'Etoile, France) antifungal susceptibility system was compared to that of broth microdilution (BMD) for the determination of MICs of various antifungal drugs. A total of 112 challenge strains and 755 clinical isolates of Candida spp. were tested against caspofungin and micafungin. An additional 452 clinical isolates of Candida albicans were tested against posaconazole. Reference BMD MIC endpoints were established after 24 h of incubation for caspofungin and micafungin and after 48 h of incubation for posaconazole. Essential agreements (EAs) between the Vitek 2 and BMD methods for caspofungin and micafungin were 99.5% and 98.6%, respectively. EA between the Vitek 2 and BMD methods was 95.6% for posaconazole. The overall categorical agreements (CAs) between the Vitek 2 system and BMD were 99.8% for caspofungin, 98.2% for micafungin, and 98.1% for posaconazole. The Vitek 2 system reliably determined caspofungin and micafungin MICs among Candida spp. and posaconazole MICs among C. albicans isolates and demonstrated excellent quantitative and qualitative agreement with the reference BMD method.

Nosocomial fungal infections: epidemiology, infection control, and prevention

Fungal infections are an increasing cause of morbidity and mortality in hospitalized patients. This article reviews the current epidemiology of nosocomial fungal infections in adult patients, with an emphasis on invasive candidiasis and aspergillosis. Recently published recommendations and guidelines for the control and prevention of these nosocomial fungal infections are summarized.

Attributable hospital cost and antifungal treatment of invasive fungal diseases in high-risk hematology patients: an economic modeling approach

Studies using patient-level data to determine the attributable cost of invasive fungal diseases (IFDs) are few. Using a case-control study with activity-based costing of patients admitted to a quaternary hospital from 2002 to 2007, we determined attributable hospitalization cost (and 12 weeks thereafter), length of stay (LOS), and costly antifungal treatment (C-AT; liposomal amphotericin B, voriconazole, posaconazole, caspofungin), expressed as defined daily doses (DDDs) per IFD episode, in patients with hematological malignancies and hematopoietic stem cell recipients. Matching criteria and median regression modeling controlled for confounding variables, including LOS prior to IFD onset. Multiple mycoses were identified in 43 matched case-control pairs (n=86). A separate sensitivity analysis included 22 unmatched patients. IFD status was associated with a median excess cost of AU$30,957 (95% confidence interval [CI]=AU$2,368 to AU$59,546; P=0.034), approximating at purchasing power parity US$21,203 (95% CI=US$1,622 to US$40,784) and €15,788 (95% CI=€1,208 to €30,368), increasing to AU$80,291 (95% CI=AU$33,636 to AU$126,946; P=0.001), i.e., US$54,993 (95% CI=US$23,038 to US$86,948) and €40,948 (95% CI=€17,154 to €64,742), with intensive care unit (ICU) requirement. Cost determinants were pharmacy costs (64%; P<0.001) inclusive of antifungal treatment (27%; P<0.001) and ward costs (27%; P=0.091), with proportions persisting through 12 weeks for 25 surviving matched pairs (pharmacy, 60% [P=0.12]; ward, 31% [P=0.21]). Median LOS was not significantly increased unless unmatched patients were included (8 days, 95% CI=1.8 to 14 days; P=0.012). Excess C-ATs were 17 DDDs (95% CI=15 to 19 DDDs; P<0.001) per case patient and 19 DDDs (95% CI=16 to 22 DDDs; P<0.001) per ICU patient. The sensitivity analysis was confirmatory (for median cost, AU$29,441, 95% CI=AU$5,571 to AU$53,310, P=0.016; for C-AT, 17 DDDs, 95% CI=16 to 18 DDDs, P<0.001). IFD results in increased hospital and ICU costs, with pharmacy costs, including antifungal treatment, being major determinants. Consumption of costly antifungal drugs may be a novel resource metric with wider generalizability than cost alone.

Bench-to-bedside review: therapeutic management of invasive candidiasis in the intensive care unit

Candida is one of the most frequent pathogens in bloodstream infections, and is associated with significant morbidity and mortality. The epidemiology of species responsible for invasive candidiasis, both at local and worldwide levels, has been changing - shifting from Candida albicans to non-albicans species, which can be resistant to fluconazole (Candida krusei and Candida glabrata) or difficult to eradicate because of biofilm production (Candida parapsilosis). Numerous intensive care unit patients have multiple risk factors for developing this infection, which include prolonged hospitalisation, use of broad-spectrum antibiotics, presence of intravascular catheters, parenteral nutrition, high Acute Physiology and Chronic Health Evaluation score, and so forth. Moreover, delaying the specific therapy was shown to further increase morbidity and mortality. To minimise the impact of this infection, several management strategies have been developed - prophylaxis, empirical therapy, pre-emptive therapy and culture-based treatment. Compared with prophylaxis, empirical and pre-emptive approaches allow one to reduce the exposure to antifungals by targeting only the patients at high risk of candidemia, without delaying therapy until the moment blood Candida is identified in blood cultures. The agents recommended for initial treatment of candidemia in critically ill patients include echinocandins and lipid formulation of amphotericin B.

Clinical and economic outcomes of decreased fluconazole susceptibility in patients with Candida glabrata bloodstream infections

BACKGROUND

The impact of reduced fluconazole susceptibility on clinical and economic outcomes in patients with Candida glabrata bloodstream infections (BSI) is unknown.

METHODS

A retrospective cohort study was conducted to evaluate 30-day inpatient mortality and postculture hospital charges in patients with C glabrata BSI with decreased fluconazole susceptibility (minimum inhibitory concentration [MIC] ≥ 16 μg/mL) versus fluconazole-susceptible C glabrata BSI (MIC ≤ 8 μg/mL). These analyses were adjusted for demographics, comorbidities, and time at risk. Secondary analyses limited the C glabrata group with decreased fluconazole susceptibility to MIC ≥ 64 μg/mL.

RESULTS

There were 45 (31%) deaths among 144 enrolled patients: 19 deaths (25%) among 76 patients with C glabrata BSI with decreased fluconazole susceptibility and 26 deaths (38%) among 68 patients with fluconazole-susceptible C glabrata BSI. Decreased fluconazole susceptibility was not independently associated with increased 30-day inpatient mortality (adjusted odds ratio, .60; 95% confidence interval (CI): .26-1.35; P = 0.22) or hospital charges (multiplicative change in hospital charges, .93; 95% CI: .60-1.43; P = 0.73). Older age was associated with increased mortality and increased time at risk was associated with increased hospital charges.

CONCLUSION

Crude mortality rates remain high in patients with C glabrata BSI. However, decreased fluconazole susceptibility was not associated with increased mortality or hospital charges.

Secular trend in candidemia and the use of fluconazole in Finland, 2004-2007

Background

In a previous study we observed an increasing trend in candidemia in Finland in the 1990s. Our aim was now to investigate further population-based secular trends, as well as outcome, and evaluate the association of fluconazole consumption and prophylaxis policy with the observed findings.

Methods

We analyzed laboratory-based surveillance data on candidemia from the National Infectious Diseases Register during 2004-2007 in Finland. Data on fluconazole consumption, expressed as defined daily doses, DDDs, was obtained from the National Agency for Medicines, and regional prophylaxis policies were assessed by a telephone survey.

Results

A total of 603 candidemia cases were identified. The average annual incidence rate was 2.86 cases per 100,000 population (range by year, 2.59-3.09; range by region, 2.37-3.85). The highest incidence was detected in males aged >65 years (12.23 per 100,000 population). Candida albicans accounted for 67% of cases, and C. glabrata ranked the second (19%), both without any significant change in proportions. C. parapsilosis accounted for 5% of cases and C. krusei 3% of cases. The one-month case-fatality varied between 28-32% during the study period. Fluconazole consumption increased from 19.57 DDDs per 100,000 population in 2000 to 25.09 in 2007. Systematic fluconazole prophylaxis was implemented for premature neonates, patients with acute leukemias and liver transplant patients.

Conclusion

The dominant proportion of C. albicans remained stable, but C. glabrata was the most frequent non-albicans species. The proportion of C. glabrata had increased from our previous study period in the presence of increasing use of fluconazole. The rate of candidemia in Finland is still low but mortality high like in other countries.

Nationwide sentinel surveillance of bloodstream Candida infections in 40 tertiary care hospitals in Spain

Candidemia studies have documented geographic differences in rates and epidemiology, underscoring the need for surveillance to monitor trends. We conducted prospective candidemia surveillance in Spain to assess the incidence, species distribution, frequency of antifungal resistance, and risk factors for acquiring a Candida infection. Prospective laboratory-based surveillance was conducted from June 2008 to June 2009 in 40 medical centers located around the country. A case of candidemia was defined as the isolation of a Candida species from a blood culture. Incidence rates were calculated per 1,000 admissions. Antifungal susceptibility tests were performed by using broth microdilution assay according to the guidelines of the Clinical and Laboratory Standards Institute. We detected 984 cases, for an overall incidence of 1.09 cases per 1,000 admissions. The crude mortality was 20.20%. Candida albicans was the most common species (49.08%), followed by C. parapsilosis (20.73%), C. glabrata (13.61%), and C. tropicalis (10.77%). Overall, decreased susceptibility to fluconazole occurred in 69 (7.01%) incident isolates. Antifungal resistance was rare, and a moderate linear correlation between fluconazole and voriconazole MICs was observed. This is the largest multicenter candidemia study conducted to date and shows the substantial morbidity and mortality of candidemia in Spain.

Recognition and prevention of nosocomial invasive fungal infections in the intensive care unit

Despite recent advances in antifungal treatments, the morbidity and mortality of fungal infections, especially invasive candidiasis, in patients in the intensive care unit setting remain high. Because of this, there has been a great interest in improving the evaluation, risk assessment, and prevention of fungal infections in the intensive care unit. Some important advances in the diagnosis of invasive candidiasis include rapid species identification and improvements in antigen testing. The introduction of several prediction rules has helped to guide clinicians in the use of prophylaxis or preemptive antifungal therapy in high-risk patients. However, the most immediate benefit has been realized with the introduction of new antifungal agents that have proved to be safer than those available in the past.

Pharmacoeconomics of voriconazole

IMPORTANCE OF THE FIELD

The recent increase in the use of antineoplastic and immune suppressive agents and the use of broad-spectrum antibiotics, prosthetic interventions, organ transplants and more aggressive surgery have been related to a greater prevalence of invasive fungal infections (IFI). Over the past few years, several new antifungal therapies have become available for these patients. Pharmacoeconomic data can play a useful role in comparing the relative benefits of treatment.

AREAS COVERED IN THIS REVIEW

This review summarizes all the available evidence regarding the pharmacoeconomics of voriconazole. A systematic review of pharmacoeconomic analyses through a non-restricted literature search was conducted (until May 2009).

WHAT THE READER WILL GAIN

The reader will gain a greater understanding of the pharmacoeconomics role of voriconazole.

TAKE HOME MESSAGE

The majority of economic analyses have shown that voriconazole is a more cost-effective alternative in the treatment of invasive fungal infections than the antifungal drugs with which it was compared.

Health care-associated candidemia--a distinct entity?

BACKGROUND

The concept of health care-associated infection (HCAI) was developed to address the fact that select patients now present to the hospital with infections due to traditionally nosocomial pathogens. Although epidemiologic studies document the clear existence of health care-associated pneumonia, little is known about fungal pathogens and their role in HCAIs.

OBJECTIVE

To describe the epidemiology of health care-associated bloodstream infections (BSIs) due to candida species and to compare patients with HCA candidemia to nosocomial candidemia.

DESIGN

Retrospective case series.

SETTING

Academic, tertiary care hospital.

MEASUREMENTS

We measured the proportion of cases of candidal BSI classified as health care-associated along with the microbiology of these infections. We compared health care-associated and nosocomial cases of candidemia with respect to demographics, severity of illness, and fluconazole susceptibility.

RESULTS

We noted 233 cases of candidal BSI over a 3-year period. Nearly one-quarter represented an HCAI that presented to the hospital, as opposed to a nosocomial process. Although patients with HCA candidemia were similar to subjects with nosocomial infection in terms of underlying comorbidities and severity of illness, those with HCA yeast BSI were more likely to be immunosuppressed and to have their infection caused by a fluconazole-resistant organism. C. glabrata was seen more often in patients presenting to the hospital with an HCA case of candidemia.

CONCLUSIONS

Clinicians must recognize the potential for candida species to cause HCA infections and to be present at time of hospital presentation. Physicians need to consider this and the distribution of species of yeast causing BSI in their institution when considering initial therapy for patients with a suspected BSI.

Clinical characteristics and risk factors for nosocomial candidemia in medical intensive care units: experience in a single hospital in Korea for 6.6 years

The aim of this study was to determine candidemia incidence among patients in a medical intensive-care unit (MICU) and the associated mortality rate and to identify risk factors associated with candidemia. We retrospectively performed a 1:3 matched case-control study of MICU patients with candidemia. Controls were matched for sex, age, and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Candidemia incidence was 9.1 per 1,000 admissions. The most common pathogen was Candida albicans. Crude mortality was 96% among candidemia patients and 52% among controls (P<0.001). Mortality differed significantly between the groups according to Kaplan-Meier survival analysis (P=0.024). Multivariate analysis identified the following independent risk factors for candidemia: central venous catheterization (odds ratio [OR] = 3.2, 95% confidence interval [CI]=1.2-9.0), previous steroid therapy (OR=4.7, 95% CI=1.8-12.1), blood transfusion during the same admission period (OR=6.3, 95% CI=2.4-16.7), and hepatic failure upon MICU admission (OR=6.9, 95% CI=1.7-28.4). In conclusion, we identify an additional independent risk factor for candidemia, the presence of hepatic failure on MICU admission. Therefore, increased awareness of risk factors, including hepatic failure, is necessary for the management of candidemia.

Epidemiology of invasive mycoses in North America

The incidence of invasive mycoses is increasing, especially among patients who are immunocompromised or hospitalized with serious underlying diseases. Such infections may be broken into two broad categories: opportunistic and endemic. The most important agents of the opportunistic mycoses are Candida spp., Cryptococcus neoformans, Pneumocystis jirovecii, and Aspergillus spp. (although the list of potential pathogens is ever expanding); while the most commonly encountered endemic mycoses are due to Histoplasma capsulatum, Coccidioides immitis/posadasii, and Blastomyces dermatitidis. This review discusses the epidemiologic profiles of these invasive mycoses in North America, as well as risk factors for infection, and the pathogens' antifungal susceptibility.

Nosocomial candidaemia in a Finnish tertiary care centre during 1987-2004

We studied the epidemiology of nosocomial candidaemia by assessing the incidence and outcome of illness and causative species in a large Finnish tertiary care centre during 1987-2004. A total of 364 episodes were observed; annual incidence varied between 0.26 per 10,000 patient-d in 2000 and 0.59 in 1989. The most common species were C. albicans (65%), C. parapsilosis (13%), and C. glabrata (9%). The proportion of C. albicans decreased from 71% during 1987-1992 to 58% during 1999-2004, and C. glabrata increased from 3% to 14%, respectively. The proportion of intensive care patients increased from 27% during 1987-1992 to 44% by 1999-2004, associated with neonates and surgical patients. The 1-month case fatality ranged from 30% to 33%. Nosocomial candidaemias did not increase, but the distribution of Candida spp. changed. Mortality remained high. The observed changes may reflect differences in prevention strategies that need to be explored for further improvements in prevention.

Comparison of whole blood, serum, and plasma for early detection of candidemia by multiplex-tandem PCR

We applied multiplex-tandem PCR (MT-PCR) to 255 EDTA whole-blood specimens, 29 serum specimens, and 24 plasma specimens from 109 patients with Candida bloodstream infection (candidemia) to determine whether a diagnosis could be expedited in comparison with the time to diagnosis by the use of standard blood culture. Overall, the MT-PCR performed better than blood culture with DNA extracted from whole blood from 52/74 (70%) patients, accelerating the time to detection (blood culture flagging) and determination of the pathogenic species (by use of the API 32C system [bioMérieux, Marcy l'Etoile, France]) by up to 4 days (mean, 2.2 days; range, 0.5 to 8 days). Candida DNA was detected more often in serum (71%) and plasma (75%) than in whole blood (54%), although relatively small numbers of serum and plasma specimens were tested. The sensitivity, specificity, positive predictive value, and negative predictive value of the assay with whole blood were 75%, 97%, 95%, and 85%, respectively. Fungal DNA was not detected by MT-PCR in 6/24 (25%) whole-blood samples drawn simultaneously with the positive blood culture sample. MT-PCR performed better with whole-blood specimens stored at -20 degrees C (75%) and when DNA was extracted within 1 week of sampling (66%). The molecular and culture identification results correlated for 61 of 66 patients (92%); one discrepant result was due to misidentification by culture. All but one sample from 53 patients who were at high risk of candidemia but did not have proven disease were negative by MT-PCR. The results demonstrate the good potential of MT-PCR to detect candidemia, to provide Candida species identification prior to blood culture positivity, and to provide improved sensitivity when applied to with serum and plasma specimens.

Treatment of invasive candidiasis with echinocandins

Blood stream infections by Candida spp. represent the majority of invasive fungal infections in intensive care patients. The high crude mortality of invasive candidiasis remained essentially unchanged during the last two decades despite new treatment options that became available. The echinocandins, the latest class of antifungals introduced since 2001, exhibit potent activity against clinically relevant fungi including most Candida spp. In several randomised multicentre phase III trials, anidulafungin, caspofungin and micafungin showed convincing efficacy when compared with standard treatment regimens. In all trials, echinocandins were at least non-inferior to standard treatments. Anidulafungin was shown to be superior to fluconazole. Echinocandins have a favourable tolerability profile and exhibit a minimal potential for drug interactions since their pharmacokinetics is independent of renal and--largely--hepatic function. As a result of these properties, echinocandins are appropriate drugs of choice for invasive candidiasis in intensive care where many patients experience organ failure and receive multiple drugs with complex interactions.

Treatment of candidemia and invasive candidiasis in the intensive care unit: post hoc analysis of a randomized, controlled trial comparing micafungin and liposomal amphotericin B

Introduction

Invasive candidiasis and candidemia are life-threatening nosocomial infections in intensive care patients.

Methods

A post hoc analysis of a phase 3 trial assessing micafungin (100 mg/day for subjects > 40 kg; 2 mg/kg/day for subjects ≤ 40 kg) versus liposomal amphotericin B (3 mg/kg/day). Subgroups were defined according to the type of ward on the first day of treatment: intensive care unit (ICU) or non-ICU. Multivariate regression was performed to identify factors associated with treatment success at end of therapy and all-cause mortality at days 8 and 30.

Results

In non-ICU subjects, treatment success was significantly higher for micafungin versus liposomal amphotericin B (85% (n = 108/127) versus 72.1% (n = 98/136); P = 0.0113). However, for ICU subjects, treatment success rates for micafungin versus liposomal amphotericin B were similar (62.5% (n = 75/120) versus 66.4% (n = 73/110); P = 0.5828). Overall, treatment success was significantly lower in ICU subjects compared with non-ICU subjects (64.3% (n = 148/230) versus 78.3% (n = 206/263); P = 0.0006). Multivariate regression analysis revealed a lower likelihood of treatment success for: ICU versus non-ICU subjects; persistent neutropenia; and high versus low Acute Physiology and Chronic Health Evaluation (APACHE) II scores. However, when interactions between potential explanatory factors were included in the analysis model, ICU status no longer emerged as a significant associated variable but the association between APACHE II score and treatment outcome remained. Further analyses indicated that the likelihood of mortality at day 8 and day 30 was lower for subjects with lower APACHE II scores. Renal function was significantly better in micafungin versus liposomal amphotericin B subjects: a difference (liposomal amphotericin B - micafungin in mean peak change in estimated glomerular filtration rate (ml/minute/1.73 m²) of -18.2 (P < 0.0001) and -17.7 (P = 0.0124) in non-ICU and ICU subjects, respectively.

Conclusions

Overall, ICU subjects had lower treatment success rates than non-ICU subjects for both liposomal amphotericin B and micafungin. Multivariate regression after controlling for potential confounding factors suggested the APACHE II score remained a potential explanatory factor associated with treatment success, mortality at day 8, and mortality at day 30.

Trial registration

Post hoc analysis - clinicaltrials.gov trial NCT00106288.

Candidemia on presentation to the hospital: development and validation of a risk score

INTRODUCTION

Candidemia results in substantial morbidity and mortality, especially if initial antifungal therapy is delayed or is inappropriate; however, candidemia is difficult to diagnose because of its nonspecific presentation.

METHODS

To develop a risk score for identifying hospitalized patients with candidemia, we performed a retrospective analysis of a large database of 176 acute-care hospitals in the United States. We studied 64,019 patients with bloodstream infection (BSI) on presentation from 2000 through 2005 (derivation cohort) and 24,685 from 2006 to 2007 (validation cohort). We used recursive partitioning (RPART) to identify the best discriminators for Candida as the cause of BSI. We compared three sets of models (equal-weight, unequal-weight, vs full model with additional variables from logistic regression model) for sensitivity analysis.

RESULTS

The RPART identified 6 variables as the best discriminators: age < 65 years, temperature <or= 98 degrees F or severe altered mental status, cachexia, previous hospitalization within 30 days, admitted from other healthcare facility, and need for mechanical ventilation. The prevalence for patients presented with 0 through 6 risk factors in the derivation cohort was 28.7%, 38.8%, 21.8%, 8.3%, 2.1%, 0.3%, and < 0.1% respectively. The corresponding candidemia rates were 0.4% (69/18,355), 0.8% (196/24,811), 1.6% (229/13,984), 3.2% (168/5,330), 4.2% (58/1,371), 9.6% (15/157), and 27.3% (3/11) respectively (P < 0.0001). Findings were similar in the validation cohort (P < 0.0001). The equal-weight risk score model, which signed 1 point to each risk factor, yielded good discrimination in both cohorts with areas under the receiver operating curve (AUROCs) of 0.70 versus 0.71 (derivation versus validation). AUROC values were similar for the unequal-weight model, which signed different weight to each risk factor based on multivariable logistic regression coefficient, (AUROCs, 0.70-0.72). Both equal-weight and unequal-weight models were well calibrated (all Hosmer-Lemshow P > 0.10, indicating predicted and observed candidemia rates did not differ significant across the 7 risk stratus). The full model with 16 risk factors had slightly higher AUROCs (0.74 versus 0.73 for derivation versus validation); however, 7 variables were no longer significant in the recalibrated model for the validation cohort, indicating that the additional items did not materially enhance the model.

CONCLUSIONS

A simple equal-weight risk score differentiated patients' risk for candidemia in a graded fashion upon hospital presentation.