Utilization of Intensive Care Interventions in Critically Ill Patients With Candidemia Versus Bacteremia: A
Mary North Jones1,2, Masayuki Nigo1,3,4, Stefano Casarin5,6,7
1Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, TX.
Insights
Critically ill patients requiring intensive care unit (ICU) resources are at higher risk for candidemia, a type of bloodstream infection. Empiric antifungal therapy may be beneficial for these high-risk ICU patients.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
Background:
- Candida species are a common cause of bloodstream infections (BSIs) in intensive care units (ICUs).
- Current guidelines lack robust recommendations for initiating empiric antifungal therapy in ICU patients with suspected BSIs.
Purpose of the Study:
- To compare characteristics of patients with ICU-onset candidemia versus bacteremia.
- To identify risk factors for mortality in these patients.
- To determine if candidemia is an independent risk factor for death in ICU patients.
Main Methods:
- Retrospective cohort study of ICU patients with BSIs from a hospital system in Houston, Texas (2016-2023).
- Validation using the publicly available Medical Information Mart for Intensive Care (MIMIC)-IV cohort.
- Multivariable regression analysis to assess candidemia as an independent risk factor for mortality, adjusting for ICU interventions and baseline parameters.
Main Results:
- Of 1509 patients in the primary cohort, 19.2% had candidemia and 80.8% had bacteremia.
- Candidemia patients showed higher utilization of invasive mechanical ventilation, vasopressors, and continuous renal replacement therapy.
- While candidemia was not independently associated with mortality in the primary cohort, it was in the MIMIC-IV cohort.
Conclusions:
- Patients with high ICU resource utilization face an increased risk of candidemia.
- Consideration of empiric antifungal therapy is suggested for ICU patients requiring high-resource care when initiating empiric antibiotics.
Objectives:
Candida species are one of the most common causes of ICU-onset bloodstream infection (BSI). Yet, there is no robust guidance on when to initiate empiric antifungals for ICU patients suspected of BSI. We compared patients with ICU-onset candidemia vs. ICU-onset bacteremia to determine which patients may benefit from empiric antifungals.
Design:
We compared characteristics between patients with bacteremia vs. candidemia at time of culture. We determined risk factors for death and constructed a multivariable regression to determine if candidemia is an independent risk factor for death.
Setting/Patients:
We included ICU patients from a hospital system in Houston, Texas (n = 8 hospitals) with a BSI from 2016 to 2023 and validated our findings using ICU patients with a BSI in the publicly available Medical Information Mart for Intensive Care (MIMIC)-IV cohort.
Interventions:
None.
Measurements And Main Results:
Of 1509 total patients in our primary cohort, 290 (19.2%) had candidemia and 1219 (80.8%) had bacteremia. Patients with candidemia were more likely to be on invasive mechanical ventilation (72.8% vs. 52.8%; p < 0.001), vasopressors (39.3% vs. 24.0%; p < 0.001), and continuous renal replacement therapy (15.2% vs. 9.4%; p = 0.006) at the time of culture. They contracted infection later in ICU stay than bacteremia patients (7.2 vs. 5.0 d; p < 0.001) and were more likely to die within 30 days of culture (unadjusted odds ratio [OR], 1.62; 95% CI, 1.25-2.09). After adjusting for ICU interventions (invasive mechanical ventilation, vasopressors, and continuous renal replacement therapy) and baseline parameters, candidemia was not independently associated with mortality compared with bacteremia in our primary cohort (OR, 1.21; 95% CI, 0.92-1.60) but was in the MIMIC-IV cohort (OR, 1.48; 95% CI, 1.003-2.17).
Conclusions:
Patients with significant ICU resource utilization are at increased risk for candidemia. Our data suggest that when initiating empiric antibiotics in patients requiring high-resource ICU care, empiric antifungal therapy should be considered.
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