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Candidemia in Adults at a Tertiary Hospital in China: Clinical Characteristics, Species Distribution, Resistance, and Outcomes

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Abstract

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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Abbreviations

AAT:

Appropriate antifungal therapy

APACHE:

Acute physiology and chronic health evaluation

AT:

Antifungal therapy

CBI:

Candida bloodstream infection

EMR:

Electronic medical record

H:

Hours

IAT:

Inappropriate antifungal therapy

ICU:

Intensive care unit

MIC:

Minimal inhibitory concentration(s)

MV:

Mechanical ventilation

SOFA:

Sequential organ failure assessment

T:

Temperature

US:

United States

WBC:

White blood cell count

WIC:

Charlson weighted index of comorbidities

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Funding

This work was supported by the Guangdong Natural Science Foundation (Grants 2014A030313305), Science and Technology Planning Project of Guangzhou, Guangdong Province, P. R. China (Grants 201510010046), Science and Technology Planning Project of Guangdong Province, P. R. China (Grants 2015A050502026) and National Natural Science Foundation of China (Grants 81570012) to Xiaojiang Tan. Dr. Farmakiotis has received research support from Astellas Pharma and consultant fees from Viracor. Dr. Mylonakis has received research support from Astellas Pharma and T2 Biosystems. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. All other authors have no financial disclosures.

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Author notes

  1. Shaoming Lin and Ruilan Chen have contributed equally to this work.

Authors and Affiliations

  1. Department of Respiratory and Critical Care Medicine, Chronic Airways Disease Laboratory, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China

    Shaoming Lin, Huijun Wang, Lianfang Wang & Xiaojiang Tan

  2. Department of Intensive Care Unit, Fangcun Branch of Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, People’s Republic of China

    Ruilan Chen

  3. The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, People’s Republic of China

    Ruilan Chen

  4. Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, People’s Republic of China

    Ruilan Chen

  5. District Five, Fuda Cancer Hospital, Jinan University School of Medicine, Guangzhou, People’s Republic of China

    Song Zhu

  6. Informatics Department, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China

    Jian Zou & Jingdong Yan

  7. Southern Medical University, Guangzhou, People’s Republic of China

    Xiangdong Zhang

  8. Department of Medicine, Division of Infectious Diseases, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA

    Dimitrios Farmakiotis & Eleftherios Mylonakis

Authors
  1. Shaoming Lin
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  2. Ruilan Chen
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  3. Song Zhu
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  4. Huijun Wang
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  8. Xiangdong Zhang
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  9. Dimitrios Farmakiotis
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  10. Xiaojiang Tan
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  11. Eleftherios Mylonakis
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Correspondence to Xiaojiang Tan or Eleftherios Mylonakis.

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Lin, S., Chen, R., Zhu, S. et al. Candidemia in Adults at a Tertiary Hospital in China: Clinical Characteristics, Species Distribution, Resistance, and Outcomes. Mycopathologia 183, 679–689 (2018). https://doi.org/10.1007/s11046-018-0258-5

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