Dynamics and Predictors of Mortality Due to Candidemia Caused by Different Candida Species: Comparison of Intensive Care Unit-Associated Candidemia (ICUAC) and Non-ICUAC

Abstract

We investigated mortality and predictors of mortality due to intensive care unit-associated candidemia (ICUAC) versus non-ICUAC by Candida species. This study included all candidemia cases in 11 hospitals from 2017 to 2018 in South Korea. The all-cause mortality rates in all 370 patients with ICUAC were approximately twofold higher than those in all 437 patients with non-ICUAC at 7 days (2.3-fold, 31.1%/13.3%), 30 days (1.9-fold, 49.5%/25.4%), and 90 days (1.9-fold, 57.8%/30.9%). Significant species-specific associations with 7- and 30-day ICUAC-associated mortality were not observed. Multivariate analysis revealed that ICU admission was an independent predictor of Candida glabrata (OR, 2.07-2.48) and Candida parapsilosis-associated mortality (OR, 6.06-11.54). Fluconazole resistance was a predictor of C. glabrata-associated mortality (OR, 2.80-5.14). Lack (less than 3 days) of antifungal therapy was the strongest predictor of 7-day mortality due to ICUAC caused by Candida albicans (OR, 18.33), Candida tropicalis (OR, 10.52), and C. glabrata (OR, 21.30) compared with 30- and 90-day mortality (OR, 2.72-6.90). C. glabrata ICUAC had a stronger association with lack of antifungal therapy (55.2%) than ICUAC caused by other species (30.6-36.7%, all p < 0.05). Most predictors of mortality associated with ICUAC were distinct from those associated with non-ICUAC and were mediated by Candida species.

Keywords: Candida species; ICU; candidemia; lack of antifungal therapy; mortality.

Figure 1

Baseline characteristics of the patients with intensive care unit-associated candidemia (ICUAC) versus non-ICUAC by Candida species and all species. The proportions of each variable (%) are indicated in the bar chart, and the statistical significance between a specific Candida species and all other Candida species within a given category (p < 0.05) is represented by colored bars (orange, more frequent; blue, less frequent). The statistical significance (p < 0.05) of each variable between ICUAC versus non-ICUAC within a given category is represented by red numbers. Abbreviations: COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure; CVD, cerebrovascular disease; ACCI, age-adjusted Charlson comorbidity index; CVC, central venous catheter; AMB, amphotericin B.

Figure 2

The cumulative 7-, 30-, and 90-day mortality rates in patients with all candidemia (338 C. albicans, 149 C. tropicalis, 147 C. glabrata, 111 C. parapsilosis, and 807 all) (A), intensive care unit-associated candidemia (ICUAC) (147 C. albicans, 83 C. tropicalis, 58 C. glabrata, 49 C. parapsilosis, and 370 all) (B), and non-ICUAC (191 C. albicans, 66 C. tropicalis, 89 C. glabrata, 62 C. parapsilosis, and 437 all) (C). Fold changes in the ICUAC mortality rates compared to the non-ICUAC mortality rates, stratified by four common Candida species and all candidemia (D). Mortality due to all candidemia within a given category is represented by yellow-colored bars. Asterisks indicate that the mortality rate in patients with candidemia due to a specific Candida species was significantly different to those in all other patients within a given category (p < 0.05).