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BACKGROUND: An increase in central line-associated bloodstream infections (CLABSIs) has been reported during the Coronavirus (COVID-19) pandemic; however, few studies have documented causative pathogens, particularly Candida species associated with candidemia. METHODS: This was a retrospective study based on the National Health Care Safety Network surveillance definitions of CLABSI caused by Candida species during pre-COVID-19 (October 2017 to February 2020) and COVID-19 (March 2020 to December 2021) periods within a local community hospital. Candida CLABSI incidence per 1,000 central line days was compared between periods using the χ2 test and correlated with COVID-19 inpatient hospitalization rates using Pearson correlation. RESULTS: Overall CLABSI (0.68 vs 1.98 per 1,000, P = .004) and Candida CLABSI incidence (0.06 vs 0.77 per 1,000, P = .003) significantly increased from pre-COVID-19 to COVID-19 periods. There was a significant correlation between COVID-19 ICU hospitalizations and CLABSIs (R = 0.18, P = .048), but not acute care hospitalizations and CLABSIs (R = 0.065, P = .250). Conversely, there was a significant association between COVID-19 acute care hospitalizations and Candida CLABSIs (R = 0.50, P < .001), but not COVID-19 ICU hospitalizations and Candida CLABSIs (R = 0.01, P = .631). CONCLUSIONS: During the COVID-19 pandemic, our facility experienced a significant increase in Candida CLABSI and a significant correlation of Candida CLABSIs with acute care COVID-19 hospitalizations.

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Background: Candida bloodstream infection (CBSI) is a growing problem among patients with cancer. Aim: To describe the main clinical and microbiological characteristics in patients with cancer who suffer CBSI. Methods: We reviewed the clinical and microbiological characteristics of all patients with CBSI diagnosed between January 2010 and December 2020, at a tertiary-care oncological hospital. Analysis was done according to the Candida species found. Multivariate logistic regression analysis was used to determine the risk factors associated with 30-day mortality. Results: There were 147 CBSIs diagnosed, 78 (53%) in patients with hematologic malignancies. The main Candida species identified were Candida albicans (n=54), Candida glabrata (n=40) and Candida tropicalis (n=29). C. tropicalis had been mainly isolated from patients with hematologic malignancies (79.3%) who had received chemotherapy recently (82.8%), and in patients with severe neutropenia (79.3%). Seventy-five (51%) patients died within the first 30 days, and the multivariate analysis showed the following risk factors: severe neutropenia, a Karnofsky Performance Scale score under 70, septic shock, and not receiving appropriate antifungal treatment. Conclusions: Patients with cancer who develop CBSI had a high mortality related with factors associated with their malignancy. Starting an empirical antifungal therapy the soonest is essential to increase the survival in these patients.(AU)

Antecedentes: Los episodios de candidemia son un problema creciente en los pacientes con cáncer. Objetivos: Describir las principales características, clínicas y microbiológicas, en pacientes con cáncer que padecen candidemia. Métodos: Se revisaron todos los episodios de candidemia diagnosticados entre enero de 2010 y diciembre de 2020 en un hospital oncológico. El análisis se realizó comparando las principales especies de Candida identificadas. Se realizó análisis de regresión logística para identificar los factores de riesgo relacionados con la mortalidad a los 30 días. Resultados: Se identificaron 147 episodios de candidemia, 78 (53%) en pacientes con neoplasias hematológicas. Las principales especies de Candida identificadas fueron Candida albicans (n=54), Candida glabrata (n=40) y Candida tropicalis (n=29). C. tropicalis fue aislada principalmente de pacientes con neoplasias hematológicas (79,3%), en aquellos que habían recibido quimioterapia de forma reciente (82,8%) y en pacientes con neutropenia grave (79,3%). Setenta y cinco pacientes (51%) fallecieron en los primeros 30días; los factores de riesgo asociados fueron la neutropenia grave, un valor inferior a 70 en la escala de Karnofsky, presencia de choque séptico y no recibir los antifúngicos apropiados. Conclusiones: Los pacientes con cáncer que cursan con candidemia presentan una alta mortalidad relacionada con factores asociados a la neoplasia. Iniciar un tratamiento antifúngico lo antes posible incrementa la supervivencia de estos pacientes.(AU)

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BACKGROUND: Candida bloodstream infection (CBSI) is a growing problem among patients with cancer. AIM: To describe the main clinical and microbiological characteristics in patients with cancer who suffer CBSI. METHODS: We reviewed the clinical and microbiological characteristics of all patients with CBSI diagnosed between January 2010 and December 2020, at a tertiary-care oncological hospital. Analysis was done according to the Candida species found. Multivariate logistic regression analysis was used to determine the risk factors associated with 30-day mortality. RESULTS: There were 147 CBSIs diagnosed, 78 (53%) in patients with hematologic malignancies. The main Candida species identified were Candida albicans (n=54), Candida glabrata (n=40) and Candida tropicalis (n=29). C. tropicalis had been mainly isolated from patients with hematologic malignancies (79.3%) who had received chemotherapy recently (82.8%), and in patients with severe neutropenia (79.3%). Seventy-five (51%) patients died within the first 30 days, and the multivariate analysis showed the following risk factors: severe neutropenia, a Karnofsky Performance Scale score under 70, septic shock, and not receiving appropriate antifungal treatment. CONCLUSIONS: Patients with cancer who develop CBSI had a high mortality related with factors associated with their malignancy. Starting an empirical antifungal therapy the soonest is essential to increase the survival in these patients.

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BACKGROUND: Candida bloodstream infection (BSI) causes appreciable mortality in neonates and children. There are few studies describing the epidemiology of Candida BSI in children living in sub-Saharan Africa. METHODS: A retrospective descriptive study was conducted at three public sector hospitals in Cape Town, South Africa. Demographic and clinical details, antifungal management and patient outcome data were obtained by medical record review. Candida species distribution and antifungal susceptibility testing results were obtained from the National Health Laboratory Service database. RESULTS: Of the 97 Candida BSI episodes identified during a five-year period, 48/97 (49%) were Candida albicans (C. albicans), and 49/97 (51%) were non-C. albicans species. The overall incidence risk was 0.8 Candida BSI episodes per 1000 admissions at Red Cross War Memorial Children's Hospital. Of the 77/97 (79%) Candida BSI episodes with available clinical information, the median age (interquartile range) at the time of BSI was 7 (1-25) months, 36/77 (47%) were associated with moderate or severe underweight-for-age and vasopressor therapy was administered to 22/77 (29%) study participants. Most of the Candida BSI episodes were healthcare-associated infections, 63/77 (82%). Fluconazole resistance was documented among 17%, 0% and 0% of C. parapsilosis, C. tropicalis and C. albicans isolates, respectively. All Candida isolates tested were susceptible to amphotericin B and the echinocandins. The mortality rate within 30 days of Candida BSI diagnosis was 13/75 (17%). On multivariable analysis, factors associated with mortality within 30 days of Candida BSI diagnosis included vasopressor therapy requirement during Candida BSI, adjusted Odds ratio (aOR) 53 (95% confidence interval 2-1029); hepatic dysfunction, aOR 13 (95% CI 1-146); and concomitant bacterial BSI, aOR 10 (95% CI 2-60). CONCLUSION: The study adds to the limited number of studies describing paediatric Candida BSI in sub-Saharan Africa. Non-C. Albicans BSI episodes occurred more frequently than C. albicans episodes, and vasopressor therapy requirement, hepatic dysfunction and concomitant bacterial BSI were associated with an increase in 30-day mortality.

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BACKGROUND: Candida infections have become one of the most common causes of morbidity and mortality in paediatric ICUs, especially following complex surgeries, all over the world. Therefore, we conducted a 5-year analysis of Candida bloodstream infections in our tertiary paediatric cardiovascular surgery ICU. METHODS: One thousand nine hundred and thirty four children, 0-16-year-old, who underwent paediatric cardiovascular surgery between January 2016-June 2021 were enrolled in this retrospective study. Blood cultures obtained from 1056 patients, who needed mechanical ventilation and indwelling devices longer than 5 days and had the signs of infection according to Center for Disease Control criteria, were evaluated. The isolated pathogens were recorded. 137 with Candida bloodstream infections were reanalysed for their age, weight, cardiac pathologies, duration of mechanical ventilation, hospitalisation and antibiotic use. RESULTS: One hundred and thirty-seven out of one thousand and fifty six patients (12.9%) had Candida growth in their blood cultures. C. albicans (n: 50, 36.5%), C. parapsilosis (n: 20, 14.6%), C. tropicalis (n: 8, 5.8%), C. glabrata (n: 5, 3.7%), and other non-albicans Candida species (n: 54, 39.4%) were isolated. The patients with Candida bloodstream infections had lower age, longer duration of mechanical ventilation, longer length of hospital stay and antibiotic use (p-values<0.05). They had cardiac pathologies as atrioventricular septal defect (18.9%), transposition of great arteries (17.6%), tetralogy of Fallot (12.4%), transposition of great arteries + double outlet right ventricle, or total anomalous pulmonary venous return + atrioventricular septal defect (37.9%), and others. The Candida bloodstream infections mortality was 11.6% (16/137). CONCLUSION: The most common cause of Candida bloodstream infections in the last five years in our paediatric cardiovascular surgery ICU was non-albicans Candida species. Prolonged mechanical ventilation, hospitalisation and antibiotic use, low age, and weight were found as the main risk factors that raise the morbidity and mortality rates of Candida bloodstream infections.

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OBJECTIVES: To analyze the distribution of pathogens and risk factors of mortality in Candida bloodstream infection patients in Intensive Care Unit (ICU). METHODS: The clinical data, infection relevant indexes, and prognosis of patients with Candida bloodstream infection in ICU of Xiangya Hospital of Central South University from January 2016 to December 2020 were retrospectively collected. The distribution of pathogenic bacteria and clinical characteristics of patients with Candida bloodstream infection were analyzed. The patients were assigned into a death group and a survival group according to their survival status, and single factor analysis and logistic regression analysis were used to analyze risk factors for death. RESULTS: A total of 80 patients with Candida bloodstream infection were enrolled, with the highest infection rate (36.3%) of Candidaalbicans. According to the drug sensitivity, all kinds of Candidas were wide type and relatively sensitive to amphotericin B. Candidaalbicans was highly sensitive to fluconazole, itraconazole, and voriconazole (≥96.6%), while non-Candidaalbicans were more resistant to fluconazole, itraconazole, and voriconazole. The overall mortality rate was 36.3%. Univariate analysis showed that the risk factors for the death of patients with Candida bloodstream infection were acute physiology and chronic health evaluation II (APACHE II) score≥20, diabetes mellitus, and mechanical ventilation. Logistic regression analysis showed that the APACHE II score≥20 was an independent risk factor for the death of patients with Candida bloodstream infection (OR=0.220, 95% CI 0.078 to 0.619, P=0.004). CONCLUSIONS: The most common strain of Candida bloodstream infection in ICU patients is Candidaalbicans. The APACHE II score≥20 is an independent risk factor for the death of patients with Candida bloodstream infection.

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Background and Objectives: Overtreatment with antifungal drugs is often observed. Antifungal stewardship (AFS) focuses on optimizing the treatment for invasive fungal diseases. The objective of the present study was to evaluate the utility of a post-prescription audit plus beta-D-glucan (BDG) assessment on reducing echinocandin use in persons with suspected invasive candidiasis. Materials and Methods: This is a prospective, pre-post quasi-experimental study of people starting echinocandins for suspected invasive candidiasis. The intervention of the study included review of each echinocandin prescription and discontinuation of treatment if a very low probability of fungal disease or a negative BDG value were found. Pre-intervention data were compared with the intervention phase. The primary outcome of the study was the duration of echinocandin therapy. Secondary outcomes were length of hospital stay and mortality. Results: Ninety-two echinocandin prescriptions were reviewed, 49 (53.3%) in the pre-intervention phase and 43 (46.7%) in the intervention phase. Discontinuation of antifungal therapy was possible in 21 of the 43 patients in the intervention phase (48.8%). The duration of echinocandin therapy was 7.4 (SD 4.7) in the pre-intervention phase, 4.1 days (SD 2.9) in persons undergoing the intervention, and 8.6 (SD 7.3) in persons in whom the intervention was not feasible (p at ANOVA = 0.016). Length of stay and mortality did not differ between pre-intervention and intervention phases. Conclusions: An intervention based on pre-prescription restriction and post-prescription audit when combined with BDG measurement is effective in optimizing antifungal therapy by significantly reducing excessive treatment duration.

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BACKGROUND: Morbidity and mortality from candidemia remain unacceptably high. While infectious disease consultation (IDC) is known to lower the mortality from Staphylococcus aureus bacteremia, little is known about the impact of IDC in candidemia. METHODS: We conducted a retrospective observational cohort study of candidemia patients at a large tertiary care hospital between 2015 and 2019. The crude mortality rate was compared between those with IDC and without IDC. Then, we systematically searched 5 databases through February 2020 and performed a meta-analysis of the impact of IDC on the mortality of patients with candidemia. RESULTS: A total of 151 patients met the inclusion criteria, 129 (85%) of whom received IDC. Thirty-day and 90-day mortality rates were significantly lower in the IDC group (18% vs 50%; P = .002; 23% vs 50%; P = .0022, respectively). A systematic literature review returned 216 reports, of which 13 studies including the present report fulfilled the inclusion criteria. Among the 13 studies with a total of 3582 patients, IDC was performed in 50% of patients. Overall mortality was 38.2% with a significant difference in favor of the IDC group (28.4% vs 47.6%), with a pooled relative risk of 0.41 (95% CI, 0.35-0.49). Ophthalmology referral, echocardiogram, and central line removal were performed more frequently among patients receiving IDC. CONCLUSIONS: This study is the first systematic literature review and meta-analysis to evaluate the association between IDC and candidemia mortality. IDC was associated with significantly lower mortality and should be considered in all patients with candidemia.

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Candida infective endocarditis (CIE) is a rare but serious complication of candidemia. Incidence and risk factors associated with CIE among candidemic patients are poorly defined from small cohorts. Identification of clinical predictors associated with this entity may guide more judicious use of cardiac imaging. We conducted a retrospective analysis of all inpatients aged ≥18 years diagnosed with candidemia at our institution. CIE was diagnosed by fulfilling two of the major Duke criteria: specifically a vegetation(s) on echocardiogram and positive blood cultures for Candida spp. We used univariable and multivariable regression analyses to identify risk factors associated with CIE. Of 1,873 patients with candidemia, 47 (2.5%) were identified to have CIE. In our multivariable logistic model, existing valvular heart disease was associated with a higher risk for CIE (adjusted odds ratio [aOR], 7.66; 95% confidence interval [CI], 2.95-19.84). Predictors that demonstrated a decreased risk of CIE included infection with C. glabrata (aOR, 0.17; 95% CI, 0.04-0.69), hematologic malignancy (aOR, 0.09; 95% CI, 0.01-0.68), and receipt of total parenteral nutrition (aOR, 0.38; 95% CI, 0.16-0.91). The 90-day crude mortality for CIE was 48.9%, similar to the overall non-CIE mortality of 41.9% (P = .338). We identified a set of clinical factors that can predict the presence of CIE among patient with candidemia. These findings may reduce the need for unnecessary expensive and invasive imaging studies in a subset of patients with a lower risk profile for endocarditis and alternative infection source.

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WHAT IS KNOWN AND OBJECTIVE: Implementation of an antifungal stewardship programme is a recognized need. However, there is insufficient information to confirm the impact of antifungal stewardship interventions. Further, few studies have evaluated the clinical effects of an antifungal stewardship intervention using 1-3, ß-D-glucan (ßDG) testing. The aim of the present study was to evaluate the impact of implementing an antifungal stewardship with monitoring of ßDG values on antifungal use and clinical outcomes. METHODS: A single institutional prospective cohort study was conducted to evaluate the impact of implementing daily reviews of antifungal agents and monitoring patients who measured ßDG values since August 2013. Antifungal consumption and clinical outcomes in patients with Candida bloodstream infection were compared before and after the intervention. RESULTS: After implementation of the programme, parental antifungal use was significantly reduced compared to that before intervention (P = 0.006). In the after-intervention group, the rate of 60-day clinical failure in patients with Candida bloodstream infection was significantly reduced, from 80.0% (28/35) to 36.4% (8/22) (P < 0.001), and the rate of 60-day mortality associated with Candida bloodstream infection tended to be reduced, from 42.9% (15/35) to 18.2% (4/22) (P = 0.081) compared to the before-intervention group. The incidence of adverse events associated with antifungal agents was significantly lower in the after-intervention group than in the before-intervention group (51.4% [18/35] vs 13.6% [3/22], P = 0.004). WHAT IS NEW AND CONCLUSION: Our findings suggest that daily review of the use of antifungal agents and monitoring of measured ßDG values was highly effective in reducing antifungal consumption and improving the clinical outcomes of patients with Candida bloodstream infection.

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BACKGROUND: Candidemia is one of the most common nosocomial bloodstream infections. Early diagnosis and antifungal treatment improve clinical outcomes in some studies but not all, with diverse data reported from different institutions. Similarly, antifungal resistance is more common in the USA than in Europe, but there is little data regarding the microbiology and clinical course of candidemia in adult patients in Asia. AIMS: (1) To capture species distribution and drug resistance rates among Candida bloodstream isolates, (2) to describe clinical features of candidemia, and (3) to identify factors associated with all-cause mortality, with emphasis on early initiation of antifungal treatment, at a large tertiary University Hospital in China. METHODS: In this single-center retrospective study, we identified all patients with candidemia, between 2008 and 2014. Demographic and clinical characteristics, microbiological information, details of antifungal therapy and clinical outcomes were collected. RESULTS: We studied 166 patients. 71 (42.8%) had cancer. Candida albicans was the most frequent species (37.3%), followed by C. parapsilosis (24.1%), C. tropicalis (22.8%), and C. glabrata (14.5%). Antifungal resistance was more frequent in non-albicans strains and especially C. glabrata. Twenty patients received inappropriate treatment with all-cause mortality of 35%. The remaining 146 patients had significantly lower mortality (21.9%, P = 0.045). Among patients who received antifungal treatment, mortality rate increased with time to appropriate antifungal therapy (AAT): 13.7%, for < 24 h, 21.1% for 24-48 h, 23.1% for > 48 h, and 32.4% among patients who received no AT (χ2 for trend P = 0.039). Initiating AAT more than 24 h after blood culture collection was an independent risk factor for mortality, after adjustment for other confounders (OR 7.1, 95% CI 1.3-39.4, P = 0.024). CONCLUSIONS: Candida albicans was the most frequent cause of candidemia at a large tertiary hospital in China, but antifungal resistance is a growing concern among non-albicans Candida species. The mortality rate of patients treated with ineffective antifungal agents based on in vitro susceptibilities was similar to that of patients who received no treatment at all, and delayed initiation of antifungal treatment was associated with increased risk of death.

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PURPOSE: The aim of this study was to monitor recent changes in the epidemiology of candidemia and in the antifungal susceptibility profiles of Candida isolates in one Italian region (Lombardy) in 2014-2015 in comparison with two other studies performed in the same area in 1997-1999 and in 2009. METHODS: A laboratory-based surveillance was conducted in 11 microbiology laboratories. Identification of Candida isolates from 868 episodes and antifungal susceptibility testing (YeastOne) was performed locally. RESULTS: A progressive increase in the rate of candidemia up to 1.27/1000 admissions and 1.59/10,000 patient days was documented. In all the three surveys, Candida albicans remains the most frequently isolated species, ranging from 52 to 59 % of the etiology of BSIs. The epidemiological shift to the more resistant C. glabrata, observed between 1997-1999 and 2009 surveys, was not confirmed by our more recent data. The pattern of etiology of BSIs occurred in 2014-2015 overlaps that of the 90s. Acquired antifungal resistance is a rare event. No isolate had an amphoterin B minimal inhibitory concentration (MIC, mg/L) value higher than the epidemiological cutoff. All the echinocandin MIC distributions are typical for wild-type organisms except for those of two C. glabrata isolates. Fluconazole resistance declined from 24.9 % in the 2009 survey to 5.4 % in the recent one. CONCLUSIONS: Data from regional surveys may highlight the influence of therapeutic practices on the epidemiology of Candida BSIs and may optimize empirical therapies.

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INTRODUCTION: Patients with C. difficile infection (CDI) experience intestinal microflora changes that can promote the overgrowth and subsequent translocation of gut resident pathogens into the blood. Consistently, CDI due to PCR-ribotype 027 strain, severe or relapsing CDI, and treatment with high-dosage vancomycin are independent risk factors for candidemia. AREAS COVERED: We review the role played by the gut microbiota during CDI and its treatment, as well as the clinical profile of CDI patients who are at risk of developing candidemia. Also, we discuss the management of these patients by focusing on pre-emptive strategies aimed at reducing the risk of candidemia, and on innovative anti-C. difficile therapies that may mitigate CDI-related effects such as the altered gut microbiota composition and prolonged intestinal mucosa damage. Expert commentary: A closer clinical and diagnostic monitoring of patients with CDI should help to limit the CDI-associated long-term consequences, including Candida infections, which worsen the outcome of hospitalized patients.

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The alterations occurring in the intestinal flora during Clostridium difficile infection (CDI) may promote the translocation of Candida to the blood and the development of candidaemia. The aim of our study was to analyse clinical findings of these patients to determine the risk factors associated with the development of candidaemia subsequent to CDI. We compared 35 patients with candidaemia subsequent to CDI with 105 patients with CDI. Patients with candidaemia showed more severe infections and higher mortality. The ribotype 027 strain and vancomycin treatment at ≥ 1000 mg/day were prevalent in patients developing candidaemia. CDI may predispose to the translocation of Candida.

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