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• W2167496979 abstract "To the Editor:Descriptive epidemiologic studies of Candida albicans and non-albicans Candida species have primarily been reported from developed countries.1Malani A. Hmoud J. Chiu L. Carver P.L. Bielaczyc A. Kauffman C.A. Candida glabrata fungemia: experience in a tertiary care center.Clin Infect Dis. 2005; 41: 975-981Crossref PubMed Scopus (139) Google Scholar, 2Abbas J. Bodey G.P. Hanna H.A. Mardani M. Girgawy E. Abi-Said D. et al.Candida krusei fungemia: an escalating serious infection in immunocompromised patients.Arch Intern Med. 2000; 160: 2659-2664Crossref PubMed Scopus (127) Google Scholar, 3Chow J.K. Golan Y. Ruthazer R. Karchmer A.W. Carmeli Y. Lichtenberg D.A. et al.Risk factors for albicans and non-albicans candidemia in the intensive care unit.Crit Care Med. 2008; 36: 1993-1998Crossref PubMed Scopus (110) Google Scholar, 4Chow J.K. Golan Y. Ruthazer R. Karchmer A.W. Carmeli Y. Lichtenberg D. et al.Factors associated with candidemia caused by non-albicans Candida species versus Candida albicans in the intensive care unit.Clin Infect Dis. 2008; 46: 1206-1213Crossref PubMed Scopus (187) Google Scholar We performed a case-control study to evaluate the risk factors and outcomes of albicans and non-albicans candidemia in a resource-limited setting. Hospitalized adults at a Thai tertiary care center from January 1, 2005, to December 31, 2006, were retrospectively categorized into 3 groups: Case group 1 comprised all adults with C albicans bloodstream infections (BSI); case group 2 comprised all hospitalized patients with non-albicans Candida species BSI; and controls were patients without candidemia who were randomly selected in a ratio of 2:1 and matched by the hospital unit and by admission date within a 3-month period. Data collected included demographics, comorbidities, severity of illnesses, previous (<90 day) surgery and previous exposure to antifungal therapy, receipt of central venous catheter (CVC) and/or vasopressors and/or total parenteral nutrition, hemodialysis, antifungal treatment, and crude mortality. Factors associated with albicans and non-albicans candidemia were compared with controls.There were 30 patients with C albicans BSIs and 24 patients with non-albicans Candida species BSIs (C glabrata [8/24; 33%], C krusei [6/24; 25%], C tropicalis [6/24; 25%], and C parasilosis [4/24; 17%]) and 60 controls without candidemia (Table 1). Case patients were from intensive care units (27/54; 50%), medicine units (15/54; 28%), and surgical units (12/54; 22%). Median time was 12 days (range, 6-21 days) from admission to first positive blood culture. By multivariate analysis, factors associated with increased risk of non-albicans BSI compared with controls included previous exposure to azoles (adjusted odds ratio [aOR], 24.4; 95% confidence interval [CI]: 1.78-55.4; P=.001), immunocompromised host status (aOR, 5.2; 95% CI: 4.6-54.9; P=.04), APACHE II score >15 (aOR, 10.3; 95% CI: 9.9-65.4; P < .001), and presence of CVC (aOR, 11.4; 95% CI: 1.9-45.6; P=.004). Reasons for prior azole therapy included inappropriate treatment of asymptomatic candiduria (8/12; 67%)] and nonstandard prophylaxis for cryptococcosis among HIV patients with CD4 counts >200 cells/mm3 (4/12; 133%). Factors associated with increased risk of C albicans BSI were APACHE II score >15 (aOR, 15.4; 95% CI: 2.5-50.9; P=.002) and presence of CVC (aOR, 3.6; 95% CI: 1.4-65.5; P=.04). Cases with albicans and non-albicans candidemia had higher mortality than the control group (P < .001), although no predictors of mortality were identified (Table 1). Additionally, outcomes were not differential with fluconazole, amphotericin B, or casposfungin exposures.Table 1Characteristics of 114 patients with Candida albicans BSI, Candida non-albicans BSI, and controls without BSIPatient characteristicsCandida albicans BSI n = 30Candida non-albicans BSI n=24Controls without BSI n = 60Age, yr, median (range)42 (17-66)43 (16-69)42 (15-68)Female sex14 (47)11 (46)30 (50)Underlying conditions Diabetes11 (35)9 (37)21 (34) Cirrhosis7 (24)5 (22)14 (23) Lung diseases6 (21)5 (22)14 (23) Chronic renal diseases5 (18)4 (18)12 (20) Cardiovascular diseases4 (15)4 (18)10 (17) Immunocompromised∗Including HIV, solid malignancy, hematologic malignancy, solid organ transplant, and receive immunosuppressive agents.5 (18)12 (50)†All patients received fluconazole within a prior 3-month period.10 (17)APACHE II score: median (range)17 (14-29)†All patients received fluconazole within a prior 3-month period.18 (13-28)†All patients received fluconazole within a prior 3-month period.10 (4-20)Previous exposure to antifungal‡P < .05.1 (3)12 (50)†All patients received fluconazole within a prior 3-month period.0 (0)Previous surgery (<90 days)7 (24)6 (25)12 (20)Vasopressors11 (35)†All patients received fluconazole within a prior 3-month period.9 (37)†All patients received fluconazole within a prior 3-month period.6 (10)Hemodialysis6 (21)†All patients received fluconazole within a prior 3-month period.5 (22)†All patients received fluconazole within a prior 3-month period.4 (7)Total parenteral nutrition8 (27)†All patients received fluconazole within a prior 3-month period.6 (25)†All patients received fluconazole within a prior 3-month period.4 (7)Presence of central venous catheter11 (35)†All patients received fluconazole within a prior 3-month period.9 (37)†All patients received fluconazole within a prior 3-month period.6 (10)Outcomes Crude mortality16 (53)†All patients received fluconazole within a prior 3-month period.13 (54)†All patients received fluconazole within a prior 3-month period.4 (7)Antifungal regimens Amphotericin B10/16 (63)7/13 (5)NA Fluconazole4/16 (25)3/13 (23)NA Caspofungin2/16 (13)2/13 (15)NA Voriconazole2/16 (13)1/13 (7)NANOTE. Data are number (%), unless indicated otherwise. Conditional logistic regression was used to compare categorical and continuous variables. To identify risk factors for albicans and non-albicans BSIs, the variables (eg, underlying disease, previous exposure to antifungal) that were associated with more than 10% of the patients who had these BSI (by use of bivariable analysis; P < .20) or were of priori clinical significance (eg, APACHE II score) were entered into backward, stepwise logistic regression models. Significant variables were grouped if they were closely correlated, and only 1 variable per group was chosen for entry into a model. The final models were chosen on the basis of plausibility and on the basis of having the lowest −2-log likelihood functions.NA, nonapplicable; BSI, bloodstream infections.∗ Including HIV, solid malignancy, hematologic malignancy, solid organ transplant, and receive immunosuppressive agents.† All patients received fluconazole within a prior 3-month period.‡ P < .05. Open table in a new tab Our findings have notable implications. First, it was difficult to differentiate C albicans and C non-albicans candidemia on clinical characteristics alone because several common risk factors were identified among patients with C albicans and C non-albicans BSI. Second, given the high prevalence of non-albicans candidemia (54%), systematic surveillance for fluconazole-resistant Candida spp seems judicious. Third, our findings suggest potential benefit of inclusion of antifungal management within anti-infective stewardship programs. Opportunities exist to minimize inappropriate azole primary prophylaxis in HIV patients with CD4>200 cells/mm3 and inappropriate treatment of candiduria and to optimize dose and duration of antifungal therapies.5Apisarnthanarak A. Mundy L.M. The impact of primary prophylaxis for cryptococcosis on fluconazole resistance in Candida species.J Acquir Immune Defic Syndr. 2008; 47: 644-645Crossref PubMed Scopus (16) Google Scholar, 6Sutepvarnon A. Apisarnthanarak A. Camins B. Mondy K. Fraser V.J. Inappropriate use of antifungal medications in a tertiary care center in Thailand: a prospective study.Infect Control Hosp Epidemiol. 2008; 29: 370-373Crossref PubMed Scopus (29) Google Scholar Focused educational interventions aimed at improving guideline compliance with antifungal treatment among patients with asymptomatic candiduria and prophylaxis against opportunistic fungal infection in HIV patients deserve further investigation. To the Editor: Descriptive epidemiologic studies of Candida albicans and non-albicans Candida species have primarily been reported from developed countries.1Malani A. Hmoud J. Chiu L. Carver P.L. Bielaczyc A. Kauffman C.A. Candida glabrata fungemia: experience in a tertiary care center.Clin Infect Dis. 2005; 41: 975-981Crossref PubMed Scopus (139) Google Scholar, 2Abbas J. Bodey G.P. Hanna H.A. Mardani M. Girgawy E. Abi-Said D. et al.Candida krusei fungemia: an escalating serious infection in immunocompromised patients.Arch Intern Med. 2000; 160: 2659-2664Crossref PubMed Scopus (127) Google Scholar, 3Chow J.K. Golan Y. Ruthazer R. Karchmer A.W. Carmeli Y. Lichtenberg D.A. et al.Risk factors for albicans and non-albicans candidemia in the intensive care unit.Crit Care Med. 2008; 36: 1993-1998Crossref PubMed Scopus (110) Google Scholar, 4Chow J.K. Golan Y. Ruthazer R. Karchmer A.W. Carmeli Y. Lichtenberg D. et al.Factors associated with candidemia caused by non-albicans Candida species versus Candida albicans in the intensive care unit.Clin Infect Dis. 2008; 46: 1206-1213Crossref PubMed Scopus (187) Google Scholar We performed a case-control study to evaluate the risk factors and outcomes of albicans and non-albicans candidemia in a resource-limited setting. Hospitalized adults at a Thai tertiary care center from January 1, 2005, to December 31, 2006, were retrospectively categorized into 3 groups: Case group 1 comprised all adults with C albicans bloodstream infections (BSI); case group 2 comprised all hospitalized patients with non-albicans Candida species BSI; and controls were patients without candidemia who were randomly selected in a ratio of 2:1 and matched by the hospital unit and by admission date within a 3-month period. Data collected included demographics, comorbidities, severity of illnesses, previous (<90 day) surgery and previous exposure to antifungal therapy, receipt of central venous catheter (CVC) and/or vasopressors and/or total parenteral nutrition, hemodialysis, antifungal treatment, and crude mortality. Factors associated with albicans and non-albicans candidemia were compared with controls. There were 30 patients with C albicans BSIs and 24 patients with non-albicans Candida species BSIs (C glabrata [8/24; 33%], C krusei [6/24; 25%], C tropicalis [6/24; 25%], and C parasilosis [4/24; 17%]) and 60 controls without candidemia (Table 1). Case patients were from intensive care units (27/54; 50%), medicine units (15/54; 28%), and surgical units (12/54; 22%). Median time was 12 days (range, 6-21 days) from admission to first positive blood culture. By multivariate analysis, factors associated with increased risk of non-albicans BSI compared with controls included previous exposure to azoles (adjusted odds ratio [aOR], 24.4; 95% confidence interval [CI]: 1.78-55.4; P=.001), immunocompromised host status (aOR, 5.2; 95% CI: 4.6-54.9; P=.04), APACHE II score >15 (aOR, 10.3; 95% CI: 9.9-65.4; P < .001), and presence of CVC (aOR, 11.4; 95% CI: 1.9-45.6; P=.004). Reasons for prior azole therapy included inappropriate treatment of asymptomatic candiduria (8/12; 67%)] and nonstandard prophylaxis for cryptococcosis among HIV patients with CD4 counts >200 cells/mm3 (4/12; 133%). Factors associated with increased risk of C albicans BSI were APACHE II score >15 (aOR, 15.4; 95% CI: 2.5-50.9; P=.002) and presence of CVC (aOR, 3.6; 95% CI: 1.4-65.5; P=.04). Cases with albicans and non-albicans candidemia had higher mortality than the control group (P < .001), although no predictors of mortality were identified (Table 1). Additionally, outcomes were not differential with fluconazole, amphotericin B, or casposfungin exposures. NOTE. Data are number (%), unless indicated otherwise. Conditional logistic regression was used to compare categorical and continuous variables. To identify risk factors for albicans and non-albicans BSIs, the variables (eg, underlying disease, previous exposure to antifungal) that were associated with more than 10% of the patients who had these BSI (by use of bivariable analysis; P < .20) or were of priori clinical significance (eg, APACHE II score) were entered into backward, stepwise logistic regression models. Significant variables were grouped if they were closely correlated, and only 1 variable per group was chosen for entry into a model. The final models were chosen on the basis of plausibility and on the basis of having the lowest −2-log likelihood functions. NA, nonapplicable; BSI, bloodstream infections. Our findings have notable implications. First, it was difficult to differentiate C albicans and C non-albicans candidemia on clinical characteristics alone because several common risk factors were identified among patients with C albicans and C non-albicans BSI. Second, given the high prevalence of non-albicans candidemia (54%), systematic surveillance for fluconazole-resistant Candida spp seems judicious. Third, our findings suggest potential benefit of inclusion of antifungal management within anti-infective stewardship programs. Opportunities exist to minimize inappropriate azole primary prophylaxis in HIV patients with CD4>200 cells/mm3 and inappropriate treatment of candiduria and to optimize dose and duration of antifungal therapies.5Apisarnthanarak A. Mundy L.M. The impact of primary prophylaxis for cryptococcosis on fluconazole resistance in Candida species.J Acquir Immune Defic Syndr. 2008; 47: 644-645Crossref PubMed Scopus (16) Google Scholar, 6Sutepvarnon A. Apisarnthanarak A. Camins B. Mondy K. Fraser V.J. Inappropriate use of antifungal medications in a tertiary care center in Thailand: a prospective study.Infect Control Hosp Epidemiol. 2008; 29: 370-373Crossref PubMed Scopus (29) Google Scholar Focused educational interventions aimed at improving guideline compliance with antifungal treatment among patients with asymptomatic candiduria and prophylaxis against opportunistic fungal infection in HIV patients deserve further investigation." @default.
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• W2167496979 title "Risk factors and outcomes of Candida albicans and non-albicans Candida species at a Thai tertiary care center" @default.
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