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INCREASED SYSTEMIC CANDIDIASIS IN ICU PATIENTS WITH PROLONGED ANTIFUNGAL TREATMENT OF CANDIDURIA

The Regional Medical Center at Memphis, Memphis, TN

PURPOSE: The incidence of candiduria in ICU patients and risk factors associated with its development have been described; However, links with developing systemic candidiasis following candiduria are lacking. This study identifies incidence and predictive factors for systemic candidiasis in ICU patients with candiduria.

METHODS: Patients admitted to a University-affiliated teaching hospital ICU from Jan–Dec 2004 were evaluated. All patients with their first candiduria isolate in the ICU were included. Patients with candiduria <48h from admission were excluded. Twelve variables (Table 1) were evaluated by univariate analysis. Variables with p<0.1 were entered into a logistic regression model for identification of independent predictors of systemic candiasis. Mortality and fungal species isolated (both urine and systemic) were also examined.

RESULTS: Of 89 patients screened, 82 met criteria. 21 (25.6%) patients developed systemic candidiasis subsequent to candiduria. Patients were similar with respect to age, prior antibiotic and antifungal exposure, prior positive bacterial and fungal cultures, blood and steroid exposure, and glucose and serum creatinine (Table 1). Mortality was higher in the systemic candidiasis group (42.9% versus 27.9%, p=0.2), but not statistically different. Patients with systemic candidiasis were more likely to be male (63% versus 37%; p=0.08), have a longer duration of initial candiduria treatment (7.4 versus 4.5 days; p=0.004), and a higher incidence of recurrent candiduria (61.9% versus 32.3%; p=0.02) compared to those with candiduria only. Logistic regression analysis identified duration of treatment as an independent predictor of systemic candidiasis (Table 2). Although 80% of urine isolates were not speciated, 49% of systemic infections were C. albicans with 28% being C. glabrata.

CONCLUSION: Systemic candidiasis occurs frequently in ICU patients following candiduria. Patients receiving a longer duration of antifungal therapy for candiduria were at highest risk with males and those with recurrent candiduria having a trend for increased risk. Over one fourth of systemic infections were C. glabrata.

CLINICAL IMPLICATIONS: Strategies should be investigated to identify or prevent systemic infection following candiduria including shortening candiduria antifungal treatment duration.
Table 1— Univariate comparison of patient factors Increased Systemic Candidiasis with Prolonged Antifungal Treatment in Patients with Candiduria in the ICU.

Factor Urine Only Systemic p-Value Age –years1 49.8±17.4 46.8±19.7 0.57 Males –n(%) 19 (30.6) 11 (52.4) 0.08 LOS prior to candiduria –days2 13 (3-109) 14 (5-121) 0.55 Steroid Treatment –n(%) 18 (29.5) 9 (42.9) 0.26 Blood products given –n(%) 27 (44.3) 9 (42.9) 0.91 Serum glucose > 180 mg/dl –n(%) 30 (49.2) 8 (38.1) 0.38 Serum Creatinine > 1.5 mg/dl –n(%) 22 (36.1) 5 (23.8) 0.42 Prior antibiotic exposure –n(%) 57 (93.4) 19 (90.5) 0.64 Prior positive bacterial cultures –n(%) 42 (68.9) 15 (71.4) 0.82 Prior systemic candidiasis –n(%) 19 (31.1) 8 (38.1) 0.82 Prior systemic antifungals –n(%) 6 (9.8) 3 (14.3) 0.69 Recurrent candiduria –n(%) 20 (32.8) 13 (61.9) 0.02 Treatment of first candiduria –n(%) 49 (80.3) 14 (66.7) 0.2 Candiduria treatment duration –days1 4.5±2.8 7.4±4.6 0.004 Mortality –n(%) 17 (27.9) 9 (42.9) 0.2

1 –Mean + standard deviation; 2 –Median (range)

DISCLOSURE: Matthew Chambers, None.