title: Candidemia in a major regional tertiary referral hospital - epidemiology, practice patterns and outcomes.
abstract: Candidemia is a common cause of nosocomial bloodstream infections, resulting in high morbidity and mortality. This study was conducted to describe the epidemiology, species distribution, antifungal susceptibility patterns and outcomes of candidemia in a large regional tertiary referral hospital.
  
  
  
  A retrospective surveillance study of patients with candidemia was conducted at Singapore General Hospital between July 2012 and December 2015. In addition, incidence densities and species distribution of candidemia episodes were analysed from 2008 to 2015.
  
  
  
  In the period of 2012 to 2015, 261 candidemia episodes were identified. The overall incidence was 0.14/1000 inpatient-days.C. glabrata(31.4%),C. tropicalis(29.9%), andC. albicans(23.8%) were most commonly isolated. The incidence ofC. glabratasignificantly increased from 2008 to 2015 (Coefficient 0.004, confidence interval 0-0.007,p= 0.04). Fluconazole resistance was detected primarily inC. tropicalis(16.7%) andC. glabrata(7.2%).fksmutations were identified in oneC. albicansand oneC. tropicalis. Candidemia episodes caused byC. tropicaliswere more commonly encountered in patients with haematological malignancies (p= 0.01), neutropenia (p< 0.001) and higher SAPS II scores (p= 0.02), while prior exposure to echinocandins was associated with isolation ofC. parapsilosis(p= 0.001). Echinocandins (73.3%) were most commonly prescribed as initial treatment. The median (range) time to initial treatment was 1 (0-9) days. The 30-day in-hospital mortality rate was 49.8%. High SAPS II score (Odds ratio, OR 1.08; 95% confidence interval, CI 1.05-1.11) and renal replacement therapy (OR 5.54; CI 2.80-10.97) were independent predictors of mortality, while drain placement (OR 0.44; CI 0.19-0.99) was protective.
  
  
  
  Decreasing azole susceptibilities toC. tropicalisand the emergence of echinocandin resistance suggest that susceptibility patterns may no longer be sufficiently predicted by speciation in our institution. Candidemia is associated with poor outcomes. Strategies optimising antifungal therapy, especially in the critically-ill population, should be explored.
authors.affiliation: Department of Pharmacy, Singapore General Hospital, Blk 8 Level 2, Outram Road, Singapore, 169608 Singapore.
authors.forename: Jocelyn Qi-Min
authors.initials: JQ
authors.lastname: Teo
authors.affiliation: Department of Pharmacy, Singapore General Hospital, Blk 8 Level 2, Outram Road, Singapore, 169608 Singapore.
authors.forename: Samuel Rocky
authors.initials: SR
authors.lastname: Candra
authors.affiliation: Department of Pharmacy, Singapore General Hospital, Blk 8 Level 2, Outram Road, Singapore, 169608 Singapore.
authors.forename: Shannon Jing-Yi
authors.initials: SJ
authors.lastname: Lee
authors.affiliation: Department of Pharmacy, Singapore General Hospital, Blk 8 Level 2, Outram Road, Singapore, 169608 Singapore.|Present address: Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore.
authors.forename: Shannon Yu-Hng
authors.initials: SY
authors.lastname: Chia
authors.affiliation: Department of Pharmacy, Singapore General Hospital, Blk 8 Level 2, Outram Road, Singapore, 169608 Singapore.
authors.forename: Hui
authors.initials: H
authors.lastname: Leck
authors.affiliation: Department of Microbiology, Singapore General Hospital, Outram Road, Singapore, 169608 Singapore.
authors.forename: Ai-Ling
authors.initials: AL
authors.lastname: Tan
authors.affiliation: Department of Pharmacy, Singapore General Hospital, Blk 8 Level 2, Outram Road, Singapore, 169608 Singapore.
authors.forename: Hui-Peng
authors.initials: HP
authors.lastname: Neo
authors.affiliation: Department of Pharmacy, Singapore General Hospital, Blk 8 Level 2, Outram Road, Singapore, 169608 Singapore.
authors.forename: Kenneth Wei-Liang
authors.initials: KW
authors.lastname: Leow
authors.affiliation: Department of Pharmacy, Singapore General Hospital, Blk 8 Level 2, Outram Road, Singapore, 169608 Singapore.|Department of Pharmacy, National University of Singapore, 18 Science Drive 4, Singapore, 117543 Singapore.
authors.forename: Yiying
authors.initials: Y
authors.lastname: Cai
authors.affiliation: Department of Pharmacy, National University of Singapore, 18 Science Drive 4, Singapore, 117543 Singapore.
authors.forename: Pui Lai Rachel
authors.initials: PLR
authors.lastname: Ee
authors.affiliation: Department of Pharmacy, Singapore General Hospital, Blk 8 Level 2, Outram Road, Singapore, 169608 Singapore.|SingHealth Duke-NUS Medicine Academic Clinical Programme, 20 College Rd, Singapore, 169856 Singapore.
authors.forename: Tze-Peng
authors.initials: TP
authors.lastname: Lim
authors.affiliation: Department of Pharmacy, Singapore General Hospital, Blk 8 Level 2, Outram Road, Singapore, 169608 Singapore.
authors.forename: Winnie
authors.initials: W
authors.lastname: Lee
authors.affiliation: Department of Pharmacy, Singapore General Hospital, Blk 8 Level 2, Outram Road, Singapore, 169608 Singapore.|Department of Pharmacy, National University of Singapore, 18 Science Drive 4, Singapore, 117543 Singapore.|Emerging Infectious Diseases, Duke-NUS Medical School, 8 College Rd, Singapore, 169857 Singapore.
authors.forename: Andrea Lay-Hoon
authors.initials: AL
authors.lastname: Kwa
keywords: Antifungal susceptibility; Bloodstream infections; Candida; Mortality; fks