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Cited by 163Antifungal resistance and susceptibilityFungal Infections and StudiesInfective Endocarditis Diagnosis and Management

Burden of Candidemia in the United States, 2017

Open access
Tsay, Sharon V, Mu, Yi, Williams, Sabrina, Epson, Erin, Nadle, Joelle, Bamberg, Wendy M, Barter, Devra M, Johnston, Helen L +22 more·2020·Clinical Infectious Diseases
DOI 10.1093/cid/ciaa193
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Abstract

Background: Candidemia is a common healthcare-associated bloodstream infection with high morbidity and mortality. There are no current estimates of candidemia burden in the United States (US). Methods: In 2017, the Centers for Disease Control and Prevention conducted active population-based surveillance for candidemia through the Emerging Infections Program in 45 counties in 9 states encompassing approximately 17 million persons (5% of the national population). Laboratories serving the catchment area population reported all blood cultures with Candida, and a standard case definition was applied to identify cases that occurred in surveillance area residents. Burden of cases and mortality were estimated by extrapolating surveillance area cases to national numbers using 2017 national census data. Results: We identified 1226 candidemia cases across 9 surveillance sites in 2017. Based on this, we estimated that 22 660 (95% confidence interval [CI], 20 210–25 110) cases of candidemia occurred in the US in 2017. Overall estimated incidence was 7.0 cases per 100 000 persons, with highest rates in adults aged ≥ 65 years (20.1/100 000), males (7.9/100 000), and those of black race (12.3/100 000). An estimated 3380 (95% CI, 1318–5442) deaths occurred within 7 days of a positive Candida blood culture, and 5628 (95% CI, 2465–8791) deaths occurred during the hospitalization with candidemia. Conclusions: Our analysis highlights the substantial burden of candidemia in the US. Because candidemia is only one form of invasive candidiasis, the true burden of invasive infections due to Candida is higher. Ongoing surveillance can support future burden estimates and help assess the impact of prevention interventions.

Integrity signals

Registry

Crossref · 10.1093/cid/ciaa193

Cites

29 of 29 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

6 of 10 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Study design and conductown data

    In 2017, CDC conducted active population-based surveillance for candidemia through the Emerging Infections Program in 45 counties in 9 states covering approximately 17 million persons (5% of the national population).

    “In 2017, the Centers for Disease Control and Prevention conducted active population-based surveillance for candidemia through the Emerging Infections Program in 45 counties in 9 states encompassing approximately 17 million persons (5% of the national population).”
    • Also stated in: § METHODS · plain
      “In 2017, surveillance for candidemia was conducted in 45 counties in 9 states (California, Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee) with a total catchment area population of 17 million persons.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [6] Toda, 2019, Population-based active surveillance for culture-confirmed candidemia—four sites, United States, 2012–2016, MMWR Surveill Summ source

      The Abstract’s Public Health Action section and the Conclusion state that candidemia surveillance expanded to nine sites in 2017. The Methods’ Data Source section describes the earlier 2012–2016 surveillance area, not the expanded 2017 area. Our copy does not substantiate the claim’s 45 counties, approximately 17 million persons, or 5% of the national population. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Study design and conductreasoning

    Because the populations under surveillance in the 9 EIP sites are diverse, EIP findings can and have been used to extrapolate to national estimates of other infections.

    “Furthermore, because the populations under surveillance in the 9 sites are diverse (by age distribution, race, urban/rural, and other factors), EIP findings can and have been used to extrapolate to national estimates of other infections [33,34].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [33] Dantes, 2013, National burden of invasive methicillin-resistant Staphylococcus aureus infections, United States, 2011, JAMA Intern Med source

      The Discussion describes diverse populations in several metropolitan surveillance areas, and Methods > Statistical Analysis explains how EIP-ABCs data were extrapolated to national estimates of invasive MRSA. The paper does not establish that the sites are diverse by urban/rural status or that EIP findings have been used to estimate other infections nationally. It also cautions that the sites were not randomly selected to be representative. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [34] Lessa, 2015, Burden of Clostridium difficile infection in the United States, N Engl J Med source

      The Methods (Surveillance Population and Definition; Statistical Analysis) describe geographically varied EIP surveillance areas and use EIP data to estimate the national burden of C. difficile infection, accounting for demographic factors. This supports the cited paper as an example of national extrapolation. It studied 10 EIP sites, however, not the nine sites named in the citing sentence, and does not establish that site diversity was the reason extrapolation was possible. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
  • Findingown data

    In this analysis, the burden of candidemia among black individuals was disproportionately high.

    “In this analysis, we found that the burden of candidemia among black individuals was disproportionately high.”
    Quote in the paperSubstantial claim
  • Findingown data

    An estimated 5628 deaths (95% CI, 2465-8791) occurred during hospitalization with candidemia in the United States in 2017.

    “An estimated 3380 (95% CI, 1318-5442) deaths occurred within 7 days of a positive Candida blood culture, and 5628 (95% CI, 2465-8791) deaths occurred during the hospitalization with candidemia.”
    • Also stated in: § RESULTS · hedged
      “An estimated 3380 (95% CI, 1318-5442) deaths occurred within 7 days of positive culture for candidemia and 5628 (95% CI, 2465-8791) deaths occurred during the hospitalization with candidemia.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Candida parapsilosis accounted for 14% of Candida isolates.

    “The most frequent Candida species isolated from culture was Candida albicans (38%), followed by Candida glabrata (30%), Candida parapsilosis (14%), and Candida tropicalis (7%).”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 15
  • May combine two claims. 4

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Candidemia is a common healthcare-associated bloodstream infection in the United States with significant morbidity and 25%-40% all-cause in-hospital mortality.

    “Candidemia is one of the most common healthcare-associated bloodstream infections in the United States (US) [1,2].It is associated with significant morbidity and 25%-40% all-cause in-hospital mortality [3].”
    Quote in the paperNot a substantial claim3 of 3 sources checked
    • cites [1] Magill, 2014, Multistate point-prevalence survey of health care-associated infections, N Engl J Med source
    • cites [2] Magill, 2018, Changes in prevalence of health care-associated infections in U.S. hospitals, N Engl J Med source
    • cites [3] Pfaller, 2007, Epidemiology of invasive candidiasis: a persistent public health problem, Clin Microbiol Rev source

      In “The Burden of Disease: Perspectives from the NHDS” (page not supplied), the paper identifies Candida as the fourth leading cause of nosocomial bloodstream infection in the United States and describes a substantial disease burden. It uses 40% crude mortality as an assumption for estimating deaths, but the cited passages do not establish a 25%–40% range or specify all-cause in-hospital mortality. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Thirty-two percent of candidemia cases occurred in black patients.

    “Overall, 64% of cases occurred in white patients, and 32% of cases occurred in black patients (Table 1).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Fifty-five percent of candidemia cases occurred in males.

    “Fifty-five percent of cases occurred in males.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Three percent of candidemia cases were among children aged 18 years or younger.

    “Forty-two percent of cases occurred in patients aged ≥ 65 years, and 3% were among children (≤ 18 years).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In 2017, 1226 candidemia cases were identified in 1140 patients across 9 EIP sites.

    “In 2017, we identified 1226 cases of candidemia in 1140 patients in 9 EIP sites, with 7% of cases being recurrent in the same patient.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Forty-two percent of candidemia cases occurred in patients aged 65 years or older.

    “Forty-two percent of cases occurred in patients aged ≥ 65 years, and 3% were among children (≤ 18 years).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Sixty-four percent of candidemia cases occurred in white patients.

    “Overall, 64% of cases occurred in white patients, and 32% of cases occurred in black patients (Table 1).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Candida tropicalis accounted for 7% of Candida isolates.

    “The most frequent Candida species isolated from culture was Candida albicans (38%), followed by Candida glabrata (30%), Candida parapsilosis (14%), and Candida tropicalis (7%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Seven percent of candidemia cases were recurrent in the same patient.

    “In 2017, we identified 1226 cases of candidemia in 1140 patients in 9 EIP sites, with 7% of cases being recurrent in the same patient.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Estimates of mortality attributable to candidemia range from 5% to 71%, varying based on setting, age group, and study design.

    “Estimates of mortality attributable to candidemia range from 5% to 71%, varying based on setting, age group, and study design [10].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [10] Falagas, 2006, Attributable mortality of candidemia: a systematic review of matched cohort and case-control studies, Eur J Clin Microbiol Infect Dis source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Multiple imputation was performed for missing patient race information based on the distribution of known values for 2017 cases, stratified by age and sex.

    “To address missing patient race information, we performed multiple imputations based on the distribution of known values for 2017 cases, stratified by age and sex.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Periodic audits were conducted at each laboratory to ensure completeness of reporting.

    “Periodic audits were conducted at each laboratory to ensure completeness of reporting.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Candidemia represents only a portion of the burden of invasive candidiasis; other forms of invasive disease may not manifest with positive blood cultures but also have severe sequelae and contribute to morbidity and mortality.

    “Candidemia represents only a portion of the burden of invasive candidiasis; other forms of invasive disease include intra-abdominal candidiasis, hepatosplenic candidiasis, endophthalmitis, osteomyelitis, and meningitis, which may not manifest with positive blood cultures, but also have severe sequelae and contribute to morbidity and mortality.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Available Candida isolates from incident blood cultures were sent to CDC for species confirmation and antifungal susceptibility testing using Clinical and Laboratory Standards Institute guidelines.

    “Available Candida isolates from incident blood cultures were sent to CDC for species confirmation and antifungal susceptibility testing using Clinical and Laboratory Standards Institute guidelines [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Clinical and Laboratory Standards Institute

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationreasoning

    The 2017 resistance rates of 6% to fluconazole and 2% to echinocandins correspond to more than 1400 fluconazole-resistant and 340 echinocandin-resistant bloodstream infections nationally in 2017.

    “Although we did not include an extrapolation of drug-resistant infections in our national estimates, resistance rates found in 2017, 6% to fluconazole and 2% to echinocandins, correspond to > 1400 fluconazole-resistant and 340 echinocandin-resistant bloodstream infections nationally in 2017.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    A standard case definition was applied to identify candidemia cases in surveillance area residents.

    “a standard case definition was applied to identify cases that occurred in surveillance area residents.”
    • Also stated in: § METHODS · plain
      “A case of candidemia was defined as a blood culture positive for Candida species in a surveillance area resident.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Sampling weights were calculated by dividing the 2017 US Census population estimate by estimated EIP site populations, stratified by age, sex, and race, and used to estimate national candidemia burden.

    “We calculated sampling weights by dividing the Census Bureau 2017 US population estimate by estimated EIP site populations, stratified by age, sex, and race.We then weighted 2017 case numbers, stratified by demographic characteristics, to estimate the national burden of candidemia and generate 95% confidence intervals (CIs).”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Thirteen percent of the US population was black in 2017 Census Bureau estimates.

    “Thirteen percent of the US population was black in 2017 Census Bureau estimates [19], whereas nearly a quarter of all estimated candidemia cases occurred among black individuals.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [19]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

18 of 18

  • The paper relies on this without support.

    There are no current estimates of candidemia burden in the United States.

    “There are no current estimates of candidemia burden in the United States (US).”

  • The authors state this as an assumption.

    The bloodstream infection with Candida species contributed, at least in part, to death within 7 days of a positive Candida blood culture.

    “Therefore, we used a conservative estimate of death within 7 days of positive blood culture for Candida, assuming that the bloodstream infection with Candida species contributed, at least in part, to death in these cases.”
2 of 2

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The proportion of C. albicans was 70-80% in the 1980-1990s and has now declined to 40-60% in most geographic areas.

    “While the proportion of C. albicans was 70–80% in the 1980–1990s,54 it has now declined to 40–60% in most geographic areas.25,55,56”

    From Epidemiology of Invasive Candidiasis (2024) · cites this paper as [25]

    The Results report that C. albicans accounted for 38% of Candida isolates in the paper’s 2017 US surveillance, supporting a substantially lower contemporary proportion. The paper does not establish the cited 40–60% range across most geographic areas; the historical 70–80% figure is attached to a different citation in the citing sentence. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • Active population-based surveillance showed the incidence of candidemia decreased from 2008 to 2017 across multiple US sites, with a coincident increase in the incidence of invasive candidiasis from non-blood sources, including abdominal sterile sites, from 2009-2017.

    “A more nuanced assessment using data from active population-based surveillance showed the incidence of candidemia decreased from 2008 to 2017 across multiple US sites,25,27,35 with a coincident increase in the incidence of IC from non-blood sources, including abdominal sterile sites, from 2009–2017.34”

    From Epidemiology of Invasive Candidiasis (2024) · cites this paper as [25]

    Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

  • In the United States, all-cause mortality of invasive candidiasis was highest among older adults and lowest among children.

    “In the US, all-cause mortality was highest among older adults and lowest among children.25,27,52”

    From Epidemiology of Invasive Candidiasis (2024) · cites this paper as [25]

    The Results report that all-cause in-hospital mortality among patients with candidemia was highest at age ≥65 (31%) and lowest at age ≤18 (9%). The paper also states that candidemia is only one form of invasive candidiasis, so these age-specific findings do not establish the pattern for invasive candidiasis as a whole. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Candidemia causes an estimated 22,000 infections annually in the United States.

    “Candidemia causes an estimated 22,000 infections annually in the United States.25”

    From Epidemiology of Invasive Candidiasis (2024) · cites this paper as [25]

  • There has been a clear worldwide trend of decreasing proportions of C. albicans as the causative pathogen of invasive candidiasis or candidemia.

    “Independent of these geographic variations, there has been a clear worldwide trend of decreasing proportions of C. albicans as the causative pathogen.”

    From Epidemiology of Invasive Candidiasis (2024) · cites this paper as [25]

    The Results report that C. albicans accounted for 38% of isolates in the US surveillance sites in 2017, but give no comparison over time. The Discussion says limited earlier site participation prevented national-level trend estimation; the copy does not address a worldwide decline in the proportion of C. albicans. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

Cites

Flagged first, then by citations

1 of the 30 references couldn’t be matched to a known paper.

Research works printed but not linked: 6

  1. Centers for Disease Control and Prevention, Emerging Infections Program (EIP)
  2. Clinical and Laboratory Standards Institute, Reference method for broth dilution antifungal susceptibility testing of yeasts, 4th ed
  3. Centers for Disease Control and Prevention, Candida auris
  4. QuickFacts
  5. Centers for Disease Control and Prevention, Active Bacterial Core surveillance report, Emerging Infections Program Network, Streptococcus pneumoniae, 2017.
  6. Centers for Disease Control and Prevention, Active Bacterial Core surveillance report, Emerging Infections Program Network, group A Streptococcus, 2017.

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Authors
Tsay, S. V., Mu, Y., Williams, S., Epson, E., Nadle, J., Bamberg, W. M., Barter, D. M., Johnston, H. L., Farley, M. M., Harb, S., Thomas, S., Bonner, L. A., Harrison, L. H., Hollick, R., Marceaux, K., Mody, R. K., Pattee, B., Shrum Davis, S., Phipps, E. C., Tesini, B. L., Gellert, A. B., Zhang, A. Y., Schaffner, W., Hillis, S., Ndi, D., Graber, C. R., Jackson, B. R., Chiller, T., Magill, S., & Vallabhaneni, S.
Affiliations
  • Centers for Disease Control and Prevention (US)
  • California Emerging Infections Program, Oakland, California,
  • Colorado Department of Public Health and Environment (US)
  • Emory University (US)
  • Georgia Emerging Infections Program , Atlanta, Georgia,
  • Maryland Emerging Infections Program, Baltimore, Maryland,
  • Johns Hopkins University (US)
  • Minnesota Department of Health (US)
  • New Mexico Emerging Infections Program , Albuquerque, New Mexico,
  • University of New Mexico (US)
  • University of Rochester (US)
  • New York Emerging Infections Program , Rochester, New York,
  • Oregon Health Authority (US)
  • Vanderbilt University (US)
  • Tennessee Emerging Infections Program , Nashville, Tennessee,
Corresponding author
Tsay, Sharon V
ORCID
Venue
Clinical Infectious Diseases
Publisher
Oxford University Press (OUP)
Published
2020-02-28
Volume
71
Issue
9
Pages
e449-e453
ISSN
  • 1058-4838 (ISSN-L)
  • 1537-6591
DOI
10.1093/cid/ciaa193
OpenAlex
W3007919525
Semantic Scholar
b8d45dbf43a735b9527e8366a98207b38030b225
Cited by
163
References
30
Citations by year
2026: 13 · 2025: 37 · 2024: 22 · 2023: 35 · 2022: 26 · 2021: 21 · 2020: 9
FWCI
2.98
Type
journal article
Language
en
Open access
Licence
public-domain
Locations
  • Clinical Infectious Diseases (publishedVersion, public-domain)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
  • Health Sciences › Medicine › Epidemiology › Fungal Infections and Studies
  • Health Sciences › Medicine › Epidemiology › Infective Endocarditis Diagnosis and Management
Keywords
candidemia, invasive candidiasis, Candida, healthcare-associated bloodstream infections, disease burden, incidence, mortality, Emerging Infections Program, population-based surveillance, United States
MeSH terms
Adult, Aged, Candida, Cross Infection, Humans, Male, Population Surveillance, United States, Incidence, Candidemia

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