The potential for fluconazole resistance is a major determinant of the choice of antifungal therapy for patients with Candida spp. bloodstream infections (BSI). Lack of prompt and consistent access to antifungal resistance testing impairs the capacity of clinicians to decide the most appropriate and cost-effective therapy for patients with Candida BSI. Our objective is to describe risk factors associated with BSI caused by Candida species with potential reduced susceptibility to fluconazole among patients encountered at a single large, tertiary, university hospital. We reviewed medical records of 234 patients with Candida BSI between January 2001 and December 2003. Cases were classified based on their infecting species into a "œfluconazole-susceptible" (flu-S) group that included species rarely resistant to fluconazole (C. albicans, C. tropicalis, C. parapsilosis, and C. lusitaniae), and a "œfluconazole-resistant" (flu-R) group with species (C. glabrata, C. krusei, C. rugosa) that, while not invariably resistant, frequently have decreased fluconazole susceptibility. We looked for risk factors that predict infection with flu-S or flu-R organisms, with special emphasis on immune status and location within the hospital. Results: Only two of 55 pediatric cases were classified as flu-R. Pediatric patients were excluded from further analysis. Of 179 adult patients , 130 (C. albicans 69, C. parapsilosis 32, C. tropicalis 28, C. lusitaniae 1) were assigned to the Flu-S group and 49 (C. glabrata 38, C. krusei 9, other species 2) to the flu-R group The risk factor univariate analysis is shown in the table. On multivariate logistic regression analysis, prior antifungal therapy and dialysis remained independent risk factors for flu-R infections. Surgery in the previous 30 days also maintained its statistical significance as a protective factor against flu-R Candida BSI. While ICU location did not maintain statistical significance as a protective factor against flu-R, its p value (0.06) indicates a strong trend. The mortality of patients with flu-R Candida BSI was greater than that of patients in the flu-S group (41% vs 25%, OR 2.03, 95% CI 1.01-4.05, P=0.065). Conclusion: The distribution of Candida spp and their expected susceptibilty to fluconazole varies within our institution. Prior therapy with antifungals and patients on dialysis are more likely to have flu-R infections, while recent surgery and ICU stay favor infections with flu-S organisms.
Full conference title:
15th Annual Focus on Fungal Infections
- FFI 15th (2005)