title: Risk factors and outcomes of candidemia caused by biofilm-forming isolates in a tertiary care hospital.
abstract: BACKGROUND
  Very few data exist on risk factors for developing biofilm-forming Candida bloodstream infection (CBSI) or on variables associated with the outcome of patients treated for this infection.
  
  
  RESULTS
  We identified 207 patients with CBSI, from whom 84 biofilm-forming and 123 non biofilm-forming Candida isolates were recovered. A case-case-control study to identify risk factors and a cohort study to analyze outcomes were conducted. In addition, two sub-groups of case patients were analyzed after matching for age, sex, APACHE III score, and receipt of adequate antifungal therapy. Independent predictors of biofilm-forming CBSI were presence of central venous catheter (odds ratio [OR], 6.44; 95% confidence interval [95% CI], 3.21-12.92) or urinary catheter (OR, 2.40; 95% CI, 1.18-4.91), use of total parenteral nutrition (OR, 5.21; 95% CI, 2.59-10.48), and diabetes mellitus (OR, 4.47; 95% CI, 2.03-9.83). Hospital mortality, post-CBSI hospital length of stay (LOS) (calculated only among survivors), and costs of antifungal therapy were significantly greater among patients infected by biofilm-forming isolates than those infected by non-biofilm-forming isolates. Among biofilm-forming CBSI patients receiving adequate antifungal therapy, those treated with highly active anti-biofilm (HAAB) agents (e.g., caspofungin) had significantly shorter post-CBSI hospital LOS than those treated with non-HAAB antifungal agents (e.g., fluconazole); this difference was confirmed when this analysis was conducted only among survivors. After matching, all the outcomes were still favorable for patients with non-biofilm-forming CBSI. Furthermore, the biofilm-forming CBSI was significantly associated with a matched excess risk for hospital death of 1.77 compared to non-biofilm-forming CBSI.
  
  
  CONCLUSIONS
  Our data show that biofilm growth by Candida has an adverse impact on clinical and economic outcomes of CBSI. Of note, better outcomes were seen for those CBSI patients who received HAAB antifungal therapy.
authors.affiliation: Institute of Infectious Diseases, Università Cattolica del Sacro Cuore, Rome, Italy. tumbarello@rm.unicatt.it
authors.forename: Mario
authors.initials: M
authors.lastname: Tumbarello
authors.forename: Barbara
authors.initials: B
authors.lastname: Fiori
authors.forename: Enrico Maria
authors.initials: EM
authors.lastname: Trecarichi
authors.forename: Patrizia
authors.initials: P
authors.lastname: Posteraro
authors.forename: Angela Raffaella
authors.initials: AR
authors.lastname: Losito
authors.forename: Alessio
authors.initials: A
authors.lastname: De Luca
authors.forename: Maurizio
authors.initials: M
authors.lastname: Sanguinetti
authors.forename: Giovanni
authors.initials: G
authors.lastname: Fadda
authors.forename: Roberto
authors.initials: R
authors.lastname: Cauda
authors.forename: Brunella
authors.initials: B
authors.lastname: Posteraro
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000935:Antifungal Agents / Q000627:therapeutic use; D018441:Biofilms / Q000254:growth & development; D058387:Candidemia / Q000188:drug therapy / Q000382:microbiology* / Q000401:mortality; D005260:Female; D006761:Hospitals; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012307:Risk Factors; D013997:Time Factors; D055815:Young Adult
chemical_list: D000935:Antifungal Agents