Epidemiology, resistance patterns, and outcomes of candidemia acquired in Italian intensive care units: insights from the GIVITI network (2020–2024)

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Abstract
This multicenter study focuses on the latest (2020-2024) trends in candidemia in 155 Italian ICUs, stressing its frequency and lethality, with a shift toward non-albicans, fluconazole-resistant species, namely C. parapsilosis. In this study, resistance to fluconazole prolonged ICU stays without increasing mortality, while non-catheter-related episodes had a more severe prognosis. Candidemia is the leading fungal bloodstream infection (BSI) in the ICU and carries high mortality. After the COVID-19 pandemic, non-albicans, fluconazole-resistant species increased in Europe, yet contemporary ICU-acquired data are scarce. The primary outcome of this study was to evaluate the incidence of ICU-acquired candidemia per 1,000 “at risk” ICU admissions (ICU length of stay [LOS] ≥ 48 h). Secondary analyses compared ICU-acquired candidemia with ICU-acquired bacterial BSI and assessed species distribution, fluconazole susceptibility, and outcomes by fluconazole resistance and by source of infection. Data were drawn from the PROSAFE network, a prospective multicentric observational project conducted across 192 Italian ICUs (2014–2023). Among 179,590 ICU admissions, 95,662 were at risk. ICU-acquired candidemia occurred in 373 patients (3.9‰ of at-risk admissions). Compared with ICU-acquired bacterial BSI, candidemia patients had longer intra-ICU and hospital LOS (32 vs 24 days and 44 vs 36 days, respectively; p < 0.001) and higher mortality (intra-ICU 41.3% vs 28.7%; intra-hospital 50.3% vs 34.1%; p < 0.001). Candida albicans was isolated in 47.2% of episodes, followed by Candida parapsilosis at 33.0%; the latter is often fluconazole-resistant (53.7%). Mortality did not increase in fluconazole-resistant episodes, but ICU LOS did (36 vs 31 days; p = 0.016). Non-catheter-related infections (197/373, 52.8%) had higher intra-hospital mortality rates (57.0% vs 42.9%; p = 0.007). ICU-acquired candidemia in Italy remains frequent and lethal, with a worrisome shift in epidemiology and resistance; the latter prolongs ICU stay without increasing mortality. Non-catheter-related episodes had a poorer prognosis. Findings support enhanced surveillance, catheter care, and earlier antifungal therapy. The online version contains supplementary material available at 10.1186/s13054-026-05886-1.
Funding Information
  • NextGenerationEU (Project no. PE00000007, INF-ACT)

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