title: Characteristics and risk factors for 28-day mortality of hospital acquired fungemias in ICUs: data from the EUROBACT study.
abstract: BACKGROUND
  To characterize and identify prognostic factors for 28-day mortality among patients with hospital-acquired fungemia (HAF) in the Intensive Care Unit (ICU).
  
  
  METHODS
  A sub-analysis of a prospective, multicenter non-representative cohort study conducted in 162 ICUs in 24 countries.
  
  
  RESULTS
  Of the 1156 patients with hospital-acquired bloodstream infections (HA-BSI) included in the EUROBACT study, 96 patients had a HAF. Median time to its diagnosis was 20 days (IQR 10.5-30.5) and 9 days (IQR 3-15.5) after hospital and ICU admission, respectively. Median time to positivity of blood culture was longer in fungemia than in bacteremia (48.7 h vs. 38.1 h; p = 0.0004). Candida albicans was the most frequent fungus isolated (57.1%), followed by Candida glabrata (15.3%) and Candida parapsilosis (10.2%). No clear source of HAF was detected in 33.3% of the episodes and it was catheter-related in 21.9% of them. Compared to patients with bacteremia, HAF patients had a higher rate of septic shock (39.6% vs. 21.6%; p = 0.0003) and renal dysfunction (25% vs. 12.4%; p = 0.0023) on admission and a higher rate of renal failure (26% vs. 16.2%; p = 0.0273) at diagnosis. Adequate treatment started within 24 h after blood culture collection was less frequent in HAF patients (22.9% vs. 55.3%; p < 0.001). The 28-day all cause fatality was 40.6%. According to multivariate analysis, only liver failure (OR 14.35; 95% CI 1.17-175.6; p = 0.037), need for mechanical ventilation (OR 8.86; 95% CI 1.2-65.24; p = 0.032) and ICU admission for medical reason (OR 3.87; 95% CI 1.25-11.99; p = 0.020) were independent predictors of 28-day mortality in HAF patients.
  
  
  CONCLUSIONS
  Fungi are an important cause of hospital-acquired BSI in the ICU. Patients with HAF present more frequently with septic shock and renal dysfunction on ICU admission and have a higher rate of renal failure at diagnosis. HAF are associated with a significant 28-day mortality rate (40%), but delayed adequate antifungal therapy was not an independent risk factor for death. Liver failure, need for mechanical ventilation and ICU admission for medical reason were the only independent predictors of 28-day mortality.
authors.affiliation: Grupo de Infecção e Sepsis; Emergency and Intensive Care Department, Centro Hospitalar S. João, EPE; Faculty of Medicine, University of Porto, Porto, Portugal. jarturpaiva@gmail.com.
authors.forename: José-Artur
authors.initials: JA
authors.lastname: Paiva
authors.affiliation: Grupo de Infecção e Sepsis; Emergency and Intensive Care Department, Centro Hospitalar S. João, EPE; Faculty of Medicine, University of Porto, Porto, Portugal. jmcrpereira@yahoo.com.
authors.forename: José Manuel
authors.initials: JM
authors.lastname: Pereira
authors.affiliation: Université Grenoble 1, U 823, Albert Bonniot Institute; Team 11: Outcome of mechanically ventilated patients and respiratory cancers, Grenoble, France. atabah@gmail.com.|Burns, Trauma, and Critical Care Research Center, The University of Queensland, Butterfield Street, Brisbane, Australia. atabah@gmail.com.|Outcomerea Organization, Paris, France. atabah@gmail.com.
authors.forename: Alexis
authors.initials: A
authors.lastname: Tabah
authors.affiliation: Department of Anaesthesiology and Intensive Therapy, Regional Hospital in Poznan, Poznan University of Medical Sciences, Poznan, Poland. mikstacki@lutycka.pl.
authors.forename: Adam
authors.initials: A
authors.lastname: Mikstacki
authors.affiliation: Infectious and Tropical Diseases Intensive Care Unit, Hospital Eduardo de Menezes, Fundação Hospitalar do Estado de Minas Gerais, Belo Horizonte, MG, Brazil. fredbruzcarv@gmail.com.
authors.forename: Frederico Bruzzi
authors.initials: FB
authors.lastname: de Carvalho
authors.affiliation: Burns, Trauma, and Critical Care Research Center, The University of Queensland, Butterfield Street, Brisbane, Australia. deskogr@yahoo.gr.|Department of Critical Care, University Hospital ATTIKON, Medical School University of Athens, Athens, Greece. deskogr@yahoo.gr.
authors.forename: Despoina
authors.initials: D
authors.lastname: Koulenti
authors.affiliation: Outcomerea Organization, Paris, France. stephane.ruckly@gmail.com.|Decision Sciences in Infectious Disease (DescID) Prevention, Control and Care, UMR 1137 Paris Diderot University, Sorbonne, Paris, France. stephane.ruckly@gmail.com.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Ruckly
authors.affiliation: Department of Anaesthesiology and Intensive Care, Istanbul University and Istanbul Medical School, Istanbul, Turkey. cakarn@istanbul.edu.tr.
authors.forename: Nahit
authors.initials: N
authors.lastname: Çakar
authors.affiliation: Université Paris Descartes, Paris Sorbonne Cité, Medical-surgical ICU, Groupe hospitalier Paris Saint-Joseph, Paris, France. bmisset@hpsj.fr.
authors.forename: Benoit
authors.initials: B
authors.lastname: Misset
authors.affiliation: Department of Critical Care, University Hospital ATTIKON, Medical School University of Athens, Athens, Greece. gdimop@med.uoa.gr.
authors.forename: George
authors.initials: G
authors.lastname: Dimopoulos
authors.affiliation: Department of Intensive Care and Anaesthesiology, Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy. m.antonelli@rm.unicatt.it.
authors.forename: Massimo
authors.initials: M
authors.lastname: Antonelli
authors.affiliation: Critical Care Department, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain. jrello@crips.es.
authors.forename: Jordi
authors.initials: J
authors.lastname: Rello
authors.affiliation: Department of Critical Care Medicine, The First Affiliated Hospital Of China Medical University, Shenyang, China. xcma2972@sina.com.
authors.forename: Xiaochun
authors.initials: X
authors.lastname: Ma
authors.affiliation: Department of Anaesthesiology and Intensive Therapy, Regional Hospital in Poznan, Poznan University of Medical Sciences, Poznan, Poland. barbaratamowicz@wp.pl.
authors.forename: Barbara
authors.initials: B
authors.lastname: Tamowicz
authors.affiliation: Université Grenoble 1, U 823, Albert Bonniot Institute; Team 11: Outcome of mechanically ventilated patients and respiratory cancers, Grenoble, France. jean-francois.timsit@bch.aphp.fr.|Outcomerea Organization, Paris, France. jean-francois.timsit@bch.aphp.fr.|Decision Sciences in Infectious Disease (DescID) Prevention, Control and Care, UMR 1137 Paris Diderot University, Sorbonne, Paris, France. jean-francois.timsit@bch.aphp.fr.|Medical and Infectious Diseases Intensive Care Unit, Bichat University Hospital, Paris Diderot University, Paris, 75018, France. jean-francois.timsit@bch.aphp.fr.
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Timsit
mesh_terms: D000368:Aged; D000935:Antifungal Agents / Q000627:therapeutic use; D003428:Cross Infection / Q000401:mortality; D005260:Female; D016469:Fungemia / Q000401:mortality* / Q000473:pathology*; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007049:Iatrogenic Disease; D015994:Incidence; D007362:Intensive Care Units / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors
chemical_list: D000935:Antifungal Agents