Temporal changes in mortality and risk factors of candidemia in intensive care unit patients

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Abstract
Background: Candida species are major causes of hospital-acquired bloodstream infections associated with high mortality in critically ill patients. This study aimed to evaluate temporal changes in species distribution, antifungal resistance, clinical outcomes, and mortality predictors in ICU patients with candidemia. Methods: This retrospective study included 250 ICU patients with candidemia between January 2018 and January 2022. The study period was divided into two cohorts (2018–2020, n = 80; 2020–2022, n = 170). Clinical, laboratory, and microbiological characteristics were compared. Multivariable analysis was performed to identify independent predictors of mortality. Results: The incidence density of candidemia significantly decreased from 4.32 to 3.10 per 1,000 ICU patient-days (IRR: 0.72; %95 CI: 0.55–0.94; p = 0,014). A shift toward non-albicans Candida species was observed, while antifungal resistance rates remained stable. Candida score values and empirical antifungal therapy rates were lower in the later period. Despite increased central venous catheter use, catheter-related candidemia decreased. Overall mortality was similar between periods; however, during the second period, mortality was higher in patients with SARS-CoV-2 infection than in those without infection [100/105 (95.2%) vs. 43/65 (66.2%), p < 0.001]. In multivariable analysis, SOFA score was independently associated with mortality in the early period (OR: 1.20, 95% CI: 1.01–1.43; p = 0.043), whereas SARS-CoV-2 infection (OR: 20.43, 95% CI: 3.53–118.14; p = 0.001), Candida score (OR: 0.19, 95% CI: 0.06–0.50; p = 0.003), lactate level at ICU admission (OR: 5.23, 95% CI: 1.55–17.57; p = 0.007), and urea level at ICU admission (OR: 1.01, 95% CI: 1.00–1.02; p = 0.030) were independent predictors in the later period. Conclusion: The high mortality observed among patients with SARS-CoV-2–associated candidemia underscores the need for heightened diagnostic awareness in deteriorating ICU patients. Early diagnostic work-up, timely initiation of antifungal therapy, and reassessment of treatment according to microbiological findings are important in this setting. Hospital-specific identification of preventable risk factors may also help optimize candidemia management and infection control strategies.

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