Data Provides Reassuring News Concerning Spread of Community-Onset Candidemia, For Now

A study conducted at a hospital in Detroit over a recent 7-year period has provided some potentially reassuring news concerning the spread of candidemia beyond the hospital walls into the community. Although the prevalence rate of community-onset candidemia spiked some years, there was no general increase with time.

However, this good news was tempered by the sobering finding was that community-onset cases still hovered around 45% of the annual cases, with the remainder being infections that developed once patients had been admitted to the hospital—so-called hospital-onset cases.

Candidemia is serious business. According to the American Thoracic Society, it causes 40% of all bloodstream infections in hospitalized patients and is the single most important cause of fungal infections globally.¹ Of the 17 known species of Candida, C albicans and C glabrata are among those that are frequent culprits.^2,3

“With the inpatient-outpatient shift in health care, many cases are now acquired in the community. Whether community-onset candidemia differs in risk factors, source, and species distribution is uncertain,” wrote Rebecca Witherell, MD, and colleagues at Ascension St. John Hospital in Detroit, Michigan, in a poster presented at the 2018 IDWeek Annual Meeting in San Francisco, CA.

To attempt to provide some clarity, the investigators took a retrospective look at blood culture results from patients treated at Ascension St. Johns Hospital from the beginning of 2010 through 2017. The search identified 212 patients (3.5% of all patients with bloodstream infections) with candidemia who also tested positive for Candida spp. in their blood cultures. Hospital-onset candidemia was defined as infection detected 4 or more days after admission. Community-onset candidemia was defined as an infection occurring within 3 days following admission, and so was presumed to have actually originated prior to hospitalization, with blossoming of the infection taking place in the early days of hospitalization.

The records for the cases of community-onset infection were also scrutinized to determine if the infection occurred before or after any health care procedures were applied. If occurring before, community-onset infections were considered to be community-associated candidemia. If occurring after, they were considered to be health care-associated candidemia.

Community-associated, community-onset-health care-associated candidemia, and hospital-onset cases were compared using a raft of items including demographics and source of the infection.

The rate of all candidemia cases fluctuated up and down with time, but on average was about 0.6 to 1.2 cases for every 1000 discharged patients. Of 86 infections (45% of the total) that originated prior to hospitalization, 81 (42.6%) were classified as community-onset-health care-associated candidemia and 5 (2.6%) as community-associated.

The number of cases of community-onset and hospital-onset also fluctuated year-by-year with no definite pattern of overall decreased or increased prevalence. Patients with candidemia related to hospitalization (ie, community-onset-health care-associated candidemia and hospital-onset) were similar in age (60.1 ± 17.0 vs 59.9 ± 17.1 years, respectively).

Among the risk factors for candidemia,⁴ a significantly greater prevalence of intravenous drug use was evident for patients whose candidemia was not associated with hospitalization (60.0% for community-onset vs 8.9% for community-onset-health care-associated candidemia and 4.8% for hospital-onset patients; P = .005).

Taking a specific look at C albicans and C glabrata revealed that the latter was more common in patients with diabetes than those without (47.1% vs 23.3%, respectively; P = .01) and in patients receiving hemodialysis (50.0% vs 28.8%, respectively; P =.03). C glabrata was less common in patients with urinary tract infections compared to other locations, including abdomen/pelvis and soft tissue/bone (24.2% vs 33.8%, respectively). Infections involving the urinary tract and soft tissue/bone were more frequent in community-onset cases. C albicans was more predominant in health care-associated cases (ie, community-onset and hospital-onset).

The findings that candidemia has remained a health care-related event that had not increased in the community over time was reassuring. However, the flip side was that year-by-year about 45% of the cases had a community origin.

“Since C glabrata accounts for a sizable proportion of candidemia cases, rapid identification would likely help in selecting appropriate antifungal agents,” stated the investigators.

REFERENCES:

1. American Thoracic Society Patient Information Series. Candida infection of the bloodstream—Candidemia. https://www.thoracic.org/patients/patient-resources/resources/candidemia.pdf.
2. Bitar D, Lortholar O, Le Strat Y, et al. Population-based analysis of invasive fungal infections, France 2001-2010. Increasing candidemia rate and decrease mortality. Emerg. Inf. Dis. 2014;20:1163-1169. doi: 10.3201/eid2007.140087.
3. Mikulska M, Del Bono V, Ratto S, Viscoli C. Occurrence, presentation and treatment of candidemia. Expert Rev. Clin. Immunol. 2012;8:755-765. doi: 10.1586/eci.12.52.
4. Segireddy M, Johnson LB, Szpunar SM, Khatib R. Differences in patient risk factors and source of candidemia caused by Candida albicans and Candida glabrata. Mycosis 2009;54:e39-43. doi: 10.1111/j.1439-0507.2009.01824.x.

DISCLOSURES

Rebecca Witherell, MD: None

PRESENTATIONS

Poster Session: Fungal Disease: Management and Outcomes

Rebecca Witherell, MD, Ascension St. John Hospital, Detroit, Michigan

Poster 363. Community-Onset Candidemia: Trends Over Seven Years

Brian Hoyle, PhD, is a medical and science writer and editor from Halifax, Nova Scotia, Canada. He has been a full-time freelance writer/editor for over 15 years. Prior to that, he was a research microbiologist and lab manager of a provincial government water testing lab. He can be reached at hoyle@square-rainbow.com.Click here to sign up for more MD Magazine content and updates.

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