European surveillance studies show that the incidence of Candida bloodstream infections (BSI) ranges from nearly 3 to 8.6 per 100 000 population per year [ 1 x 1 Marchetti, O, Bille, J, Fluckiger, U et al. Epidemiology of candidemia in Swiss tertiary care hospitals: secular trends, 1991–2000. Clin Infect Dis. 2004; 38: 311–320 Crossref | PubMed | Scopus (340) | Google Scholar See all References , 2 x 2 Poikonen, E, Lyytikainen, O, Anttila, VJ et al. Secular trend in candidemia and the use of fluconazole in Finland, 2004–2007. BMC Infect Dis. 2010; 10: 312 Crossref | PubMed | Scopus (60) | Google Scholar See all References , 3 x 3 Sandven, P, Bevanger, L, Digranes, A, Haukland, HH, Mannsaker, T, and Gaustad, P. Candidemia in Norway (1991 to 2003): results from a nationwide study. J Clin Microbiol. 2006; 44: 1977–1981 Crossref | PubMed | Scopus (133) | Google Scholar See all References , 4 x 4 Arendrup, MC, Bruun, B, Christensen, JJ et al. National surveillance of fungemia in Denmark (2004 to 2009). J Clin Microbiol. 2011; 49: 325–334 Crossref | PubMed | Scopus (147) | Google Scholar See all References , 5 x 5 Asmundsdottir, LR, Erlendsdottir, H, and Gottfredsson, M. Nationwide study of candidemia, antifungal use, and antifungal drug resistance in Iceland, 2000 to 2011. J Clin Microbiol. 2013; 51: 841–848 Crossref | PubMed | Scopus (45) | Google Scholar See all References , 6 x 6 Almirante, B, Rodriguez, D, Park, BJ et al. Epidemiology and predictors of mortality in cases of Candida bloodstream infection: results from population-based surveillance, Barcelona, Spain, from 2002 to 2003. J Clin Microbiol. 2005; 43: 1829–1835 Crossref | PubMed | Scopus (437) | Google Scholar See all References ].

To determine the epidemiology of Candida bloodstream infections, variables influencing mortality, and antifungal resistance rates in ICUs in Spain. Prospective, observational, multicenter population-based study. Medical and surgical ICUs in 29 hospitals distributed throughout five metropolitan areas of Spain. Adult patients (≥ 18 yr) with an episode of Candida bloodstream infection during admission to any surveillance area ICU from May 2010 to April 2011. Candida isolates were sent to a reference laboratory for species identification by DNA sequencing and susceptibility testing using the methods and breakpoint criteria promulgated by the European Committee on Antimicrobial Susceptibility Testing. Prognostic factors associated with early (0-7 d) and late (8-30 d) mortality were analyzed using logistic regression modeling. We detected 773 cases of candidemia, 752 of which were included in the overall cohort. Among these, 168 (22.3%) occurred in adult ICU patients. The rank order of Candida isolates was as follows: Candida albicans (52%), Candida parapsilosis (23.7%), Candida glabrata (12.7%), Candida tropicalis (5.8%), Candida krusei (4%), and others (1.8%). Overall susceptibility to fluconazole was 79.2%. Cumulative mortality at 7 and 30 days after the first episode of candidemia was 16.5% and 47%, respectively. Multivariate analysis showed that early appropriate antifungal treatment and catheter removal (odds ratio, 0.27; 95% CI, 0.08-0.91), Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.11; 95% CI, 1.04-1.19), and abdominal source (odds ratio, 8.15; 95% CI, 1.75-37.93) were independently associated with early mortality. Determinants of late mortality were age (odds ratio, 1.04; 95% CI, 1.01-1.07), intubation (odds ratio, 7.24; 95% CI, 2.24-23.40), renal replacement therapy (odds ratio, 6.12; 95% CI, 2.24-16.73), and primary source (odds ratio, 2.51; 95% CI, 1.06-5.95). Candidemia in ICU patients is caused by non-albicans species in 48% of cases, C. parapsilosis being the most common among these. Overall mortality remains high and mainly related with host factors. Prompt adequate antifungal treatment and catheter removal could be critical to decrease early mortality.

In patients with Candida parapsilosis candidemia, the use of an echinocandin-based regimen for the first 72 hours of therapy had no impact on the odds for clinical failure, despite the lower in vitro activity of this class of antifungals. Background. Concerns have arisen regarding the optimal antifungal regimen for Candida parapsilosis bloodstream infection (BSI) in view of its reduced susceptibility to echinocandins. Methods. The Prospective Population Study on Candidemia in Spain (CANDIPOP) is a prospective multicenter, population-based surveillance program on Candida BSI conducted through a 12-month period in 29 Spanish hospitals. Clinical isolates were identified by DNA sequencing, and antifungal susceptibility testing was performed by the European Committee on Antimicrobial Susceptibility Testing methodology. Predictors for clinical failure (all-cause mortality between days 3 to 30, or persistent candidemia for ≥72 hours after initiation of therapy) in episodes of C. parapsilosis species complex BSI were assessed by logistic regression analysis. We further analyzed the impact of echinocandin-based regimen as the initial antifungal therapy (within the first 72 hours) by using a propensity score approach. Results. Among 752 episodes of Candida BSI identified, 200 (26.6%) were due to C. parapsilosis species complex. We finally analyzed 194 episodes occurring in 190 patients. Clinical failure occurred in 58 of 177 (32.8%) of evaluable episodes. Orotracheal intubation (adjusted odds ratio [AOR], 2.81; P = .018) and septic shock (AOR, 2.91; P = .081) emerged as risk factors for clinical failure, whereas early central venous catheter removal was protective (AOR, 0.43; P = .040). Neither univariate nor multivariate analysis revealed that the initial use of an echinocandin-based regimen had any impact on the risk of clinical failure. Incorporation of the propensity score into the model did not change this finding. Conclusions. The initial use of an echinocandin-based regimen does not seem to negatively influence outcome in C. parapsilosis BSI.

Research from JAMA Internal Medicine — Current and Potential Usefulness of Pneumococcal Urinary Antigen Detection in Hospitalized Patients With Community-Acquired Pneumonia to Guide Antimicrobial Therapy

Fungemia due to rare yeasts constitutes an emerging but poorly investigated condition. Data on risk factors, clinical features, therapy, and outcome of episodes of fungemia due to rare (non-Candida, non-Cryptococcus) yeasts were analyzed in a population-based surveillance program conducted in 29 Spanish hospitals between May 2010 and April 2011. Species identification (DNA sequencing) and antifungal susceptibility testing (EUCAST and CLSI methods) were centrally performed. Fourteen out of 767 episodes of fungemia (1.8%) were due to rare yeasts: Trichosporon asahii, Magnusiomyces capitatus (three cases each), Rhodotorula mucilaginosa, Wickerhamomyces anomalus (two cases each), and Pichia kudriavzevii, Cyberlindnera fabianii, Kodamaea ohmeri, and Lodderomyces elongisporus (one case each). Misidentification by local laboratories was observed in two isolates. Breakthrough fungemia occurred in two episodes due to M. capitatus. MIC values for echinocandins were generally high (particularly for M. capitatus, T. asahii, and R. mucilaginosa isolates [≥2 mg/l]), whereas T. asahii isolates showed MICs ≥1 mg/l to amphotericin B. Patients with fungemia due to rare yeasts were more likely to have hematological malignancies (28.6% vs. 7.8%; P-value = .021), chronic lung disease (50.0% vs. 22.3%; P-value = .023), and prior immunosuppression (57.1% vs. 22.2%; P-value = .005) compared to those with candidemia. The rate of clinical failure (persistent fungemia and/or 30-day mortality) was 46.2% and did not significantly differ from that observed in episodes of candidemia. In conclusion, non-Candida, non-Cryptococcus yeasts are uncommon causes of fungemia, with immunosuppression and chronic lung disease as predisposing factors. Outcome does not appear to be worse than that of candidemia.