Candida bloodstream infections in intensive care units: Analysis of the extended prevalence of infection in intensive care unit study*
Daniel H. Kett, MD; Elie Azoulay, MD, PhD; Pablo M. Echeverria, MD; Jean-Louis Vincent, MD, PhD, FCCM; and for the Extended Prevalence of Infection in the ICU Study (EPIC II) Group of Investigators
Objectives: To provide a global, up-to-date picture of theprevalence, 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 bloodstreaminfections 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 withGram-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 dysfunctionscores 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 mortalityrates and resource use. (Crit Care Med 2011; 39:665– 670) KEY WORDS: fungemia; bacteremia; intensive care; epidemiology; outcome assessment (health care)
andida bloodstream infections (BSIs) and other forms of invasive candidiasis are the most common invasive fungal infections among hospitalized patients (1). In the United States, infections resulting from Candida BSI are currently the fourthleading cause of nosocomial BSIs among hospitalized patients and third among intensive care unit (ICU) patients
(2). Invasive Candida infections are an increasingly problematic in ICU patients as a result of the high crude mortality, ranging from 35% to 67% (2–7). Additionally, invasive candidiasis is also associated with signiﬁcant cost and healthcare use (4, 8 –13). The increased length ofstay in the hospital and the ICU are major contributors to the economic burden of Candida BSI with estimated cost associated with an episode of
*See also p. 884. From the Department of Medicine (DHK, PME), Division of Pulmonary and Critical Care, The University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL; Service de Reanimation ´ Medicale (EA), Groupe de...
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