Changes in incidence and antifungal drug resistance in candidemia: results from population-based laboratory surveillance in Atlanta and Baltimore, 2008-2011.
BACKGROUND
Candidemia is common and associated with high morbidity and mortality; changes in population-based incidence rates have not been reported.


METHODS
We conducted active, population-based surveillance in metropolitan Atlanta, Georgia, and Baltimore City/County, Maryland (combined population 5.2 million), during 2008-2011. We calculated candidemia incidence and antifungal drug resistance compared with prior surveillance (Atlanta, 1992-1993; Baltimore, 1998-2000).


RESULTS
We identified 2675 cases of candidemia with 2329 isolates during 3 years of surveillance. Mean annual crude incidence per 100 000 person-years was 13.3 in Atlanta and 26.2 in Baltimore. Rates were highest among adults aged ≥65 years (Atlanta, 59.1; Baltimore, 72.4) and infants (aged <1 year; Atlanta, 34.3; Baltimore, 46.2). In both locations compared with prior surveillance, adjusted incidence significantly declined for infants of both black and white race (Atlanta: black risk ratio [RR], 0.26 [95% confidence interval {CI}, .17-.38]; white RR: 0.19 [95% CI, .12-.29]; Baltimore: black RR, 0.38 [95% CI, .22-.64]; white RR: 0.51 [95% CI: .29-.90]). Prevalence of fluconazole resistance (7%) was unchanged compared with prior surveillance; 32 (1%) isolates were echinocandin-resistant, and 9 (8 Candida glabrata) were multidrug resistant to both fluconazole and an echinocandin.


CONCLUSIONS
We describe marked shifts in candidemia epidemiology over the past 2 decades. Adults aged ≥65 years replaced infants as the highest incidence group; adjusted incidence has declined significantly in infants. Use of antifungal prophylaxis, improvements in infection control, or changes in catheter insertion practices may be contributing to these declines. Further surveillance for antifungal resistance and efforts to determine effective prevention strategies are needed.
Mycotic Diseases Branch, Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. ara0@cdc.gov
Angela Ahlquist
AA
Cleveland
Monica M
MM
Farley
Lee H
LH
Harrison
Betsy
B
Stein
Rosemary
R
Hollick
Shawn R
SR
Lockhart
Shelley S
SS
Magill
Gordana
G
Derado
Benjamin J
BJ
Park
Tom M
TM
Chiller
D000293:Adolescent; D000328:Adult; D000368:Aged; D000935:Antifungal Agents / Q000494:pharmacology / Q000627:therapeutic use; D015142:Baltimore / Q000453:epidemiology; D002175:Candida / Q000187:drug effects* / Q000302:isolation & purification; D058387:Candidemia / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D002648:Child; D002675:Child, Preschool; D025141:Drug Resistance, Fungal; D005260:Female; D005845:Georgia / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007223:Infant; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance; D011446:Prospective Studies
D000935:Antifungal Agents