Diagnostic issues, clinical characteristics, and outcomes for patients with fungemia

Abstract

This study investigated microbiological, clinical, and management issues and outcomes for Danish fungemia patients. Isolates and clinical information were collected at six centers. A total of 334 isolates, 316 episodes, and 305 patients were included, corresponding to 2/3 of the national episodes. Blood culture positivity varied by system, species, and procedure. Thus, cases with concomitant bacteremia were reported less commonly by BacT/Alert than by the Bactec system (9% [11/124 cases] versus 28% [53/192 cases]; P < 0.0001), and cultures with Candida glabrata or those drawn via arterial lines needed longer incubation. Species distribution varied by age, prior antifungal treatment (57% occurrence of C. glabrata, Saccharomyces cerevisiae, or C. krusei in patients with prior antifungal treatment versus 28% occurrence in those without it; P = 0.007), and clinical specialty (61% occurrence of C. glabrata or C. krusei in hematology wards versus 27% occurrence in other wards; P = 0.002). Colonization samples were not predictive for the invasive species in 11/100 cases. Fifty-six percent of the patients had undergone surgery, 51% were intensive care unit (ICU) patients, and 33% had malignant disease. Mortality increased by age (P = 0.009) and varied by species (36% for C. krusei, 25% for C. parapsilosis, and 14% for other Candida species), severity of underlying disease (47% for ICU patients versus 24% for others; P = 0.0001), and choice but not timing of initial therapy (12% versus 48% for patients with C. glabrata infection receiving caspofungin versus fluconazole; P = 0.023). The initial antifungal agent was deemed suboptimal upon species identification in 15% of the cases, which would have been 6.5% if current guidelines had been followed. A large proportion of Danish fungemia patients were severely ill and received suboptimal initial antifungal treatment. Optimization of diagnosis and therapy is possible.

Fig. 1.

Time to blood culture positivity overall and by species. Numbers of episodes per species are indicated in parentheses. AF, antifungal; BC, blood culture.

Fig. 2.

Initial antifungal compound by age group. Solid squares, fluconazole; open triangles, amphotericin B formulation; gray circles, caspofungin; ×, voriconazole.

Fig. 3.

Thirty-day mortality according to age (a) and according to timing of initiation of therapy for 261 patients receiving at least 1 day of antifungal treatment (b). Numbers on bars indicate the number of patients in each group. We calculated the days to the start of therapy by subtracting the start date of antifungal therapy from the culture date of the first blood sample that was positive for yeast growth. Negative values indicate the number of days the patient had been on antifungal treatment at the time the blood culture was drawn.