PURPOSE: Non-albicans candidemia has increased in frequency over the last five years, with growing prevalence and resistance of C. glabrata and incompletely defined risk factors.
METHODS: We retrospectively reviewed all patients with Candidemia from 2005 to 2009 at the Roudebush VA Medical Center in Indianapolis, Indiana. One hundred thirty-seven patients with Candidemia were classified based on species, year, and fluconazole susceptibility. Hospital-wide azole use was assessed in total grams per year. The 103 patients with positive bloodstream infections for C. albicans or C. glabrata underwent further comparative risk factor analysis and assessment of prior antibiotic and antifungal use.
RESULTS: C. albicans fungemia peaked in 2006 at 52% of all isolates, declining thereafter to 29% in 2008 and 35% in 2009. Meanwhile, C. glabrata increased from a nadir of 27% in 2007 to 45% and 40% in 2008 and 2009, respectively. Other non-albicans Candida remained relatively stable. Average MIC of C. glabrata for fluconazole increased from 23.2 to 30.8 to 36.7 from 2007 through 2009. Risk factors identified for C. glabrata vs. C. albicans infection include recent abdominal surgery (40.8% vs. 27%; OR 2.2, p=0.01), diabetes mellitus (53.1% vs. 36.5%; OR 3.4, p<0.0001), and fluoroquinolone use (73.5% vs. 54%, p=0.03). C. glabrata patients were more likely to have received azoles prior to their fungemia (42.9% vs. 27%, p=0.14). Patients in the intensive care unit were more likely to develop C. albicans (53.9% vs. 24.9%; OR 0.38; p=0.0009). Other risk factors for candidemia including TPN, corticosteroids, chemotherapy, malignancy, or intravascular devices were not found to favor either species.
CONCLUSION: C. glabrata is emerging as the predominant species in fungemia, especially in diabetic patients, those with recent abdominal surgery, and those recently treated with fluoroquinolones.
CLINICAL IMPLICATIONS: In addition to recent azole exposure and moderate to severe illness as proposed by the 2009 IDSA guidelines for Candidiasis, empiric treatment with echinochandins may be considered in the presence of diabetes, recent abdominal surgery, or fluoroquinolone use. Prospective studies are needed to further assess these findings.
DISCLOSURE: Kara Goss, Grant monies (from sources other than industry) Chadi Hage supported by a VA-CDA-2; No Product/Research Disclosure Information