Evaluation of candidemia risk factors and candidemia-related mortality risk factors in Pamukkale University Health Application and Research Center Intensive Care Units

Candida infections are among the most common nosocomial infections. They are especially common in intensive care units and are associated with mortality up to 50% and severe morbidity. Because of the lack of clear clinical symptoms, the diagnosis of candidemia can be made through laboratory tests. These tests are time-consuming and do not contribute to early diagnosis and initiation of treatment. Therefore, by comparing the risk factors involved in the development of candidemia and Gram-negative bacilli (GNB) bacteremia, predictors of candidemia were tried to be identified. The study also aims to identify modifiable mortality risk factors. In addition, it was aimed to provide appropriate treatment and patient management by demonstrating the antifungal resistance profile of Candida species. Patients older than 18 years of age who were hospitalized with candidemia between January 2022 and July 2023 in the intensive care unit of Pamukkale University were included in the study. Patients were monitored prospectively, and their data were collected. The data were input to the SPSS 17.0 software package and were statistically analyzed. Liquid microdilution method was used to determine the antifungal susceptibility of Candida species grown in culture. The study included 82 patients with candidemia. The 82 patients with Gram-negative bacilli bacteremia were chosen as the comparison group. The mean age of both groups was above 65 years, and the majority of the patients were male (48 (58.5%) in the candidemia group and 52 (63.4%) in the GNB group). Among Candida species, C. parapsilosis (33 (40.2%)) was the most common. This was followed by C. albicans (24 (29.3%)), C. tropicalis (11 (13.4%)), C. glabrata (9 (11%)), C. kefyr (2 (2.4%)), C. krusei (1 (1.2%)), C. lusitaniae (1 (1.2%)) with decreasing frequency. According to multivariate regression analysis, antipsudomonal carbapenem use (OR=2.316, CI=1.093-4.909, p=0.028), presence of urinary catheter (OR=2.614, CI=1. 214-5.624, p=0.014), intubation (OR=3.076, CI=1.480-6.394, p=0.003) and concurrent gram-positive bacteremia (OR=4.289, CI=1.797-10.234, p=0.001) were found as risk factors. The mortality rate in the candidemia group was found to be 53.65%. Factors predicting 30-day mortality were determined to be SOFA score at the time of diagnosis (OR=1.210, CI=1.029-1.422, p=0.021), thrombocytopenia level below 100,000 after diagnosis (OR=9.015, CI=1.717-47.332, p=0.009) and CRP values 72 hours after diagnosis (OR=1.007, CI=1.000-1.013, p=0.035). Antifungal resistance rates among Candida species were 2.43% for fluconazole, 3.65% for voriconazole, 7.31% for caspofungin and 2.43% for amphotericin B. 4.76% of C. albicans and 23.33% of C. parapsilosis strains had decreased susceptibility to fluconazole. It was determined that 36.36% of C. tropicalis strains and 28.57% of C. albicans strains had decreased susceptibility to caspofungin. In conclusion, in this study, the use of antipsudomonal carbapenem, presence of urinary catheter, intubation, and presence of concurrent gram-positive bacteremia were found to be the distinguishing factors in the differentiation of candidemia and GNB bacteremia. SOFA score at the time of diagnosis, thrombocytopenia level below 100.000 after diagnosis and CRP values 72 hours after diagnosis were found to be associated with mortality in patients with candidemia. Among Candida species, fluconazole resistance was 2.43%, voriconazole resistance was 3.65%, caspofungin resistance was 7.31% and amphotericin B resistance was 2.43%. Resistance to anidulofungin and micafungin was not detected among the isolated strains.