title: Impact of therapeutic strategies on the prognosis of candidemia in the ICU.
abstract: OBJECTIVE
  To determine the epidemiology of Candida bloodstream infections, variables influencing mortality, and antifungal resistance rates in ICUs in Spain.
  
  
  METHODS
  Prospective, observational, multicenter population-based study.
  
  
  METHODS
  Medical and surgical ICUs in 29 hospitals distributed throughout five metropolitan areas of Spain.
  
  
  METHODS
  Adult patients (≥ 18 yr) with an episode of Candida bloodstream infection during admission to any surveillance area ICU from May 2010 to April 2011.
  
  
  METHODS
  Candida isolates were sent to a reference laboratory for species identification by DNA sequencing and susceptibility testing using the methods and breakpoint criteria promulgated by the European Committee on Antimicrobial Susceptibility Testing. Prognostic factors associated with early (0-7 d) and late (8-30 d) mortality were analyzed using logistic regression modeling.
  
  
  RESULTS
  We detected 773 cases of candidemia, 752 of which were included in the overall cohort. Among these, 168 (22.3%) occurred in adult ICU patients. The rank order of Candida isolates was as follows: Candida albicans (52%), Candida parapsilosis (23.7%), Candida glabrata (12.7%), Candida tropicalis (5.8%), Candida krusei (4%), and others (1.8%). Overall susceptibility to fluconazole was 79.2%. Cumulative mortality at 7 and 30 days after the first episode of candidemia was 16.5% and 47%, respectively. Multivariate analysis showed that early appropriate antifungal treatment and catheter removal (odds ratio, 0.27; 95% CI, 0.08-0.91), Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.11; 95% CI, 1.04-1.19), and abdominal source (odds ratio, 8.15; 95% CI, 1.75-37.93) were independently associated with early mortality. Determinants of late mortality were age (odds ratio, 1.04; 95% CI, 1.01-1.07), intubation (odds ratio, 7.24; 95% CI, 2.24-23.40), renal replacement therapy (odds ratio, 6.12; 95% CI, 2.24-16.73), and primary source (odds ratio, 2.51; 95% CI, 1.06-5.95).
  
  
  CONCLUSIONS
  Candidemia in ICU patients is caused by non-albicans species in 48% of cases, C. parapsilosis being the most common among these. Overall mortality remains high and mainly related with host factors. Prompt adequate antifungal treatment and catheter removal could be critical to decrease early mortality.
authors.affiliation: 1Infectious Diseases Department, Hospital Universitari Vall d´Hebron, Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain. 2Microbiology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain. 3Intensive Care Medicine Department, Hospital Universitario Dr. Peset, Valencia, Spain. 4Critical Care and Emergency Department, Hospital Universitario Virgen del Rocío, Seville, Spain. 5Infectious Diseases and Microbiology Unit, Hospital Universitario de Valme, Instituto de Biomedicina de Sevilla (IbiS), Seville, Spain. 6Department of Mycology, Spanish National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Spain.
authors.forename: Mireia
authors.initials: M
authors.lastname: Puig-Asensio
authors.forename: Javier
authors.initials: J
authors.lastname: Pemán
authors.forename: Rafael
authors.initials: R
authors.lastname: Zaragoza
authors.forename: José
authors.initials: J
authors.lastname: Garnacho-Montero
authors.forename: Estrella
authors.initials: E
authors.lastname: Martín-Mazuelos
authors.forename: Manuel
authors.initials: M
authors.lastname: Cuenca-Estrella
authors.forename: Benito
authors.initials: B
authors.lastname: Almirante
mesh_terms: D018806:APACHE; D000368:Aged; D000935:Antifungal Agents / Q000627:therapeutic use*; D002175:Candida / Q000145:classification / Q000302:isolation & purification*; D058387:Candidemia / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D062905:Central Venous Catheters / Q000009:adverse effects; D025141:Drug Resistance, Fungal; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011159:Population Surveillance / Q000379:methods; D015995:Prevalence; D011379:Prognosis; D011446:Prospective Studies; D013030:Spain / Q000453:epidemiology
chemical_list: D000935:Antifungal Agents