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Candidemia Surveillance

Purpose

The Emerging Infections Program (EIP) conducts Candidemia surveillance in all ten EIP sites throughout the United States. The purpose of this surveillance system is to describe epidemiological characteristics of Candidemia such as incidence, Candida species distribution, antifungal drug resistance, treatment practices, and outcomes on a local and national level, in order to develop and implement effective prevention and control strategies.

Candidemia is an invasive bloodstream infection (BSI) caused by a yeast called Candida. Certain species of Candida are part of the normal flora in humans and can be found in small amounts in areas such as the gastrointestinal tract, female genital tract, and on the skin. In these areas, low levels of Candida are kept in check by the body’s immune system. However, in instances of over-growth, Candida can become harmful and if the yeast enters the blood stream it causes a serious, often life threatening infection called Candidemia. 

Candidemia is an important public health problem due to the high morbidity and mortality associated with invasive infection, as well as the burden of increased hospital cost and length of stay. Risk factors for developing Candidemia include: presence of a central venous catheter, admission to an intensive care unit, having a weakened immune system (e.g. organ transplant, HIV/AIDS, cancer chemotherapy), taking broad-spectrum antibiotics, having a very low neutrophil count (neutropenia), having kidney failure or being on hemodialysis, having abdominal surgery and having diabetes 1. Given the risk factors, Candidemia is most likely to occur following a recent hospital admission or contact with a healthcare setting such as a nursing home. Among hospitalized patients with BSI, those infected with Candida had the highest mortality.  Recent studies estimate the mortality attributed to Candidemia to be about 30% in the United States 2. Candida does not spread directly from person to person. However, since it can be found on the skin, Candida can be transmitted from one person to another and may lead to infection in individuals with high risk factors. 

References

1 Invasive Candidiasis Risk & Prevention Retrieved from URL  

  https://www.cdc.gov/fungal/diseases/candidiasis/invasive/risk-prevention.html

2 Invasive Candidiasis Statistics Retrieved from URL

    https://www.cdc.gov/fungal/diseases/candidiasis/invasive/statistics.html


Goals & Objectives

1. To describe the incidence of Candidemia in in the United States utilizing active, population-based, laboratory surveillance. 
2. To describe the epidemiology of Candida bloodstream infections. 
3. To describe the species distribution of Candida isolates causing BSI in the surveillance areas.
4. To describe the prevalence and risk factors for antifungal drug resistance among Candida bloodstream isolates. 
5. To describe treatment and outcomes of Candidemia including time to initiation of treatment, type of treatment, time to clearance of infection, morbidity and mortality, and factors associated with morbidity and mortality, among patients with Candidemia.
6. To identify best practices to prevent Candida infections. 
7. To conduct additional surveillance for other forms of invasive Candidiasis.

Activities

In Connecticut, prospective laboratory-based surveillance will be conducted to identify blood cultures positive for Candida spp. Data will be abstracted via chart review on cases using standardized data collection instruments and the Candida spp. isolates will be sent to CDC for species confirmation, antifungal resistance testing, and in some cases, molecular typing.

Recent Candida Publications

1) Magill SS, Edwards JR, Bamberg W et al. Multistate Point-Prevalence Survey of Health Care– Associated Infections. N Engl J Med. 2014;370:1198–1208. 
2) Pfaller MA, Diekema DJ. Epidemiology of invasive candidiasis: a persistent public health problem. Clin Microbiol Rev 2007;20:133-63.
3) Almirante B, Rodriguez D, Park BJ et al. Epidemiology and predictors of mortality in cases of Candida bloodstream infection: results from population-based surveillance, Barcelona, Spain, from 2002 to 2003. J Clin Microbiol 2005;43:1829-35.
4) Cleveland AA, Harrison LH, Farley MM et al. Declining Incidence of Candidemia and the Shifting Epidemiology of Candida Resistance in Two US Metropolitan Areas, 2008–2013: Results from Population-Based Surveillance. PLOS One 2015: 10(3): e0120452.
5) Alexander BD, Johnson MD, Pfieffer CD et al. Increasing Echinocandin Resistance in Candida glabrata: Clinical Failure Correlates with Presence of FKS Mutations and Elevated Minimum Inhibitory Concentrations. Clin Infect Dis. 2013:56(12):1724-32. 
6) Vallabhaneni S, Cleveland AA, Farley M et al. Epidemiology and Risk Factors for Echinocandin Nonsusceptible Candida glabrata Bloodstream Infections: Data From a Large Multisite PopulationBased Candidemia Surveillance Program, 2008-2014. OFID. 2015:2(4): ofv163. 
7) Pappas PG, Kauffman CA, Andres DR et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. CID. 2016:62(4):e1-e50. 
8) Sprung CL, Sakr Y, Vincent J-L, et al.  An evaluation of systemic inflammatory response syndrome signs in the Sepsis Occurrence in Acutely Ill Patients (SOAP) study.  Intensive Care Med 2006;32:421-7.  
9) Morgan J, Meltzer MI, Plikaytis BD et al. Excess mortality, hospital stay, and cost due to candidemia: a case-control study using data from population-based candidemia surveillance. Infect Control Hosp Epidemiol 2005;26:540-7.  

Project Contact

Paula Clogher, MPH
Project Coordinator
Connecticut Emerging Infections Program
One Church Street, 7th floor
New Haven, CT 06510
203-764-4358
paula.clogher@yale.edu