Intensive Care Medicine

, Volume 29, Issue 12, pp 2162–2169 | Cite as

Candidemia in critically ill patients: difference of outcome between medical and surgical patients

  • Pierre Emmanuel Charles
  • Jean Marc Doise
  • Jean Pierre Quenot
  • Hervé Aube
  • Frédéric Dalle
  • Pascal Chavanet
  • Nadine Milesi
  • Ludwig Serge Aho
  • Henri Portier
  • Bernard Blettery



Candidemia is increasingly encountered in critically ill patients with a high fatality rate. The available data in the critically ill suggest that patients with prior surgery are at a higher risk than others. However, little is known about candidemia in medical settings. The main goal of this study was to compare features of candidemia in critically ill medical and surgical patients.


Ten-year retrospective cohort study (1990–2000).


Medical and surgical intensive care units (ICUs) of a teaching hospital.


Fifty-one patients with at least one positive blood culture for Candida species.

Main results

Risk factors were retrieved in all of the patients: central venous catheter (92.1%), mechanical ventilation (72.5%), prior bacterial infection (70.6%), high fungal colonization index (45.6%). Candida albicans accounts for 55% of all candidemia. The overall mortality was 60.8% (85% and 45.2% in medical and surgical patients, respectively). Independent factors associated with survival were prior surgery (hazard ratio [HR] =0.25; 0.09–0.67 95% confidence interval [CI], p<0.05), antifungal treatment (HR =0.11; 0.04–0.30 95% CI, p<0.05) and absence of neutropenia (HR =0.10; 0.02–0.45 95% CI, p<0.05). Steroids, neutropenia and high density of fungal colonization were more frequently found among medical patients compared to surgical ones.


Candidemia occurrence is associated with a high mortality rate among critically ill patients. Differences in underlying conditions could account for the poorer outcome of the medical patients. Screening for fungal colonization could allow identification of such high-risk patients and, in turn, improve outcome.


Candida Candidemia Prophylaxis Colonization Surgery Outcomes Fungemia 

Supplementary material

Table S1 Main features of candidemia

stable1.pdf (56 kb)
(PDF 57 KB)

Table S2 Management of candidemia in the ICUs

stable2.pdf (52 kb)
(PDF 53 KB)


  1. 1.
    Beck-Sague C, Jarvis W (1993) Secular trends in the epidemiology of nosocomial fungal infections in the United States, 1980–1990. National Nosocomial Infections Surveillance System. J Infect Dis 167:1247–1251PubMedGoogle Scholar
  2. 2.
    Jarvis W, Martone W (1992) Predominant pathogens in hospital infections. J Antimicrob Chemther 29:19–24Google Scholar
  3. 3.
    Rangel-Frausto M, Wiblin T, Blumberg H, Saiman L, Patterson J, Rinaldi M, Pfaller M, Edwards JJ, Jarvis W, Dawson J, Wenzel R (1999) National epidemiology of mycoses survey (NEMIS): variations in rates of bloodstream infections due to Candida species in seven surgical intensive care units and six neonatal intensive care units. Clin Infect Dis 29:253–258PubMedGoogle Scholar
  4. 4.
    Vincent J, Bihari D, Suter P, Bruining H, White J, Nicolas-Chanoin M, Wolff M, Spencer R, Hemmer M (1995) The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA 274:639–644PubMedGoogle Scholar
  5. 5.
    Blumberg H, Jarvis W, Soucie J, Edwards J, Patterson J, Pfaller M, Rangel-Frausto M, Rinaldi M, Saiman L, Wiblin R, Wenzel R (2001) Risk factors for candidal bloodstream infections in surgical intensive care unit patients: the NEMIS prospective multicenter study. The National Epidemiology of Mycosis Survey. Clin Infect Dis 33:177–186PubMedGoogle Scholar
  6. 6.
    Eubanks P, De Virgilio C, Klein S, Bongard F (1993) Candida sepsis in surgical patients. Am J Surg 166:617–620PubMedGoogle Scholar
  7. 7.
    Nolla-Salas J, Sitges-Serra A, Leon-Gil C, Martinez-Gonzalez J, Leon-Regidor M, Ibanez-Lucia P, Torres-Rodriguez J (1997) Candidemia in non-neutropenic critically ill patients: analysis of prognostic factors and assessment of systemic antifungal therapy. Study Group of Fungal Infection in the ICU. Intensive Care Med 23:23–30PubMedGoogle Scholar
  8. 8.
    Petri M, Konig J, Moecke H, Gramm H, Barkow H, Kujath P, Dennhart R, Schafer H, Meyer N, Kalmar P, Thulig P, Muller J, Lode H (1997) Epidemiology of invasive mycosis in ICU patients: a prospective multicenter study in 435 non-neutropenic patients. Paul-Ehrlich Society for Chemotherapy, Divisions of Mycology and Pneumonia Research. Intensive Care Med 23:317–325PubMedGoogle Scholar
  9. 9.
    Soutter D, Todd T (1986) Systemic candidiasis in a surgical intensive care unit. Can J Surg 29:197–199PubMedGoogle Scholar
  10. 10.
    Tang E, Tang G, Berne T (1993) Prognostic indicators in fungemia of the surgical patients. Arch Surg 128:759–763PubMedGoogle Scholar
  11. 11.
    Borzotta A, Beardsley K (1999): Candida infections in critically ill trauma patients. Arch Surg 134:657–665CrossRefPubMedGoogle Scholar
  12. 12.
    Pittet D, Monod M, Suter P, Frenk E, Auckenthaler R (1994) Candida colonization and subsequent infections in critically ill surgical patients. Ann Surg 220:751–758PubMedGoogle Scholar
  13. 13.
    Voss A, le Noble J, Verduyn Lunel F, Foudraine N, Meis J (1997) Candidemia in intensive care unit patients: risk factors for mortality. Infection 25:8-11PubMedGoogle Scholar
  14. 14.
    Hadley S, Lee W, Ruthazer R, Nasraway SJ (2002) Candidemia as a cause of septic shock and multiple organ failure in nonimmunocompromised patients. Crit Care Med 30:1808–1814PubMedGoogle Scholar
  15. 15.
    Komshian S, Uwaydah A, Sobel J, Crane L (1989) Fungemia caused by Candida species and Torulopsis glabrata in the hospitalized patient: frequency, characteristics and evaluation of factors influencing outcome. Rev Infect Dis 11:379–390Google Scholar
  16. 16.
    Blot S, Vandewoude K, Hoste E, Colardyn F (2002) Effects of nosocomial candidemia on outcomes of critically ill patients. Am J Med 113:480–485CrossRefPubMedGoogle Scholar
  17. 17.
    Pelz R, Hendrix C, Swoboda S, Diener-West M, Merz W, Hammonds J, Lipsett P (1999) A double blind placebo controlled trial of prophylactic fluconazole to prevent candida infections in critically ill surgical patients. Crit Care Med 27: A33Google Scholar
  18. 18.
    Ables A, Blumer N, Valainis G, Godeaick M, Palesh Y (1998) Fluconazole prophylaxis of severe infection in trauma and post-surgical patients. Crit Care Med 26:52AGoogle Scholar
  19. 19.
    Eggimann P, Francioli P, Bille J, Schneider R, Wu M, Chapuis G, Chiolero R, Pannatier A, Schilling J, Geroulanos S, Glauser M, Calandra T (1999) Fluconazole prophylaxis prevents intra-abdominal candidiasis in high-risk surgical patients. Crit Care Med 27:1066–1072PubMedGoogle Scholar
  20. 20.
    Garbino J, Lew DP, Romand JA, Hugonnet S, Auckenthaler R, Pittet D (2002) Prevention of severe Candida infections in nonneutropenic, high-risk, critically ill patients: a randomized, double-blind, placebo-controlled trial in patients treated by selective digestive decontamination. Intensive Care Med 28:1708–1717CrossRefPubMedGoogle Scholar
  21. 21.
    Le Gall J, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963PubMedGoogle Scholar
  22. 22.
    Bone R (1993) The pathogenesis of sepsis. Ann Intern Med 115:457–469Google Scholar
  23. 23.
    Vincent J, Anaissie E, Bruining H, Demajo W, el-Ebiary M, Haber J, Hiramatsu Y, Nitenberg G, Nystrom P, Pittet D, Rogers T, Sandven P, Sganga G, Schaller M, Solomkin J (1998) Epidemiology, diagnosis and treatment of systemic Candida infection in surgical patients under intensive care. Intensive Care Med 24:206–216PubMedGoogle Scholar
  24. 24.
    Richet H, Roux P, Des Champs C, Esnault Y, Andremont A, Group FCS (2002) Candidemia in French hospitals: incidence rates and characteristics. Clin Microbiol Infect 8:405–412CrossRefPubMedGoogle Scholar
  25. 25.
    Pittet D, Li N, Woolson R, Wenzel R (1997) Microbiological factors influencing the outcome of nosocomial bloodstream infections: a 6-year validated, population-based model. Clin Infect Dis 24:1068–1078PubMedGoogle Scholar
  26. 26.
    Wey S, Mori M, Pfaller M, Woolson R, Wenzel R (1988) Hospital-acquired candidemia. The attributable mortality and excess length of stay. Arch Intern Med 148:2642–2645PubMedGoogle Scholar
  27. 27.
    Harvey R, Myers J (1987) Nosocomial fungemia in a large teaching hospital. Arch Intern Med 147:2117–2120PubMedGoogle Scholar
  28. 28.
    Craven D, Kunches L, Lichtenberg D, Kollisch N, Barry M, Heeren T, McCabe W (1988) Nosocomial infection and fatality in medical and surgical intensive care unit patients. Arch Intern Med 148:1161–1168PubMedGoogle Scholar
  29. 29.
    Winston D, Chandrasekar P, Lazarus H, Goodman J, Silber J, Horowitz H, Shadduck R, Rosenfeld C, Ho W, Islam M (1993) Fluconazole prophylaxis of fungal infections in patients with acute leukemia. Results of a randomized placebo-controlled, double-blind, multicenter trial. Ann Intern Med 118:495–503PubMedGoogle Scholar
  30. 30.
    Goodman J, Winston D, Greenfield R, Chandrasekar P, Fox B, Kaizer H, Shadduck R, Shea T, Stiff P, Friedman D (1992) A controlled trial of fluconazole to prevent fungal infections in patients undergoing bone marrow transplantation. N Engl J Med 326:845–851PubMedGoogle Scholar
  31. 31.
    Desai M, Rutan R, Heggers J, Herndon D (1992) Candida infection with and without nystatin prophylaxis. An 11-year experience with patients with burn injury. Arch Surg 127:159–162PubMedGoogle Scholar
  32. 32.
    Bow E, Laverdiere M, Lussier N, Rotstein C, Cheang M, Ioannou S (2002) Antifungal prophylaxis for severely neutropenic chemotherapy recipients: a meta-analysis of randomized-controlled clinical trials. Cancer 94:3230–3246CrossRefPubMedGoogle Scholar
  33. 33.
    Nucci M, Anaissie E (2001) Revisiting the source of candidemia: skin or gut? Clin Infect Dis 33:1959–1967CrossRefPubMedGoogle Scholar
  34. 34.
    Rutledge R, Mandel S, Wild R (1986) Candida species. Insignificant contaminant or pathogenic species. Am Surg 52:299–302PubMedGoogle Scholar
  35. 35.
    Calandra T, Bille J, Schneider R, Mosimann F, Francioli P (1989) Clinical significance of Candida isolated from peritoneum in surgical patients. Lancet 2:1437–1440PubMedGoogle Scholar
  36. 36.
    Alverdy J, Aoys E (1991) The effect of glucocorticoid administration on bacterial translocation. Evidence for an acquired mucosal immunodeficient state. Ann Surg 214:719–723PubMedGoogle Scholar
  37. 37.
    Tancrede C, Andremont A (1985) Bacterial translocation and gram-negative bacteremia in patients with hematological malignancies. J Infect Dis 152:99–103PubMedGoogle Scholar
  38. 38.
    Cirera I, Bauer T, Navasa M, Vila J, Grande L, Taura P, Fuster J, Garcia-Valdecasas J, Lacy A, Suarez M, Rimola A, Rodes J (2001) Bacterial translocation of enteric organisms in patients with cirrhosis. J Hepatol 34:32–37CrossRefPubMedGoogle Scholar
  39. 39.
    Anaissie E, Rex J, Uzun O, Vartivarian S (1998) Predictors of adverse outcome in cancer patients with candidemia. Am J Med 104:238–245PubMedGoogle Scholar
  40. 40.
    Slotman G, Shapiro E, Moffa S (1994) Fungal sepsis: multisite colonization versus fungemia. Am Surg 60:107–113PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2003

Authors and Affiliations

  • Pierre Emmanuel Charles
    • 1
  • Jean Marc Doise
    • 1
  • Jean Pierre Quenot
    • 1
  • Hervé Aube
    • 1
  • Frédéric Dalle
    • 2
  • Pascal Chavanet
    • 3
  • Nadine Milesi
    • 4
  • Ludwig Serge Aho
    • 5
  • Henri Portier
    • 3
  • Bernard Blettery
    • 1
  1. 1.Service de Réanimation MédicaleDijon University HospitalDijonFrance
  2. 2.Laboratoire de Parasitologie-MycologieDijon University HospitalDijonFrance
  3. 3.Service des Maladies InfectieusesDijon University HospitalDijonFrance
  4. 4.Service de Réanimation ChirurgicaleDijon University HospitalDijonFrance
  5. 5.Service d'Epidémiologie et d'Hygiène HospitalièreDijon University HospitalDijonFrance

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