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Declining Incidence of Candidemia and the Shifting Epidemiology of Candida Resistance in Two US Metropolitan Areas, 2008–2013: Results from Population-Based Surveillance
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BACKGROUND: Recent reports have demonstrated a decline in bacterial bloodstream infections (BSIs) following adherence to central line insertion practices; however, declines have been less evident for BSIs due to Candida species. METHODS: We conducted active, population-based laboratory surveillance for candidemia in metropolitan Atlanta, GA and Baltimore, MD over a 5-year period. We calculated annual candidemia incidence and antifungal drug resistance rates. RESULTS: We identified 3,848 candidemia cases from 2008-2013. Compared with 2008, candidemia incidence per 100,000 person-years decreased significantly by 2013 in both locations (GA: 14.1 to 9.5, p<0.001; MD: 30.9 to 14.4, p<0.001). A total of 3,255 cases (85%) had a central venous catheter (CVC) in place within 2 days before the BSI culture date. In both locations, the number of CVC-associated cases declined (GA: 473 to 294; MD: 384 to 151). Candida albicans (CA, 36%) and Candida glabrata (CG, 27%) were the most common species recovered. In both locations, the proportion of cases with fluconazole resistance decreased (GA: 8.0% to 7.1%, -10%; MD: 6.6% to 4.9%, -25%), while the proportion of cases with an isolate resistant to an echinocandin increased (GA: 1.2% to 2.9%, +147%; MD: 2.0% to 3.5%, +77%). Most (74%) echinocandin-resistant isolates were CG; 17 (<1%) isolates were resistant to both drug categories (multidrug resistant [MDR], 16/17 were CG). The proportion of CG cases with MDR Candida increased from 1.8% to 2.6%. CONCLUSIONS: We observed a significant decline in the incidence of candidemia over a five-year period, and increases in echinocandin-resistant and MDR Candida. Efforts to strengthen infection control practices may be preventing candidemia among high-risk patients. Further surveillance for resistant Candida is warranted.
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“Findings from EIP surveillance data have indicated a decrease in overall candidemia incidence in their longest-running surveillance sites of Atlanta, GA, and Baltimore, MD, with the incidence of all species decreasing except C. tropicalis [8].”
From Invasive candidiasis species distribution and trends, United States, 2009-2017 (2021) · cites this paper as [8]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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 [35]
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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 (6,28–30).”
From Population-Based Active Surveillance for Culture-Confirmed Candidemia — Four Sites, United States, 2012–2016 (2019) · cites this paper as [28]
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“This contrasts with data from the early 1990s, when infants had the highest incidence (6), followed by substantial decreases by the late 2000s (26,28).”
From Population-Based Active Surveillance for Culture-Confirmed Candidemia — Four Sites, United States, 2012–2016 (2019) · cites this paper as [28]
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“although C. glabrata has been reported to represent more than 30% of the non-albicans Candida in some geographic areas [4, 6–9].”
From Invasive candidiasis species distribution and trends, United States, 2009-2017 (2021) · cites this paper as [8]
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“Population-based surveillance in two U.S. metropolitan areas found that annual candidemia incidence per 100,000 population declined during 2008–2013 (from 14.1 to 9.5 in Atlanta and 30.9 to 14.4 in Baltimore), likely because of improved infection prevention and control practices (17).”
From Population-Based Active Surveillance for Culture-Confirmed Candidemia — 10 Sites, United States, 2017–2021 (2025) · cites this paper as [17]
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“Limited data from resource-limited settings suggest that timely administration of antimicrobials in patients with sepsis and septic shock is beneficial and potentially feasible (121-126).”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [122]
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“The percentage of Black patients affected by candidemia increased during the study period, likely mirroring the disproportionate effect of the COVID-19 pandemic on Black patients (3,17,25).”
From Population-Based Active Surveillance for Culture-Confirmed Candidemia — 10 Sites, United States, 2017–2021 (2025) · cites this paper as [17]
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“Candida strains with acquired resistance to echinocandins, specifically C. glabrata, while still generally infrequent, are increasing in incidence in some hospitals [10,14].”
From Treatment of Invasive Candidiasis: A Narrative Review (2018) · cites this paper as [10]
In the citing paper
“Specifically, C. glabrata has become an important pathogen in North America, Europe (with the exception of Spain), and Australia, whereas C. parapsilosis is the dominant non-albicans species in South America, Japan, and Spain [8,9,10].”
From Treatment of Invasive Candidiasis: A Narrative Review (2018) · cites this paper as [10]
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“The use of echinocandins and development of cross-resistance is creating apprehension, for the signs of multidrug resistance amongst azoles and echinocandins have already been described [168,169,170].”
From Candida glabrata Biofilms: How Far Have We Come? (2017) · cites this paper as [170]
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Metadata
- Authors
- Cleveland, A. A., Harrison, L. H., Farley, M. M., Hollick, R., Stein, B., Chiller, T. M., Lockhart, S. R., & Park, B. J.
- Affiliations
- Centers for Disease Control and Prevention (US)
- Johns Hopkins University (US)
- Emory University (US)
- Corresponding author
- Cleveland, Angela Ahlquist
- Venue
- PLOS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2015-03-30
- Volume
- 10
- Issue
- 3
- Pages
- e0120452
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC4378850
- OpenAlex
- W2044502735
- Cited by
- 304
- References
- 26
- Citations by year
- 2026: 10 · 2025: 18 · 2024: 21 · 2023: 28 · 2022: 31 · 2021: 27 · 2020: 32 · 2019: 36 · 2018: 31 · 2017: 31 · 2016: 28 · 2015: 11
- FWCI
- 26.22
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- public-domain
- creativecommons.org/publicdomain/zero/1.0/ (vor)
- Locations
- PLoS ONE (publishedVersion, public-domain)
- Europe PMC (PubMed Central) (publishedVersion, public-domain)
- PubMed Central (publishedVersion, public-domain)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Centers for Disease Control and Prevention
- Topics
- Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
- Health Sciences › Medicine › Ophthalmology › Ocular Infections and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Infective Endocarditis Diagnosis and Management
- Keywords
- candidemia, candidemia incidence, antifungal resistance, echinocandin resistance, fluconazole resistance, Candida glabrata, Candida albicans, multidrug resistance, central venous catheters, bloodstream infection, infection control, Atlanta, Baltimore, population-based surveillance, central line-associated bloodstream infection
- MeSH terms
- Adolescent, Adult, Aged, Aged, 80 and over, Antifungal Agents, Candida, Child, Child, Preschool, Female, Georgia, Humans, Infant, Infant, Newborn, Male, Microbial Sensitivity Tests, Middle Aged, Population Surveillance, Baltimore, Incidence, Drug Resistance, Fungal, Young Adult, Candidemia
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