title: Candidemia in Patients with Body Temperature Below 37°C and Admitted to Internal Medicine Wards: Assessment of Risk Factors.
abstract: BACKGROUND
  An increasing number of candidemia episodes has been reported in patients cared for in internal medicine wards. These usually older and frail patients may not be suspected as having candidemia because they lack fever at the onset of the episode. To identify the risk factors associated with the lack of fever at the onset of candidemia (ie, the collection of the first positive blood culture for Candida spp.) in patients cared for in internal medicine wards, we compared 2 group of patients with or without fever.
  
  
  METHODS
  We retrospectively review data charts from 3 tertiary care, university hospitals in Italy, comparing patients with or without fever at onset of candidemia. Consecutive candidemic episodes in afebrile patients and matched febrile controls were identified during the 3-year study period. Patient baseline characteristics and several infection-related variables were examined. Random forest analysis was used, given the number of predictors to be considered and the potential complexity of their relations with the onset of fever.
  
  
  RESULTS
  We identified 147 candidemic episodes without fever at onset and 147 febrile candidemia episodes. Factors associated with the lack of fever at onset of candidemia were diabetes, Clostridium difficile infection, and a shorter delta time from internal medicine wards admission to the onset of candidemia. The only variable associated with fever was the use of intravascular devices. Quite unexpectedly, antifungal therapy was administered more frequently to patients without fever, and no differences on 30-day mortality rate were documented in the 2 study groups.
  
  
  CONCLUSIONS
  Clinicians should be aware that an increasing number of patients with invasive candidiasis cared for in internal medicine wards may lack fever at onset, especially those with diabetes and C. difficile infection. Candidemia should be suspected in patients with afebrile systemic inflammatory response syndrome or in worsening clinical condition: blood cultures should be taken, and a timely and appropriate antifungal therapy should be considered.
authors.affiliation: Infectious Diseases Clinic, Nuovo Santa Chiara University Hospital, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Tascini
authors.affiliation: Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Falcone
authors.affiliation: Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Bassetti
authors.affiliation: Department of Medical Sciences, University of Turin, Italy; Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy.
authors.forename: Francesco G
authors.initials: FG
authors.lastname: De Rosa
authors.affiliation: Emergency Medicine Unit, Nuovo Santa Chiara University Hospital, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy.
authors.forename: Emanuela
authors.initials: E
authors.lastname: Sozio
authors.affiliation: Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Russo
authors.affiliation: Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Sbrana
authors.affiliation: Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Ripoli
authors.affiliation: Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy.
authors.forename: Maria
authors.initials: M
authors.lastname: Merelli
authors.affiliation: Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Scarparo
authors.affiliation: Emergency Medicine Unit, Nuovo Santa Chiara University Hospital, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy.
authors.forename: Franco
authors.initials: F
authors.lastname: Carmassi
authors.affiliation: Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Venditti
authors.affiliation: Infectious Diseases Clinic, Nuovo Santa Chiara University Hospital, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy. Electronic address: menichettifrancesco@gmail.com.
authors.forename: Francesco
authors.initials: F
authors.lastname: Menichetti
mesh_terms: D000368:Aged; D001831:Body Temperature / Q000502:physiology; D058387:Candidemia / Q000175:diagnosis* / Q000453:epidemiology; D016009:Chi-Square Distribution; D003428:Cross Infection / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology; D005260:Female; D005334:Fever / Q000175:diagnosis / Q000209:etiology*; D006784:Hospitals, Teaching; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data*; D007388:Internal Medicine; D007558:Italy / Q000453:epidemiology; D008297:Male; D015337:Multicenter Studies as Topic; D015999:Multivariate Analysis; D012189:Retrospective Studies; D012307:Risk Factors; D018709:Statistics, Nonparametric
keywords: Candidemia; Fever; Internal medicine wards; Risk factors