The epidemiology of candidemia in two United States cities: results of a population-based active surveillance.
Abstract
We conducted prospective, active population-based surveillance for candidemia (defined as any Candida species isolated from blood) in Atlanta and San Francisco (total population, 5.34 million) during 1992-1993. The average annual incidence of candidemia at both sites was 8 per 100,000 population. The highest incidence (75 per 100,000) occurred among infants </=1 year old. In 19% of patients, candidemia developed prior to or on the day of admission. Underlying medical conditions included cancer (26%), abdominal surgery (14%), diabetes mellitus (13%), and human immunodeficiency virus infection (10%). In 47% of cases, species of Candida other than Candida albicans were isolated, most commonly Candida parapsilosis, Candida glabrata, and Candida tropicalis. Antifungal susceptibility testing of 394 isolates revealed minimal levels of azole resistance among C. albicans, C. tropicalis, and C. parapsilosis. These data document the substantial burden of candidemia and its changing epidemiology. Continued surveillance will be important to monitor the epidemiology of candidemia and to detect emergence of resistance to azoles.
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In population-based surveillance performed in the metropolitan areas of Atlanta, Georgia, and Baltimore, Maryland, candidemia incidence (primarily among adults) increased 10%-40% from the early 1990s and the late 2000s, which was followed by more recent reports of decreases in these areas.
“In population-based surveillance performed in the metropolitan areas of Atlanta, Georgia, and Baltimore, Maryland, candidemia incidence (primarily among adults) increased 10%–40% from the early 1990s and the late 2000s, which was followed by more recent reports of decreases in these areas (6,28–30).”
From Population-Based Active Surveillance for Culture-Confirmed Candidemia — Four Sites, United States, 2012–2016 (2019) · cites this paper as [29]
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Experimental — accuracy not yet measuredAntifungal drug susceptibility testing in that surveillance revealed minimal levels of azole resistance among bloodstream isolates of C. albicans, C. tropicalis, and C. parapsilosis.
“Antifungal drug susceptibility testing revealed minimal levels of azole resistance among bloodstream isolates of C. albicans, C. tropicalis, and C. parapsilosis (16).”
In a prospective population-based active surveillance conducted in Atlanta, Ga., and San Francisco, Calif., between 1992 and 1993, C. albicans was found to account for 52% of Candida BSI.
“In a prospective population-based active surveillance conducted in Atlanta, Ga., and San Francisco, Calif., between 1992 and 1993, C. albicans was found to account for 52% of Candida BSI.”
The overall incidence of candidemia was higher during this study than in an earlier population-based surveillance study in Atlanta and San Francisco.
“Compared to the findings of an earlier population-based surveillance study in Atlanta and San Francisco (16), the overall incidence of candidemia was higher during this study.”
The incidence of candidemia in Connecticut (7 cases per 100,000 population) is similar to the incidence in Atlanta and San Francisco during 1992 and 1993 (8 cases per 100,000) and to the incidence in Iowa between 1998 and 2001 (6 cases per 100,000).
“The incidence of disease in Connecticut (7 cases per 100,000 population) is similar to the incidence in Atlanta and San Francisco during 1992 and 1993 (8 cases per 100,000) (16) as well as to the incidence determined in a population-based study conducted in Iowa between 1998 and 2001 (6 cases per 100,000) (8).”
Other population-based and sentinel surveillance studies of nosocomial candidiasis showed that the proportion of fungemia due to C. albicans remained almost constant throughout the 1990s at about 50%.
“Other population-based and sentinel surveillance studies of nosocomial candidiasis, although not longitudinal in design, also showed that the proportion of fungemia due to C. albicans remained almost constant throughout the 1990s at about 50% and that the proportion due to Candida species other than C. albicans ranged from 42 to 48% (8, 9, 16, 26; reviewed in reference 23).”
The proportion of fungemia due to Candida species other than C. albicans ranged from 42 to 48% in those studies.
“Other population-based and sentinel surveillance studies of nosocomial candidiasis, although not longitudinal in design, also showed that the proportion of fungemia due to C. albicans remained almost constant throughout the 1990s at about 50% and that the proportion due to Candida species other than C. albicans ranged from 42 to 48% (8, 9, 16, 26; reviewed in reference 23).”
In a previous study, Kao et al. documented amphotericin B MICs ranging from 0.016 to 6 μg/ml, with 7% of isolates demonstrating potential resistance at concentrations of ≥2 μg/ml.
“In a previous study (16), Kao et al. documented amphotericin B MICs ranging from 0.016 to 6 μg/ml, with 7% of isolates demonstrating potential resistance at concentrations of ≥2 μg/ml.”
Our susceptibility results show the expected high level of resistance in C. krusei.
“Our susceptibility results for Candida species other than C. albicans mirror those of a study by Kao et al. (16) and the results of other studies (25, 37) in showing a low level of in vitro azole resistance in C. glabrata and C. tropicalis, no resistance in C. parapsilosis or the newly reported C. dubliniensis, and the expected high level of resistance in C. krusei.”
Our susceptibility results show no resistance in C. parapsilosis or C. dubliniensis.
“Our susceptibility results for Candida species other than C. albicans mirror those of a study by Kao et al. (16) and the results of other studies (25, 37) in showing a low level of in vitro azole resistance in C. glabrata and C. tropicalis, no resistance in C. parapsilosis or the newly reported C. dubliniensis, and the expected high level of resistance in C. krusei.”
Our susceptibility results for Candida species other than C. albicans show a low level of in vitro azole resistance in C. glabrata and C. tropicalis.
“Our susceptibility results for Candida species other than C. albicans mirror those of a study by Kao et al. (16) and the results of other studies (25, 37) in showing a low level of in vitro azole resistance in C. glabrata and C. tropicalis, no resistance in C. parapsilosis or the newly reported C. dubliniensis, and the expected high level of resistance in C. krusei.”
The decreased susceptibility of C. krusei to amphotericin B (MIC90, 2 μg/ml) is consistent with previous reports for this organism.
“The decreased susceptibility of C. krusei to amphotericin B (MIC90, 2 μg/ml) is consistent with previous reports for this organism (16, 26).”
The high incidence of candidemia among infants, as well as the significant difference by race in this age group, was noted in the study of Kao et al. and is known to be an important public health problem in this population.
“The high incidence of candidemia among infants, as well as the significant difference by race in this age group, was noted in the study of Kao et al. (16) and is known to be an important public health problem in this population (17, 35, 42).”
We confirmed the continuing predominance of C. albicans and C. parapsilosis in the neonatal population.
“We confirmed the continuing predominance of C. albicans and C. parapsilosis in the neonatal population that Kao et al. (16) and Pfaller et al. (29) previously reported.”
Antifungal prophylaxis with fluconazole has proven effective in preventing candidemia due to C. parapsilosis in the neonatal setting.
“Although antifungal prophylaxis with fluconazole has proven effective in preventing candidemia due to C. parapsilosis in the neonatal setting (117), a recent example of the emergence of fluconazole resistance in a strain endemic to a Finnish neonatal ICU underscores the importance of good infection control practices, rather than antifungal prophylaxis, in preventing infection with C. parapsilosis”
From Epidemiology of Invasive Candidiasis: a Persistent Public Health Problem (2007) · cites this paper as [117]
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- Authors
- Kao, A. S., Brandt, M. E., Pruitt, W. R., Conn, L. A., Perkins, B. A., Stephens, D. S., Baughman, W. S., Reingold, A. L., Rothrock, G. A., Pfaller, M. A., Pinner, R. W., & Hajjeh, R. A.
- Affiliations
- Centers for Disease Control and Prevention (US)
- Emory University (US)
- University of California, Berkeley (US)
- University of Iowa (US)
- Corresponding author
- Hajjeh, R. A.
- Venue
- Clinical Infectious Diseases
- Publisher
- Oxford University Press (OUP)
- Published
- 1999-11-01
- Volume
- 29
- Issue
- 5
- Pages
- 1164-1170
- ISSN
- 1058-4838 (ISSN-L)
- 1537-6591
- OpenAlex
- W2162281126
- Cited by
- 457
- References
- 47
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 9 · 2023: 3 · 2022: 9 · 2021: 6 · 2020: 7 · 2019: 9 · 2018: 1 · 2017: 9 · 2016: 13 · 2015: 14 · 2014: 21 · 2013: 19 · 2012: 19
- FWCI
- 12.84
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Clinical Infectious Diseases (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Centers for Disease Control and Prevention (SD-15/15-CID96-001)
- Topics
- Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
- Health Sciences › Medicine › Epidemiology › Fungal Infections and Studies
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Yeasts and Rust Fungi Studies
- Keywords
- candidemia, Candida species, bloodstream infection, incidence, infants, antifungal susceptibility, azole resistance, Candida albicans, Candida parapsilosis, Candida tropicalis, Candida glabrata, HIV infection, diabetes mellitus, cancer, abdominal surgery, Atlanta, San Francisco
- MeSH terms
- Acquired Immunodeficiency Syndrome, Adolescent, Adult, Aged, Candidiasis, Child, Child, Preschool, Female, Georgia, Humans, Infant, Infant, Newborn, Male, Microbial Sensitivity Tests, Middle Aged, Prospective Studies, San Francisco, Incidence, Fungemia
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