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Focus on Fungal Infections Newsletter
Focus on Fungal Infections Newsletter

Focus on Candida Bloodstream Infections…

Dr. Henry Blumberg from Emory University School of Medicine presented epidemiological data on Candida bloodstream infections (CBSIs), and reported on the National Epidemiology of Mycosis Survey (NEMIS) study.

Infections with Candida species are the fourth leading cause of nosocomial bloodstream infections in the United States. However, since the introduction of fluconazole, there has been a shift in the frequency of CBSIs from those caused by C. albicans species to those caused by non-albicans species. Recent population-based surveillance studies of candidemia have reported an incidence of 52% for C. albicans infections, and 48% for non-albicans infections.1 Dr. Blumberg pointed out that this shift is being driven mainly by an increase in C. glabrata infections.

The NEMIS study was a prospective, multicenter study in surgical intensive care units (SICUs) and neonatal intensive care units (NICUs) conducted between 1994 and 1995 in order to determine rates of and risk factors for CBSIs in these high-risk patients.2 The study reported that 1% of patients developed a CBSI infection in the SICU, and 1.2% developed a CBSI in the NICU. In the SICU, 48% of CBSIs were due to C. albicans, compared with 63% in the NICU. A multivariate analysis of the SICU data found that the dominant independent risk factors for developing a CBSI were prior surgery, acute renal failure, and parenteral nutrition.3 Receipt of an antifungal agent was associated with a decreased risk and lower mortality. According to Dr. Blumberg, “If you can eliminate all CBSIs, you can reduce the overall mortality in the SICU by 8%.”

The NEMIS study sets the stage for large, prospective, multicenter, randomized interventional studies of antifungal prophylaxis in which some high-risk surgical patients can be enrolled. Until then, antifungal prophylaxis should be used only for carefully selected high-risk patients, including a very small proportion of patients in the SICU.

Dr. Michael Pfaller from the University of Iowa College of Medicine discussed laboratory aspects of mycologic epidemiology, and reported on the sentinel antifungal resistance surveillance studies of candidemia conducted at the University of Iowa over a 10-year period. These studies reported on trends in species distribution, antifungal susceptibility, and molecular epidemiology for more than 6,000 CBSIs. The studies found an increased frequency of C. glabrata and a decreased frequency of C. albicans CBSIs with increasing age, results that complemented the epidemiology data presented by Dr. Blumberg. The studies also found that BSI isolates of C. albicans were more susceptible than C. glabrata and C. krusei to amphotericin B. These non-albicans species also demonstrated decreased susceptibility to fluconazole and itraconazole. The data was also analyzed for cross-resistance to the newer triazole antifungal agents (voriconazole, posaconazole, and ravuconazole). It was found that fluconazole- and itraconazole-resistant Candida isolates were significantly less susceptible to the newer agents compared to the isolates that were only fluconazole-resistant. In Dr. Pfaller’s opinion, these sentinel antifungal resistance surveillance programs provide important information that may be useful in developing strategies to manage CBSIs by patient group, and that ongoing surveillance will enhance efforts to limit the extent of resistance.


1. Kao S, et al. The epidemiology of candidemia in two United States cities: results of a population-based active surveillance. Clin Infect Dis 1999;29:1164–70.

2. Rangel-Frausto MS, et al. National epidemiology of mycoses survey (NEMIS): Variations in rates of blood stream infections due to Candida species in seven surgical intensive care units and six neonatal intensive care units. Clin Infect Dis 1999;29:253–8.

3. Blumberg HM, et al. Risk factors for Candidal blood stream infections in surgical intensive care unit patients: The NEMIS prospective multicenter study. Clin Infect Dis 2001;33:177–86.

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