Background: Candidemia is one of the 3 most frequent bloodstream infections in hospitalized patients in the United States. In patients with acute leukemia, a high-risk group for invasive fungal infections, protocol-based azole prophylaxis is common; therefore, most cases (up to 99%) of candidemia are caused by non-albicans species (spp.). In this patient population, candidemia has not been adequately studied, in the absence of routine antifungal prophylaxis. We describe the epidemiology and Candida spp. distribution in a contemporary series of patients with acute leukemia and candidemia, in the absence of routine antifungal prophylaxis.
Methods: We retrospectively reviewed medical records of adult (>18 year-old) patients with acute leukemia, who were diagnosed with candidemia (≥1 positive blood culture for Candida spp.) at Brigham and Womens Hospital (12/1/2006-12/31/2012), where providers do not routinely use antifungal prophylaxis, but administer micafungin to most patients with neutropenic fever that persists despite antibacterials.
Results: Of 302 first candidemia episodes, 39 (13%) occurred in patients with acute leukemia. Mean age (SD) was 47 (14) years and 16/39 (41%) were female. The most common spp. were C. parapsilosis (38.5%) and C. albicans (34%). Seven strains (18%) were fluconazole-resistant. C. parapsilosis fungemia was associated with prior micafungin exposure (OR 9.4, p=0.004). All but one (97%) patients received appropriate antifungal treatment (AAT: echinocandin if not already receiving one, azole for susceptible strains, amphotericin-B) at a median of 1 (IQR 0-2) day from blood culture collection; there was no association between AAT and 28-day crude mortality (28%) (time-varying p=0.441).
Conclusion: Without routine antifungal prophylaxis, C. albicans is a common cause of candidemia in patients with acute leukemia. Due to the rarity of antifungal resistance and slow in-vitro growth of Candida isolates (C. glabrata), the time to culture positivity was short, and appropriate antifungals were promptly initiated (Fig. 1). Candida spp. distribution reflects institutional practices of antifungal administration. There is a need for candidemia surveillance and antifungal stewardship protocols.
S. Koo, Wako Diagnostics: Grant Investigator , Research support
D. Farmakiotis, None
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