Candidemia in nonneutropenic critically ill patients: Risk factors for non-albicans Candida spp.

Objective:The objective of this study was to determine the clinical features associated with candidemia caused by non-albicans Candida spp. and with potentially fluconazole-resistant Candida spp. (C. glabrata and C. krusei) among candidemic intensive care unit patients. Design:The authors conducted a nationwide prospective cohort study. Setting:The study was conducted in Australian intensive care units. Patients:All patients with intensive care unit-acquired candidemia over a 3-yr period were included in the study. Measurements:Clinical risk factors occurring up to 30 days before candidemia, Candida spp. associated with candidemia, and outcomes were determined. Risk factors associated with either non-albicans Candida spp. or with potentially fluconazole-resistant Candida spp. (C. glabrata or C. krusei) were assessed using multivariate logistic regression. Main Results:Among 179 episodes of intensive care unit-acquired candidemia, C. albicans accounted for 62%, C. glabrata 18%, C. krusei 4%, and other Candida spp. 16%. Independently significant variables associated with non-albicans Candida bloodstream infection included recent prior gastrointestinal surgery (adjusted odds ratio, 2.87; 95% confidence interval, 1.68–4.91) and recent prior systemic antifungal exposure (4.6; 1.36–15.53). Those associated with potentially fluconazole-resistant candidemia included recent prior gastrointestinal surgery (3.31; 1.79–6.11) and recent prior fluconazole exposure (5.47; 1.23–24.32). No significant differences in outcomes were demonstrated for non-albicans or potentially fluconazole-resistant candidemia. Conclusions:Among candidemic intensive care unit patients, prior gastrointestinal surgery and systemic antifungal exposure were significantly associated with both a non-albicans Candida spp. and a potentially fluconazole-resistant Candida spp. LEARNING OBJECTIVESOn completion of this article, the reader should be able to:List clinical features discriminating between candidemia caused by C. albicans and those caused by other species.Describe predisposing factors that help discriminate between candidemia which are potentially fluconazole-resistant.Use this information in a clinical setting.Dr. Playford has disclosed that he was a consultant/advisor for Pfizer and Merck; was on the advisory board for Schering-Plough; and is a recipient of grant/research funds from Pfizer and Merck. Dr. Marriott has disclosed that she was/is a recipient of grant/research funds from Pfizer; was/is a consultant/advisor for Merck, Sharpe & Dohme and Sanofi-Pasteur; and was/is on the advisory board for Roche. Dr. Nguyen has disclosed that he has no financial relationships with or interests in any commercial companies pertaining to this educational activity. Dr. Chen has disclosed that she was a recipient of grant/research funds from Pfizer; is a recipient of grant/research funds from Gilead Sciences, Inc.; and is on the advisory board for Gilead Sciences, Inc. and Pfizer Australia. Dr. Ellis has disclosed that he was/is a recipient of grant/research funds from Pfizer Australia, Merck, Sharpe & Dohme Australia, Gilead Sciences Australia, and Schering-Plough Australia; was/is a consultant/advisor for Pfizer Australia, Merck, Sharpe & Dohme Australia, Gilead Sciences Australia, and Schering-Plough Australia; and was/is on the speaker's bureau for Pfizer Australia, Merck, Sharpe & Dohme Australia, Gilead Sciences Australia, and Schering-Plough Australia. Dr. Slavin has disclosed that she was/is a recipient of grant/research funds from Pfizer Inc., Gilead Sciences, Schering-Plough, and Merck and Co.; and was/is on the advisory board for Pfizer Inc., Gilead Sciences, Schering-Plough, and Merck and Co. Dr. Sorrell has disclosed that she was/is a recipient of grant/research funds from Merck, Sharpe & Dohme Australia, Pfizer, and Gilead; and was/is a consultant/advisor for Pfizer, Merck, Gilead, and Schering-Plough.All faculty and staff in a position to control the content of this CME activity have disclosed that they have no financial relationship with, or financial interests in, any commercial companies pertaining to this educational activity.Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity.Visit the Critical Care Medicine Web Site (www.ccmjournal.org) for information on obtaining continuing medical education credit.