Epidemiological Trends of Fungemia in Greece with a Focus on Candidemia during the Recent Financial Crisis: a 10-Year Survey in a Tertiary Care Academic Hospital and Review of Literature

Abstract

Updated information on the epidemiology of candidemia, particularly during severe socioeconomic events, is important for proper management of these infections. A systematic literature review on candidemia in Greece and a retrospective surveillance study were conducted in a tertiary university hospital during the years of the recent financial crisis (2009 to 2018) in order to assess changes in incidence rates, patient characteristics, species distribution, antifungal susceptibilities, and drug consumption. The average annual incidence of 429 candidemic episodes was 2.03/10,000 bed days, with 9.88 in adult intensive care units (ICUs), 1.74 in surgical wards, and 1.81 in internal medicine wards, where a significant increase was observed (1.15, 1.85, and 2.23/10,000 bed days in 2009 to 2011, 2012 to 2014, and 2015 to 2018, respectively; P = 0.004). Candida albicans was the most common species (41%), followed by Candida parapsilosis species complex [SC] (37%), Candida glabrata SC (11%), Candida tropicalis (7%), Candida krusei (1%), and other rare Candida spp. (3%). Mixed infections were found in 20/429 (4.7%) cases, while 33 (7%) cases were due to non-Candida spp. Overall, 44/311 (14%) isolates were resistant/non-wild type (WT) to the nine antifungals tested, with 23/113 (20%) C. parapsilosis SC and 2/34 (6%) C. glabrata SC isolates being resistant to fluconazole (1 panechinocandin and 2 panazole resistant). All isolates were susceptible/WT to amphotericin B and flucytosine. While the overall consumption of antifungals diminished (P = 0.02), with a mean of 17.93 defined daily doses (DDD)/100 bed days, increased micafungin use was correlated with the rise in C. parapsilosis SC (P = 0.04). A significant increase of candidemia in internal medicine wards and of C. parapsilosis SC infections was found during the years of financial crisis. Although resistance rates remain low (<14%), fluconazole-resistant C. parapsilosis SC and multidrug-resistant C. glabrata SC isolates are of major concern.

Keywords: Candida spp.; Greece; antifungal susceptibility; bloodstream infection; epidemiology; financial crisis.

FIG 1

Species distribution of Candida bloodstream infections in Greece before (1993 to 2009) and during the current (2009 to today) debt crisis. A significant increase in C. parapsilosis species complex isolates is recorded during the financial crisis era.

FIG 2

Temporal changes in candidemia incidence (per 10,000 hospital/unit bed days). The incidence of candidemia was calculated for each year as the ratio of Candida BSI episodes per 10,000 hospital/unit bed days for each and all wards. Statistically significant differences in the incidence rates of candidemia in internal medicine wards after 2012 (P = 0.004) were recorded, while significant correlations between incidence rates and hospital bed days for internal medicine wards and in total were found (r, Spearman’s correlation coefficient).

FIG 3

Species distribution of Candida bloodstream isolates during 2009 to 2018 in our hospital. The percentage of each of the 5 common Candida species isolated from blood cultures is presented for each year. Statistically significant differences between C. albicans and non-albicans Candida spp. (P < 0.001) were recorded.

FIG 4

Annual antifungal consumption in defined daily doses (DDD) per 100 bed days. iv, intravenous; po, per os (oral).