Fungemia due to Uncommon Candida species in Patients with Cancer: Increasing Incidence, Frequent Resistance and High Mortality rates
Background: Bloodstream infections (BSI) with uncommon Candida species (UCspp: other than albicans, glabrata, krusei, parapsilosis, tropicalis) in cancer patients are not well-characterized. We evaluated the epidemiology and in-vitro susceptibility patterns, as well as factors associated with all-cause mortality.
Methods: We identified all episodes of BSI due to UCspp between 1998 and 2013 in our cancer center. Electronic medical records were reviewed for demographic, clinical, laboratory data and all-cause mortality.
Results: Candida species were isolated from 1,395 blood culture specimens during the study period; of those, 191 (68 patients) were due to UCspp. The overall incidence-density was 7.4 episodes per 100,000 patient-days. The incidence of BSI from UCspp and their proportion relative to all positive blood cultures and all episodes of candidemia increased significantly between 1998 and 2013 (Incidence density, Poisson-regression for trend P<.0001; Proportion, Cochran-Armitage for trend P<.0001, Fig. 1). Forty-two patients had leukemia (62%) and 43 (63%) were neutropenic (ANC<500/mcL). C. guilliermondii was the most common species isolated (28, 41%), followed by C. lusitaniae (19, 28%), C. kefyr (13, 19%), C. famata (7, 10%), and C. dubliniensis (1, 1.5%). Thirty-seven patients (54%) had an intra-abdominal source (recent abdominal surgery, peritonitis, gastrointestinal GVHD, or biliary sepsis). Thirty-seven patients (54%) had breakthrough infections, most frequently while being treated with an echinocandin (21 patients, 57%). C. kefyr (82%) and C. lusitaniae (21%) isolates frequently had caspofungin MICs above the epidemiological cutoff values. C. guilliermondii was more frequently resistant to voriconazole (24%) than other species. The crude 30-day mortality rate was 59% and was significantly associated with ICU stay on the date of candidemia (adjusted hazard ratio [aHR] 4), persistent (>7 days, not recovered) neutropenia (aHR 3), and high APACHE II score (aHR 2.8).
Conclusion: The incidence of BSI from UCspp is increasing in patients with cancer. Uncommon Candida species are frequently resistant to azoles and echinocandins, and associated with breakthrough infections and high mortality rates.
D. S. Jung,
Y. Jiang, None
J. Tarrand, None
D. Kontoyiannis, Pfizer, Astellas Pharma US, Gilead, and Merck & Co.,Inc: Research support, Research support