Candida is an important cause of bloodstream infections (BSI), causing significant mortality and morbidity in health care settings. From January 2008 to December 2010 all consecutive patients who developed candidemia at San Martino University Hospital, Italy were enrolled in the study. A total of 348 episodes of candidaemia were identified during the study period (January 2008–December 2010), with an incidence of 1,73 episodes/1000 admissions. Globally, albicans and non-albicans species caused around 50% of the cases each. Non-albicans included Candida parapsilosis (28.4%), Candida glabrata (9.5%), Candida tropicalis (6.6%), and Candida krusei (2.6%). Out of 324 evaluable patients, 141 (43.5%) died within 30 days from the onset of candidemia. C. parapsilosis candidemia was associated with the lowest mortality rate (36.2%). In contrast, patients with C. krusei BSI had the highest mortality rate (55.5%) in this cohort. Regarding the crude mortality in the different units, patients in Internal Medicine wards had the highest mortality rate (54.1%), followed by patients in ICU and Hemato-Oncology wards (47.6%). This report shows that candidemia is a significant source of morbidity in Italy, with a substantial burden of disease, mortality, and likely high associated costs. Although our high rates of candidemia may be related to high rates of BSI in general in Italian public hospitals, reasons for these high rates are not clear and warrant further study. Determining factors associated with these high rates may lead to identifying measures that can help to prevent disease.
References
[1]
Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, et al. (2004) Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis 39: 309–17.
[2]
Marchetti O, Bille J, Fluckiger U, Eggimann P, Ruef C, et al. (2004) Fungal Infection Network of Switzerland. Epidemiology of candidaemia in Swiss tertiary care Hospitals: secular trends 1991–2000. Clin Infect Dis 38: 311–20.
[3]
Asmundsdóttir LR, Erlendsdóttir H, Gottfredsson M (2002) Increasing incidence of candidemia: results from a 20-year nationwide study in Iceland. J Clin Microbiol 4: 3489–92.
[4]
Zaoutis TE, Argon J, Chu J, Berlin JA, Walsh TJ, et al. (2005) The epidemiology and attributable outcomes of candidemia in adults and children hospitalized in the United States: a propensity analysis. Clin Infect Dis 41: 1232–9.
[5]
Horn DL, Neofytos D, Anaissie EJ, Fishman JA, Steinbach WJ, et al. (2009) Epidemiology and outcomes of candidemia in 2019 patients: data from the prospective antifungal therapy alliance registry. Clin Infect Dis 48: 1695–703.
[6]
Nguyen MH, Peacock JE, Morns AJ, Tanner DC, Nguyen ML, et al. (1996) The changing face of Candidemia: emergence of non-Candida albicans species and antifungal resistance. Am J Med 100: 617–623.
[7]
Rocco TR, Reinsert SE, Simms HH (2000) Effects of fluconazole administration in critically ill patients: analysis of bacterial and fungal resistance. Arch Surg 135: 160–65.
[8]
Bassetti M, Righi E, Costa A, Fasce R, Molinari MP, Rosso R, et al. (2006) Epidemiological trends in nosocomial candidemia in intensive care. BMC Infect Dis 6: 21.
[9]
Bassetti M, Ansaldi F, Nicolini L, Malfatto E, Molinari MP, et al. (2009) Incidence of candidaemia and relationship with fluconazole use in an intensive care unit. J Antimicrob Chemother 64: 625–9.
[10]
Leroy O, Gangneux JP, Montravers P, Mira JP, Gouin F, et al. (2009) Epidemiology, management, and risk factors for death of invasive Candida infections in critical care: a multicenter, prospective, observational study in France (2005–2006). Crit Care Med 37: 1612–8.
[11]
Clinical and Laboratory Standards Institute (2008) Reference method for broth dilution antifungal susceptibility testing of yeasts: third edition (M27-A3). Wayne, , PA: CLSI.
[12]
European Committee on Antimicrobial Susceptibility test (2011) Antimicrobials for Candida infections - EUCAST clinical MIC breakpoints. 2011-04-27 (v 3.0). Available: http://www.srga.org/eucastwt/MICTAB/inde?x.html.
[13]
Pfaller MA, Jones RN, Doern GV, Sader HS, Hollis RJ, et al. (1998) International surveillance of bloodstream infections due to Candida species: frequency of occurrence and antifungal susceptibilities of isolates collected in 1997 in the United States, Canada, and South America for the SENTRY program. J Clin Microbiol 36: 1886–1889.
[14]
Pfaller MA, Messer SA, Boyken L, Tendolkar S, Hollis RJ, et al. (2004) Geographic variation in the susceptibilities of invasive isolates of Candida glabrata to seven systemically active antifungal agents: a global assessment from the ARTEMIS Antifungal Surveillance Program conducted in 2001 and 2002. J Clin Microbiol 42: 3142–3146.
[15]
Macphail GL, Taylor GD, Buchanan-Chell M, Ross C, Wilson S, et al. (2002) Epidemiology, treatment and outcome of candidemia: a five-year review at three Canadian hospitals. Mycoses 45: 141–145.
[16]
Tortorano AM, Peman J, Bernhardt H, Klingspor L, Kibbler CC, et al. (2004) Epidemiology of candidaemia in Europe: results of 28-month European Confederation of Medical Mycology (ECMM) hospital-based surveillance study. Eur J Clin Microbiol Infect Dis 23: 317–322.
[17]
Almirante B, Rodriguez D, Park BJ, Cuenca-Estrella M, Planes AM, et al. (2005) 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 43: 1829–1835.
[18]
Cisterna R, Ezpeleta G, Telleria O, Spanish Candidemia Surveillance Group (2010) Nationwide sentinel surveillance of bloodstream Candida infections in 40 tertiary care hospitals in Spain. J Clin Microbiol 48: 4200–6.
[19]
Poikonen E, Lyytik?inen O, Anttila VJ, Koivula I, Lumio J, et al. (2010) Secular trend in candidemia and the use of fluconazole in Finland, 2004–2007. BMC Infect Dis 10: 312.
[20]
Richet H, Roux P, Des CC, Esnault Y, Andremont A (2002) Candidemia in French hospitals: incidence rates and characteristics. Clin Microbiol Infect 8: 405–412.
[21]
Clark TA, Slavinski SA, Morgan J, Lott T, Arthington-Skaggs BA, et al. (2004) Epidemiologic and molecular characterization of an outbreak of Candida parapsilosis bloodstream infections in a community hospital. J Clin Microbiol 42: 4468–4472.
[22]
Komshian SV, Uwaydah AK, Sobel JD, Crane LR (1989) Fungemia caused by Candida species and Torulopsis glabrata in the hospitalized patient: frequency, characteristics, and evaluation of factors influencing outcome. Rev Infect Dis 11: 379–390.
[23]
Lin MY, Carmeli Y, Zumsteg J, Flores EL, Tolentino J, et al. (2005) Prior antimicrobial therapy and risk for hospital acquired Candida glabrata and Candida krusei fungemia: a case-case-control study. Antimicrob Agents Chemother 49: 4555–4560.
[24]
Garbino J, Kolarova L, Rohner P, Lew D, Pichna P, et al. (2002) Secular trends of candidemia over 12 years in adult patients at a tertiary care hospital. Medicine (Baltimore) 81: 425–433.
[25]
Pappas PG, Rex JH, Lee J, Hamill RJ, Larsen RA, et al. (2039) A prospective observational study of candidemia: epidemiology, therapy, and influences on mortality in hospitalized adult and pediatric patients. Clin Infect Dis 37: 634–643.
[26]
Colombo AL, Nucci M, Salomao R (1999) High rate of non-albicans candidemia in Brazilian tertiary care hospitals. Diagn Microbiol Infect Dis 34: 281–86.
[27]
Luzzati R, Amalfitano G, Lazzarini L, Soldani F, Bellino S, et al. (2000) Nosocomial candidemia in non-neutropenic patients at an Italian tertiary care hospital. Eur J Clin Microbiol Infect Dis 19: 602–7.
[28]
Tortorano AM, Kibbler C, Peman J, Bernhardt H, Klingspor L, et al. (2006) Candidaemia in Europe: epidemiology and resistance. Int J Antimicrob Agents 27: 359–66.
[29]
Taylor GD, Buchanan-Chell M, Kirkland T, McKenzie M, Wiens R (1994) Trends and sources of nosocomial fungaemia. Mycoses 37: 187–190.
[30]
Messer SA, Moet GJ, Kirvy JT, Jones RN (2009) Activity of contemporary antifungal agents, including the novel echinocandin anidulafungin, tested against Candida spp., Cryptococcus spp., and Aspergillus spp.: report from the SENTRY antimicrobial surveillance program (2006 to 2007). J Clin Microbiol 47: 1942–1946.
[31]
Pfaller MA, Castanheira M, Messer SA, Moet GJ, Jones RN (2011) Echinocandin and triazole antifungal susceptibility profiles for Candida spp., Cryptococcus neoformans, and Aspergillus fumigatus: application of new CLSI clinical breakpoints and epidemiologic cutoff values to characterize resistance in the SENTRY Antimicrobial Surveillance Program (2009). Diagn Microbiol Infect Dis 69: 45–50.
[32]
Doern L, Herwaldt A, Pfaller MA (2002) Epidemiology of candidemia: 3-year results from the emerging infections and the epidemiology of Iowa organisms study. J Clin Microbiol 40: 1298–1302.
[33]
Dóczi I, Dósa E, Hajdú E, Nagy E (2002) Aetiology and antifungal susceptibility of yeast bloodstream infections in a Hungarian university hospital between 1996 and 2000. J Med Microbiol 51: 677–81.
[34]
Fraser VJ, Jones M, Dunkel J, Storfer S, Medoff G, et al. (1992) Candidemia in a tertiary care hospital: epidemiology, risk factors, and predictors of mortality. Clin Infect Dis 15: 414–21.
[35]
Poikonen E, Lyytikainen O, Anttila VJ, Ruutu P (2003) Candidemia in Finland, 1995–1999. Emerg Infect Dis 9: 985–90.
[36]
Nucci M, Colombo AL, Silveira F, Richtmann R, Salomao R, et al. (1998) Risk factors for death in patients with candidemia. Infect Control Hosp Epidemiol 19: 846–850.
[37]
Nolla-Salas J, Sitges-Serra A, León-Gil C, Martínez-González J, León-Regidor MA, et al. (1997) Candidemia in non-neutropenic critically ill patients: analysis of prognostic factors and assessment of systemic antifungal therapy. Intensive Care Med 23: 23–3.
[38]
Viscoli C, Girmenia C, Marinus A, Collette L, Martino P, et al. (1999) Candidemia in cancer patients: a prospective, multicenter surveillance study by the Invasive Fungal Infection Group (IFIG) of the European Organization for Research and Treatment of Cancer (EORTC). Clin lnfect Dis 28: 1071–9.
[39]
Garey KW, Rege M, Pai MP, Mingo DE, Suda KJ, et al. (2006) Time to initiation of fluconazole therapy impacts mortality in patients withcandidemia: a multi-institutional study. Clin Infect Dis 43: 25–31.
[40]
Morrell M, Fraser VJ, Kollef MH (2005) Delaying the empiric treatment of candida bloodstream infection until positive blood culture results are obtained: a potential risk factor for hospital mortality. Antimicrob Agents Chemother 49: 3640–3645.