Epidemiological patterns of candidaemia: A comprehensive analysis over a decade.

Polymicrobial bloodstream infections involving Candida species: analysis of patients and review of the literature

BackgroundMolecular rapid diagnostic tests, such as the microarray-based Verigene Gram-Negative Blood Culture Test (BC-GN), when performed in conjunction with antimicrobial stewardship, are associated with improved clinical outcomes in bloodstream infections (BSIs). Optimal use of Verigene BC-GN to aid in clinical decision-making, however, can be hindered by a lack of confidence in results if patients have polymicrobial GN BSIs.MethodsBlood culture data from patients tested by Verigene BC-GN from June 2015 – July 2016 from the Detroit Medical Center and University of Maryland Medical Center were retrospectively reviewed and evaluated for incidence of missed GNs in GN BSIs. Missed GNs entailed those not detected in the tested sample and those that grew in a separate complementary positive blood culture bottle collected but not tested using Verigene BC-GN. For blood culture sets with missed GNs, potential clinical significance was evaluated.ResultsA total of 1,003 sets of GN blood cultures were reviewed. Fifty-seven (5.6%) were determined to be polymicrobial GN BSIs by traditional microbiological culture methods. Verigene BC-GN did not identify one or more GNs in 37 cases (65% of polymicrobial GN BSIs; 3.7% of total GN BSIs.); 25 were missed by the probe in the tested culture and 12 where missed due to isolation in the complementary blood culture bottle that was not tested by Verigene BC-GN. While potentially inappropriate de-escalation of antibiotic therapy could have occurred in 18 (31.5%) of polymicrobial GN BSIs, this represented only 1.8% of total GN BSIs.ConclusionCurrent practices utilizing Verigene BC-GN can result in the omission of undetected GNs in over half of polymicrobial GN BSIs. These misses were a combination of technology and workflow limitations. The potential for inappropriate de-escalation of antibiotic therapy in the entire cohort, however, was infrequent (<2% of total cases).DisclosuresP. Lephart, Nanosphere: Grant Investigator, Grant recipient; J. K. Johnson, Nanosphere: Grant Investigator, Grant recipient

BackgroundRecent literature questions the utility of follow-up blood cultures (FUBC), especially for gram-negative bloodstream infections (BSIs). This has yet to be evaluated in the burn intensive care unit (BICU), where many BSIs are gram-negative. We evaluated the FUBC frequency, positivity rate, and clinical significance of persistent BSI (p-BSI) in BICU patients.MethodsPatients ≥ 18 years old admitted to the US Army Institute of Surgical Research for combat-related thermal burns from 1/2003–6/2014 were included. P-BSI was defined as the same organism isolated from initial and FUBC (within 1–5 days). Non-p-BSI (np-BSI) included patients without subsequent isolation of the same organism between 1–5 days post-positive blood culture. Exclusion criteria were initial blood culture with usual skin flora, polymicrobial BSI, fungemia, and death within 24 hours of notification of initial positive blood culture. Those factors significantly associated with mortality on univariate analysis were evaluated with binomial logistic regression (BLR).ResultsOf 126 patients meeting inclusion criteria with BSI, 53 (42.1%) had p-BSI and 73 (57.9%) had np-BSI (table 1). 50 (67.6%) np-BSI patients had FUBC. P-BSI and np-BSI patients did not differ in age, gender, or race, but p-BSI and np-BSI patients had median total body surface area (TBSA) burns of 47 (IQR 34–63) and 35.3 (IQR 23.3–56.6), respectively (p=0.021). P-BSI patients had longer hospitalizations, ICU stays, and intubations (p< 0.01; table 1). Microbiology did not differ between p-BSI and np-BSI (p=0.517). Notably, 20 (37.7%) p-BSI patients died compared to 8 (10.8%) np-BSI patients (p< 0.001; table 2). BLR revealed that p-BSI (p=0.031), TBSA (p< 0.001), ISS (p=0.008), and length of ICU stay (p=0.002) and intubation (p< 0.001) were independently significantly associated with mortality.Table 1: Clinical characteristics of burn patients with and without persistent bacteremiaTable 2: Univariate analysis evaluating associations with mortality in burn patients with bacteremiaConclusionP-BSI was common in this burn population. Severe burns and longer duration of hospitalization, ICU stays, and intubation, but not microbiology were associated with p-BSI. However, p-BSI (in addition to more traditionally identified risk factors like TBSA and duration of hospitalization, ICU, and ventilator days), was independently associated with increased mortality. FUBC may serve as an additional prognostic factor in burn patients with BSI.DisclosuresAll Authors: No reported disclosures

Prognosis of Amphotericin B in the Treatment of Breakthrough Candidemia in Patients with Hematologic Malignancies

Predictors and Outcomes of Antibiotic Adequacy for Bloodstream Infections in Veterans With Spinal Cord Injury

OBJECTIVE To characterize the epidemiology of bloodstream infections in Switzerland, comparing selected pathogens in community and university hospitals. DESIGN Observational, retrospective, multicenter laboratory surveillance study. METHODS Data on bloodstream infections from 2008 through 2014 were obtained from the Swiss infection surveillance system, which is part of the Swiss Centre for Antibiotic Resistance (ANRESIS). We compared pathogen prevalences across 26 acute care hospitals. A subanalysis for community-acquired and hospital-acquired bloodstream infections in community and university hospitals was performed. RESULTS A total of 42,802 bloodstream infection episodes were analyzed. The most common etiologies were Escherichia coli (28.3%), Staphylococcus aureus (12.4%), and polymicrobial bloodstream infections (11.4%). The proportion of E. coli increased from 27.5% in 2008 to 29.6% in 2014 (P = .04). E. coli and S. aureus were more commonly reported in community than university hospitals (34.3% vs 22.7%, P<.001 and 13.9% vs 11.1%, P<.001, respectively). Fifty percent of episodes were community-acquired, with E. coli again being more common in community hospitals (41.0% vs 32.4%, P<.001). The proportion of E. coli in community-acquired bloodstream infections increased in community hospitals only. Community-acquired polymicrobial infections (9.9% vs 5.6%, P<.001) and community-acquired coagulase-negative staphylococci (6.7% vs 3.4%, P<0.001) were more prevalent in university hospitals. CONCLUSIONS The role of E. coli as predominant pathogen in bloodstream infections has become more pronounced. There are distinct patterns in community and university hospitals, potentially influencing empirical antibiotic treatment. Infect Control Hosp Epidemiol 2016;37:1060-1067.

Candidemia is a bloodstream infection (BSI) by Candida spp. and is associated with high mortality. However, there have been few reports about BSI in head and neck cancer (HNC). We aimed to evaluate the impact of candidemia in patients with HNC and compared it with bacteremia. A multicenter retrospective study. We retrospectively analyzed 83 BSI episodes in HNC (2011 to 2020) and divided them into the candidemia and bacteremia groups. We then compared the survival rate and risk factors for candidemia between the groups. The overall cumulative incidence (risk) of candidemia in BSI was 12 out of 83 episodes (14.5%). The 1-year mortality for the bacteremia and candidemia groups was 33.3% and 58.3%, respectively (log-rank p = 0.041). Broad-spectrum antibiotics (odds ratio [OR]: 29.5; 95% confidence interval [CI], 2.49-350), mucositis (OR 11.0; 95% CI, 1.52-80.1), and malignant wounds (OR 79.5; 95% CI 1.33-4737) were significant risk factors for candidemia in HNC. Candidemia causes high mortality in patients with HNC. To our knowledge, malignant wounds have not been previously reported as a risk factor for candidemia. For early diagnosis and treatment of candidemia, risk factors should be considered, and antifungal therapy started earlier.

T2Candida enables detection of five Candida species in whole blood within approximately 5 hours. Routinely drawn EDTA blood samples were prospectively stored and tested with T2Candida in patients with invasive candidiasis identified by routine index blood or sterile site cultures. T2Candida was compared to diagnostic blood and sterile site cultures and also performed with samples obtained prior and after collection of index cultures. T2Candida was evaluated with 133 samples of 32 patients with candidemia and 22 patients with deep-seated invasive candidiasis. In the candidemic group 28/32 (87.5%) patients had at least one positive T2Candida result at any time point. A total of 17/25 (68%) candidemic patients had a positive T2Candida sample that was drawn concurrently to the index blood culture. In the per patient analysis 17/18 (94.4%) candidemic patients with matched T2Candida samples and peripheral blood cultures at any timepoint had a positive T2Candida test. T2Candida revealed discordant Candida species identification in two candidemic patients. Six of 22 (27.3%) deep-seated IC patients had a positive T2Candida result. Despite advanced time-to-results the clinical value of T2Candida in diagnosing candidemia seems to be limited by missing blood culture positive cases. Positivity rates of T2Candida increased when serial T2Candida samples were tested. In patients with suspected deep-seated invasive candidiasis T2Candida might act as a blood based adjunct to sterile site cultures.

Bloodstream infections (BSIs) are related to high mortality and morbidity. Rapid administration of effective antimicrobial treatment is crucial for patient survival. Recently developed rapid methods to identify pathogens directly from blood culture bottles speed up diagnosis of BSIs. The present study compares the performance of two rapid identification methods, FilmArray and direct MALDI-TOF MS, on identifying microorganisms directly from positive blood culture bottles with polymicrobial growth. FilmArray and direct MALDI-TOF MS were performed directly on positive clinical and simulated polymicrobial blood culture bottles. Assay results were compared with standard culture methods. In total, 110 polymicrobial blood culture samples, of which 96 samples contained two microorganisms while 14 samples contained three microorganisms, were studied. FilmArray was able to identify 215/234 (92.0%) of isolates detected by the standard culture method and successfully identified all microorganisms in 88/110 (80.0%) of blood culture bottles. In contrast, direct MALDI-TOF MS was only able to identify 65/234 (27.8%) of isolates and managed to identify all microoganisms in 2/110 (2.1%) of blood culture bottles. FilmArray is a rapid method for direct identification of polymicrobial blood culture samples that can complement the conventional identification methods. Direct MALDI-TOF MS has low performance with polymicrobial samples.

Background During the COVID-19 pandemic, distinguishing bloodstream infections (BSI) from viral illness was challenging, often leading to excessive culture use and increased diagnostic burden in referral hospitals. We aimed to identify clinical predictors of BSI in hospitalized COVID-19 patients to guide targeted diagnostics and optimize resource allocation.Figure 1.Temporal trends in COVID-19 cases, blood culture testing, and BSI during the pandemic in South Korea.(A) Monthly number of confirmed COVID-19 cases in South Korea from January 2020 to August 2023, with major outbreak periods (Delta and Omicron) indicated. The inset shows the early pandemic phase.(B) Monthly number of patients who underwent blood culture within 14 days of COVID-19 diagnosis (green), and those with non-contaminant bloodstream infections (red). Both blood culture utilization and BSI detection increased during outbreak peaks, reflecting the diagnostic burden associated with pandemic surges.Figure 2.Kaplan–Meier survival analysis by blood culture result within 15 days of COVID-19 diagnosisKaplan–Meier curves comparing 15-day survival between patients with non-contaminant bloodstream infection (red) and those with negative or contaminated cultures (blue) following COVID-19 diagnosis. Survival was significantly lower in the BSI group (P&amp;lt;0.001). Methods We conducted a retrospective cohort study across three hospitals in South Korea (Jan 2020 - Dec 2023). Patients with confirmed COVID-19 who underwent blood culture within 15 days were included. BSI was defined as isolation of non-commensal organisms or commensals from ≥2 concurrent culture sets. Data were extracted from electronic records. The primary outcome was 15-day mortality. Independent predictors of BSI were identified via multivariate logistic regression. Results A total of 3,082 hospitalized COVID-19 patients (median age 67 years, 59.1% male) underwent blood culture within 15 days of diagnosis, and 304 (9.9%) had BSI. The number of blood cultures and BSI incidence increased during pandemic surges. BSI was associated with higher 15-day mortality (21.4% vs. 5.0%, p&amp;lt; 0.001). During the study period, a total of 5,095 blood cultures were performed, of which 501 (9.8%) yielded non-contaminant pathogens. Most frequently identified pathogens included Staphylococcus aureus (14.4%), Escherichia coli (14.2%), Klebsiella pneumoniae (12.8%), and Candida species (8.2%). In multivariate logistic regression, independent predictors of BSI included age ≥65 years, diabetes, fever ≥38.1°C, systolic BP ≤90 mmHg, procalcitonin ≥1 ng/mL, CRP ≥6 mg/dL, creatinine ≥1.0 mg/dL, and culture ≥2 days after COVID-19 diagnosis. Conclusion Identifying clinical predictors for BSI in COVID-19 can guide targeted blood culture practices, improving diagnostic stewardship. Risk-based testing strategies may reduce unnecessary cultures and support efficient resource use in future pandemics. Disclosures All Authors: No reported disclosures

During the COVID-19 pandemic, an increase in the incidence of bloodstream infections caused by fungi of the Candida genus, also known as candidemia, was observed in patients with SARS-CoV-2 infection. This study aimed to assess the incidence of candidemia, the factors related to COVID-19-associated candidemia (CAC), and prognostic factors. A non-concurrent cohort of 87 cases of patients aged over 18 years with candidemia between March 2020 and February 2022 was evaluated. Incidence density (ID) was calculated by the number of patient-days during the period. All causes of mortality within 30 days of observation were considered. Logistic regression and Cox proportional hazards regression were used, respectively, to determine factors associated with CAC and prognostic factors. Values <0.05 were considered significant. The ID of CAC was eight times higher than candidemia in patients without COVID-19 [2.40 per 1000 person-days vs. 0.27 per 1000 person-days; P<.01]. The corticosteroid therapy was as an independent factor associated with CAC [OR=15.98 (3.64-70.03), P<.01], while abdominal surgery was associated with candidemia in patients without COVID-19 [OR=0.09 (0.01-0.88), P=.04]. Both patients with and without COVID-19 had a high 30 days-mortality rate (80.8% vs. 73.8%, respectively; P=.59). Liver disease [HR=3.36 (1.22-9.27); P=.02] and the Charlson score [HR=1.17 (1.01-1.34); P=.03] were independent factors of death, while the use of antifungals [HR=0.15 (0.07-0.33); P<.01] and removal of the central venous catheter [HR=0.26 (0.12-0.56); P<.01] independently reduced the risk of death. These findings highlight the high incidence of candidemia in COVID-19 patients and its elevated mortality.

BackgroundRecent epidemiological studies on bloodstream infection (BSI) that include the proportion, species distribution and dynamic changes are scarce in China. This study was performed to understand these epidemiological data of BSI over the past 10 years in China.MethodsUsing a prospective nosocomial infection surveillance system, this study was retrospectively performed in one of the largest hospitals in China. The time trend was tested using the Cochran–Armitage trend test in R Programming Language.ResultsFrom 2010 to 2019, there were totally 9381 episodes of BSI cases out of 1,437,927 adult-hospitalized patients in the hospital, the total proportion of BSI cases was 6.50‰ (6.50 episodes per 1000 adult-hospitalized patients) and the proportion had significantly decreased (8.24–6.07‰, time trend P < 0.001). Among the 9381 episodes of BSI, 93.1% were bacteremia and others were fungemia (6.9%). As the most common species, the composition ratios of coagulase-negative staphylococcus (25.6–32.5%), Escherichia coli (9.8–13.6%) and Klebsiella pneumoniae (5.3–10.4%) had been dynamically increased (all time trends P < 0.05) and the proportion of Pseudomonas aeruginosa had decreased (4.0–2.4%, time trend P = 0.032). However, Staphylococcus aureus (3.3–3.1%) and Acinetobacter baumannii (4.4–4.2%) had not changed significantly (P > 0.05). These common species were consistent with China Antimicrobial Surveillance Network reported in 2018 (2018 CHINET report), but their composition ratios were different. In addition, among bacteremia, the proportion of multidrug-resistant bacteria gradually increased from 52.9 to 68.4% (time trend P < 0.001).ConclusionThe proportion and species distribution of BSI were dynamically changing along certain trends. These trends deserved more attention from clinicians and researchers.

Introduction: The threat of Invasive fungal infections has been increasing in the contemporary health care scenarios, with candidal infections being the most common. Candidal bloodstream infections (BSIs) account for one?fourth of the nosocomial BSIs. Candida albicans once the most common has now been replaced by nonalbicans Candida (NAC), accounting for majority of cases of candidal infections. The knowledge and understanding of specific risk factors, epidemiology, prophylactic measures, and outcomes with relation to speciation are changing rapidly. Emergence of antifungal resistance is a cause of concern. With this background, a retrospective study was undertaken. Aims and Objectives: To isolate Candida spp. from blood cultures of patients with clinically diagnosed or suspected septicemia; to determine incidence of candidemia; to identify and speciate Candida isolates and carry out the antifungal susceptibility test. Materials and Methods: This retrospective study was conducted at the Department of Microbiology, CMC and Hospital, Ludhiana from January 2014 to December 2020. Blood cultures received during this period by BACTEC automated culture system; Becton Dickinson were included in the study. The positive blood culture bottles were cultured on Sabouraud dextrose agar. Recovered Candida isolates were speciated and antifungal susceptibility testing was performed as per Clinical and Laboratory Standards Institute guideline (CLSI). Results: A total of 396 out of 52, 066 blood cultures were culture positive for Candida species. Therefore the overall prevalence rate of isolation of Candida species was 0.76% in our study. The incidence of blood stream infection caused by Non albicans Candida species (72.98%) was higher than Candida albicans (27.02%). Among NAC spp. Candida tropicalis (28.28%) was the most common, followed by Candida parapsilosis (18.94%), Candida glabrata (11.87%), Candida krusei (9.09%), and Candida gullermondii (4.30%) and Candida dubliniensis (0.5%). Candida spp. demonstrated higher resistance to azole group of antifungal agents, as compared to amphotericin B. Resistance was significantly higher among NAC spp. , Itraconazole, Clotrimazole, Fluconazole, Ketoconazole and Amphotericin B- 46.37%, 42.21% 39.10%, 34.60%, and 4.15%, respectively. Conclusion: Species-level identification of Candida and their antifungal sensitivity testing should to be performed to achieve better clinical result and to select an appropriate and effective antifungal therapy. High resistance to antifungal agents is an alarming sign to the healthcare professionals.

The aim of this study was to identify retrospectively trends in fungal bloodstream infections in The Netherlands in the period from 1987 to 1995. Results of over 395,000 blood cultures from five Dutch university hospitals were evaluated. Overall, there were more than 12 million patient days of care during the nine-year study period. The rate of candidemia doubled in the study period, reaching an incidence of 0.71 episodes per 10,000 patient days in 1995. The general increase in candidemia was paralleled by an increase in non-Candida albicans bloodstream infections, mainly due to Candida glabrata. However, more than 60% of the infections were caused by Candida albicans. Fluconazole-resistant species such as Candida krusei did not emerge during the study period. The increasing rate of candidemia found in Dutch university hospitals is similar to the trend observed in the USA, but the rate is lower and the increase is less pronounced.

BackgroundFew studies have assessed the time to blood culture positivity as a predictor of clinical outcome in fungal bloodstream infections (BSIs). The purpose of this study was to evaluate the time to positivity (TTP) of blood cultures in patients with Candida albicans BSIs and to assess its impact on clinical outcome.MethodsA historical cohort study with 89 adults patients with C. albicans BSIs. TTP was defined as the time between the start of incubation and the time that the automated alert signal indicating growth in the culture bottle sounded.ResultsPatients with BSIs and TTPs of culture of ≤36 h (n=39) and >36 h (n=50) were compared. Septic shock occurred in 46.2% of patients with TTPs of ≤36 h and in 40.0% of patients with TTP of >36 h (p=0.56). A central venous catheter source was more common with a BSI TTP of ≤36 h (p=0.04). Univariate analyis revealed that APACHE II score≥20 at BSI onset, the development of at least one organ system failure (respiratory, cardiovascular, renal, hematologic, or hepatic), SOFA at BSI onset, SAPS II at BSI onset, and time to positivity were associated with death. By using logistic regression analysis, the only independent predictor of death was time to positivity (1.04; 95% CI, 1.0-1.1, p=0.035), with the chance of the patient with C. albicans BSI dying increasing 4.0% every hour prior to culture positivity.ConclusionA longer time to positivity was associated with a higher mortality for Candida albicans BSIs; therefore, initiating empiric treatment with antifungals may improve outcomes.