Candidemia: the impact of antifungal prophylaxis in a surgical intensive care unit.
BACKGROUND
Candidemia is fourfold more common in 1990 compared to 1980. In addition, a shift to non-albicans species has occurred in some institutions. Antifungal prophylaxis (AP) is effective in high-risk patients including critically ill surgical patients, but its use has been attributed to a resultant shift to non-albicans candida species. We hypothesized that the use of fluconazole prophylaxis would lead to a decreased incidence of candidemia but a possible increased incidence of resistant species of Candida, especially Candida glabrata (CG).


METHODS
From 1990 to 2002, all patients with candidemia (C) in the surgical intensive care unit (SICU) of a large tertiary care hospital were identified and reviewed retrospectively. Antifungal prophylaxis began in 2000 for high-risk patients. The periods were separated into PRE (1990-2000), and POST prophylaxis (2000-2002).


RESULTS
Excluding the year of the trial studying prophylaxis, (1998; five cases of C) a total of 83 patients developed candidemia: 69 PRE (83%) (1.94/1000 patient days) and 14 POST (17%) (0.76/1000 patient days) (OR 0.44; 95% CI 0.25, 0.78; p = 0.004). In the PRE period C. albicans (45%) and CG (30%) were predominant, whereas in the POST period, CG (9/14, 64%) (p = 0.05), and C. albicans (3/14, 21%) were common. Non-albicans species were 38/69 (55%) PRE and 11/14 (79%) POST, p = 0.14. Mortality in the group was 43/83 (52%) and did not differ PRE/POST or based on treatment. Predictors of SICU mortality (model r2 = 0.61) included hospital length of stay (LOS) (OR 1.14, CI 1.04, 1.25), fever (OR 51.2, CI 2.46, 1064), and broad-spectrum antibiotics (OR 69.7, CI 2.08, 2351), whereas post-transplantation status (OR 0.005, CI 0.00, 0.56), blood sugar <180 mg/dL (OR 0.03, CI 0.01, 0.81), and fungal prophylaxis (OR 0.03, CI 0.01, 0.58) were associated with a decreased risk of mortality.


CONCLUSIONS
Unfortunately, the mortality of candidemia remains high in SICU patients (52%). In the SICU, risk factors for candidemia and mortality are common. However, antifungal prophylaxis has significantly decreased the annual incidence of candidemia without a statistically significant shift to non-albicans pathogens.
Swoboda
Sandra M
SM
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Merz
William G
WG
Lipsetta
Pamela A
PA
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019072:Antibiotic Prophylaxis; D000935:Antifungal Agents / Q000627:therapeutic use*; D002177:Candidiasis / Q000453:epidemiology / Q000517:prevention & control*; D005260:Female; D015725:Fluconazole / Q000627:therapeutic use*; D016469:Fungemia / Q000453:epidemiology / Q000517:prevention & control*; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies
D000935:Antifungal Agents; D015725:Fluconazole