title: Declining incidence of candidemia and the shifting epidemiology of Candida resistance in two US metropolitan areas, 2008-2013: results from population-based surveillance.
abstract: BACKGROUND
  Recent reports have demonstrated a decline in bacterial bloodstream infections (BSIs) following adherence to central line insertion practices; however, declines have been less evident for BSIs due to Candida species.
  
  
  METHODS
  We conducted active, population-based laboratory surveillance for candidemia in metropolitan Atlanta, GA and Baltimore, MD over a 5-year period. We calculated annual candidemia incidence and antifungal drug resistance rates.
  
  
  RESULTS
  We identified 3,848 candidemia cases from 2008-2013. Compared with 2008, candidemia incidence per 100,000 person-years decreased significantly by 2013 in both locations (GA: 14.1 to 9.5, p<0.001; MD: 30.9 to 14.4, p<0.001). A total of 3,255 cases (85%) had a central venous catheter (CVC) in place within 2 days before the BSI culture date. In both locations, the number of CVC-associated cases declined (GA: 473 to 294; MD: 384 to 151). Candida albicans (CA, 36%) and Candida glabrata (CG, 27%) were the most common species recovered. In both locations, the proportion of cases with fluconazole resistance decreased (GA: 8.0% to 7.1%, -10%; MD: 6.6% to 4.9%, -25%), while the proportion of cases with an isolate resistant to an echinocandin increased (GA: 1.2% to 2.9%, +147%; MD: 2.0% to 3.5%, +77%). Most (74%) echinocandin-resistant isolates were CG; 17 (<1%) isolates were resistant to both drug categories (multidrug resistant [MDR], 16/17 were CG). The proportion of CG cases with MDR Candida increased from 1.8% to 2.6%.
  
  
  CONCLUSIONS
  We observed a significant decline in the incidence of candidemia over a five-year period, and increases in echinocandin-resistant and MDR Candida. Efforts to strengthen infection control practices may be preventing candidemia among high-risk patients. Further surveillance for resistant Candida is warranted.
authors.affiliation: Mycotic Diseases Branch, Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Angela Ahlquist
authors.initials: AA
authors.lastname: Cleveland
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Lee H
authors.initials: LH
authors.lastname: Harrison
authors.affiliation: Georgia Emerging Infections Program, Atlanta Veterans Affairs Medical Center and Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America.
authors.forename: Monica M
authors.initials: MM
authors.lastname: Farley
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Rosemary
authors.initials: R
authors.lastname: Hollick
authors.affiliation: Georgia Emerging Infections Program, Atlanta Veterans Affairs Medical Center and Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America.
authors.forename: Betsy
authors.initials: B
authors.lastname: Stein
authors.affiliation: Mycotic Diseases Branch, Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Tom M
authors.initials: TM
authors.lastname: Chiller
authors.affiliation: Mycotic Diseases Branch, Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Shawn R
authors.initials: SR
authors.lastname: Lockhart
authors.affiliation: Mycotic Diseases Branch, Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Park
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000935:Antifungal Agents / Q000627:therapeutic use; D015142:Baltimore / Q000453:epidemiology; D002175:Candida / Q000187:drug effects; D058387:Candidemia / Q000188:drug therapy / Q000453:epidemiology*; D002648:Child; D002675:Child, Preschool; D025141:Drug Resistance, Fungal / Q000187:drug effects; D005260:Female; D005845:Georgia / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D011159:Population Surveillance; D055815:Young Adult
chemical_list: D000935:Antifungal Agents
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