title: Prior colonisation with Candida species fails to guide empirical therapy for candidaemia in critically ill adults.
abstract: OBJECTIVE
  Pre-emptive fluconazole (fcz) anti-fungal therapy is often based upon Candida colonisation of at least 2 non-contiguous non-sterile sites. The aim of this study was to evaluate the relationship between candidaemia and prior colonisation of non-sterile sites.
  
  
  METHODS
  A retrospective observational study was performed in the intensive care unit/high dependency unit (ICU/HDU) of a University hospital on alternate years from 1999-2007, where a pre-emptive anti-fungal therapy policy was introduced in 2005.
  
  
  RESULTS
  A higher proportion of blood isolates were Candida glabrata compared with non-sterile isolates (16/46 vs 106/1062; p < 0.001), similarly a greater proportion of blood isolates were fcz-resistant compared with non-sterile isolates (15/46 vs 101/1062; p < 0.001). No trend over time was detected in the proportion of C. glabrata and Candida albicans isolates from blood and non-sterile sites, or in the fcz-sensitivity of isolates from these sites. C. glabrata candidaemia was more likely to occur in the absence of non-sterile site colonisation compared with non-glabrata candidaemia (12/16 vs 8/30; p = 0.005). Of candidaemic patients, 43% had no preceding colonisation by any Candida spp.; in 67% of these patients, candidaemia was due to C. glabrata.
  
  
  CONCLUSIONS
  Pre-emptive therapy based upon colonisation of at least two sites may be inadequate as 43% of candidaemic patients had no evidence of prior colonisation, 67% of whom had candidaemia due to C. glabrata. Furthermore if pre-emptive anti-fungal therapy is instituted in non-colonised patients there is a risk of selecting an inappropriate anti-fungal for C. glabrata. Despite the introduction of pre-emptive fcz therapy, no time trend was detected in the proportion of fcz-sensitive isolates from blood and non-sterile sites.
authors.affiliation: Department of Microbiology, Kelvin Laboratories, Royal Group Hospital Trust, Grosvenor Road, BT12 6BA, Belfast, UK. judith.troughton@belfasttrust.hscni.net
authors.forename: Judith A
authors.initials: JA
authors.lastname: Troughton
authors.forename: Gail
authors.initials: G
authors.lastname: Browne
authors.forename: Danny F
authors.initials: DF
authors.lastname: McAuley
authors.forename: M James
authors.initials: MJ
authors.lastname: Walker
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Patterson
authors.forename: Ronan
authors.initials: R
authors.lastname: McMullan
mesh_terms: D018806:APACHE; D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000935:Antifungal Agents / Q000494:pharmacology; D002176:Candida albicans / Q000187:drug effects / Q000302:isolation & purification*; D041221:Candida glabrata / Q000187:drug effects / Q000302:isolation & purification*; D058387:Candidemia / Q000097:blood / Q000188:drug therapy / Q000382:microbiology*; D025141:Drug Resistance, Fungal; D005260:Female; D015725:Fluconazole / Q000494:pharmacology; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D006113:United Kingdom
chemical_list: D000935:Antifungal Agents; D015725:Fluconazole