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. 2022 Oct 17;9(10):ofac545.
doi: 10.1093/ofid/ofac545. eCollection 2022 Oct.

Recurrent Candidemia: Trends and Risk Factors Among Persons Residing in 4 US States, 2011-2018

Emma E Seagle  1   2 , Brendan R Jackson  2 , Shawn R Lockhart  2 , Emily N Jenkins  1   2 , Andrew Revis  3   4   5 , Monica M Farley  3   5   6 , Lee H Harrison  7 , William Schaffner  8 , Tiffanie M Markus  8 , Rebecca A Pierce  9 , Alexia Y Zhang  9 , Meghan M Lyman  2
Affiliations

Recurrent Candidemia: Trends and Risk Factors Among Persons Residing in 4 US States, 2011-2018

Emma E Seagle et al. Open Forum Infect Dis. .

Abstract

Background: Candidemia is a common healthcare-associated infection with high mortality. Estimates of recurrence range from 1% to 17%. Few studies have focused on those with recurrent candidemia, who often experience more severe illness and greater treatment failure. We describe recurrent candidemia trends and risk factors.

Methods: We analyzed population-based candidemia surveillance data collected during 2011-2018. Persons with >1 episode (defined as the 30-day period after a positive Candida species) were classified as having recurrent candidemia. We compared factors during the initial episode between those who developed recurrent candidemia and those who did not.

Results: Of the 5428 persons identified with candidemia, 326 (6%) had recurrent infection. Recurrent episodes occurred 1.0 month to 7.6 years after any previous episode. In multivariable logistic regression controlling for surveillance site and year, recurrent candidemia was associated with being 19-44 years old (vs ≥65 years; adjusted odds ratio [aOR], 3.05 [95% confidence interval {CI}, 2.10-4.44]), being discharged to a private residence (vs medical facility; aOR, 1.53 [95% CI, 1.12-2.08]), hospitalization in the 90 days prior to initial episode (aOR, 1.66 [95% CI, 1.27-2.18]), receipt of total parenteral nutrition (aOR, 2.08 [95% CI, 1.58-2.73]), and hepatitis C infection (aOR, 1.65 [95% CI, 1.12-2.43]).

Conclusions: Candidemia recurrence >30 days after initial infection occurred in >1 in 20 persons with candidemia. Associations with younger age and hepatitis C suggest injection drug use may play a modifiable role. Prevention efforts targeting central line care and total parenteral nutrition use may help reduce the risk of recurrent candidemia.

Keywords: Candida; candidemia; fungal; healthcare-associated; recurrent.

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Conflict of interest statement

Potential conflicts of interest. Monica M. Farley reports institutional support from the Centers for Disease Control and Prevention via the Emerging Infections Program cooperative agreement, NIH grant to institution for the Infectious Diseases Clinical Research Consortium (IDCRC) Leadership Group (unrelated to this project), honoraria for Grand Rounds presentation at NYU in January 2022 (unrelated to this project), and serves in a leadership role on the National Foundation for Medical Research Finance Committee (unrelated to this project). Lee H. Harrison reports support for attending meetings and/or travel from GSK and participation on a Data Safety Monitoring Board or Advisory Board (Merck). William Schaffner reports institutional support from the Centers for Disease Control and Prevention via the Emerging Infections Program cooperative agreement and serves as Medical Director for National Foundation for Infectious Diseases outside the submitted work. Tiffanie M. Markus reports institutional support from the Centers for Disease Control and Prevention via the Emerging Infections Program cooperative agreement. Rebecca A. Pierce reports institutional support from the Centers for Disease Control and Prevention via the Emerging Infections Program and Epidemiology and Laboratory Capacity cooperative agreements. All other authors report no conflicts of interest.

Figures

Figure 1.
Figure 1.
Temporal depiction of recurrent candidemia by person during 2011–2018 (N = 326). Each line represents 1 person with each square representing the candidemia onset date for 1 episode of candidemia; First episode is the initial episode before recurrence. Abbreviation: IQR, interquartile range.
Figure 2.
Figure 2.
Change in Candida species isolated and antifungal resistance between first and second episode among persons with recurrent candidemia during 2011–2018. Only those with available antifungal susceptibility testing results for the first and second episodes were included for the resistance graph (n = 274); episode 1 is the initial episode before recurrence.
Figure 3.
Figure 3.
Time and variation of species isolated between first and second candidemia episodes (N = 326). Percentages in the graph refer to same species; first episode is the initial episode before recurrence.
Figure 4.
Figure 4.
Persistence of certain clinical factors across the first 4 episodes. Percentage calculation: proportion of prior episode (eg, of those who had the factor in episode 1, how many had the factor in episode 2); episode 1 is the initial episode before recurrence.
See this image and copyright information in PMC

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