CANDIDEMIA IN NON-NEUTROPENIC CRITICALLY ILL PATIENTS - ANALYSIS OF PROGNOSTIC FACTORS AND ASSESSMENT OF SYSTEMIC ANTIFUNGAL THERAPY

Objective: To determine the incidence and prognosis of candidemia in n on-neutropenic critically ill patients, to define mortality-related fa ctors, and to evaluate the results of systemic antifungal therapy. Des ign: A prospective multicenter survey in which medical and/or surgical intensive care units (ICUs) in 28 hospitals in Spain participated. Pa tients: All critically ill patients with positive blood cultures for C andida species admitted to the participating ICUs over a 15-month peri od were included. Interventions: Candidemia was defined as the presenc e of at least one positive blood culture containing Candida species. T he follow-up period was defined as the time elapsed from the first pos itive blood culture for Candida species to discharge or death during h ospitalization. Antifungal therapy was considered to be ''early'' when it was administered within 48 h of the date when the first positive b lood culture was obtained and ''late'' when it was administered more t han 48 h after the first positive blood culture. Measurements and main results: Candidemia was diagnosed in 46 patients (mean age 59 years), with an incidence of 1 critically ill patient per 500 ICU admissions. The species most frequently isolated were Candida albicans (60%) and C. parapsilosis (17%). Fluconazole alone was given to 27 patients, amp hotericin B alone to 10, and sequential therapy to 6. Three patients d id not receive antifungal therapy. The overall mortality was 56% and t he attributable mortality 21.7%. In the univariate analysis, mortality was significantly associated with a higher Acute Physiology and Chron ic Health Evaluation (APACHE) II score at the onset of candidemia (p=0 .04) and with the time elapsed between the episode of candidemia and t he start of antifungal therapy 48 h or more later (p<0.02). Patients w ith an APACHE II score lower than 21 at the onset of candidemia had a higher probability of survival than patients who were more seriously i ll(p=0.04). Patients with ''early'' antifungal therapy (less than or e qual to 48 h between the onset of candidemia and the start of antifung al therapy) had a higher probability of survival compared with patient s with late therapy (p=0.06). No significant differences were noted be tween the two groups on different antifungal therapy. Conclusions: The incidence of candidemia in ICU patients was very low. An APACHE II sc ore >20 at the time of candidemia was associated with a higher mortali ty. Further studies with a large number of patients are needed to asse ss the effect of early antifungal therapy on the decrease in mortality associated with candidemia and to determine the appropriate dosage of fluconazole and duration of treatment.