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Journal of Clinical Microbiology, April 2005, p. 1829-1835, Vol. 43, No. 4
0095-1137/05/$08.00+0     doi:10.1128/JCM.43.4.1829-1835.2005

Epidemiology and Predictors of Mortality in Cases of Candida Bloodstream Infection: Results from Population-Based Surveillance, Barcelona, Spain, from 2002 to 2003

Benito Almirante,1* Dolors Rodríguez,1 Benjamin J. Park,2 Manuel Cuenca-Estrella,3 Ana M. Planes,4 Manuel Almela,5 Jose Mensa,6 Ferran Sanchez,7 Josefina Ayats,8 Montserrat Gimenez,9 Pere Saballs,10 Scott K. Fridkin,2 Juliette Morgan,2 Juan L. Rodriguez-Tudela,3 David W. Warnock,2 Albert Pahissa,1 the Barcelona Candidemia Project Study Group,{dagger}

Infectious Diseases Division,1 Microbiology Department, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona,4 Microbiology Department,5 Infectious Diseases Division, Hospital Clinic-IDIBAPS,6 Microbiology Department, Hospital de la Santa Creu i Sant Pau,7 Microbiology Department, Hospital Universitari de Bellvitge, Hospitalet de Llobregat,8 Microbiology Department, Hospital Universitari Germans Trias i Pujol, Badalona,9 Infectious Diseases Division, Hospital del Mar, Barcelona,10 Mycology Department, Instituto de Salud Carlos III, Madrid, Spainm,3 Mycotic Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Diseases Control and Prevention, Atlanta, Georgia2

Received 20 October 2004/ Returned for modification 7 December 2004/ Accepted 16 December 2004

We conducted population-based surveillance for Candida bloodstream infections in Spain to determine its incidence, the extent of antifungal resistance, and risk factors for mortality. A case was defined as the first positive blood culture for any Candida spp. in a resident of Barcelona, from 1 January 2002 to 31 December 2003. We defined early mortality as occurring between days 3 to 7 after candidemia and late mortality as occurring between days 8 to 30. We detected 345 cases of candidemia, for an average annual incidence of 4.3 cases/100,000 population, 0.53 cases/1,000 hospital discharges, and 0.73 cases/10,000 patient-days. Outpatients comprised 11% of the cases, and 89% had a central venous catheter (CVC) at diagnosis. Overall mortality was 44%. Candida albicans was the most frequent species (51% of cases), followed by Candida parapsilosis (23%), Candida tropicalis (10%), Candida glabrata (8%), Candida krusei (4%), and other species (3%). Twenty-four isolates (7%) had decreased susceptibility to fluconazole (MIC ≥ 16 µg/ml). On multivariable analysis, early death was independently associated with hematological malignancy (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.1 to 10.4). Treatment with antifungals (OR, 0.05; 95% CI, 0.01 to 0.2) and removal of CVCs (OR, 0.3; 95% CI, 0.1 to 0.9) were protective factors for early death. Receiving adequate treatment, defined as having CVCs removed and administration of an antifungal medication (OR, 0.2; 95% CI, 0.08 to 0.8), was associated with lower odds of late mortality; intubation (OR, 7.5; 95% CI, 2.6 to 21.1) was associated with higher odds. The incidence of candidemia and prevalence of fluconazole resistance are similar to other European countries, indicating that routine antifungal susceptibility testing is not warranted. Antifungal medication and catheter removal are critical in preventing mortality.

* Corresponding author. Mailing address: Infectious Diseases Division, Hospital Universitari Vall d'Hebron, Avda. Vall d'Hebron, 119-129, 08035 Barcelona, Spain. Phone: 34 93 2746090. Fax: 34 93 4282762. E-mail: balmirante{at}vhebron.net.

{dagger} Contributing members of the Barcelona Candidemia Project Study Group are listed in Acknowledgments.

Journal of Clinical Microbiology, April 2005, p. 1829-1835, Vol. 43, No. 4
0095-1137/05/$08.00+0     doi:10.1128/JCM.43.4.1829-1835.2005




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