Incidence and outcome of invasive candidiasis in intensive care units (ICUs) in Europe: results of the EUCANDICU project

Background

The objective of this study was to assess the cumulative incidence of invasive candidiasis (IC) in intensive care units (ICUs) in Europe.

Methods

A multinational, multicenter, retrospective study was conducted in 23 ICUs in 9 European countries, representing the first phase of the candidemia/intra-abdominal candidiasis in European ICU project (EUCANDICU).

Results

During the study period, 570 episodes of ICU-acquired IC were observed, with a cumulative incidence of 7.07 episodes per 1000 ICU admissions, with important between-center variability. Separated, non-mutually exclusive cumulative incidences of candidemia and IAC were 5.52 and 1.84 episodes per 1000 ICU admissions, respectively. Crude 30-day mortality was 42%. Age (odds ratio [OR] 1.04 per year, 95% CI 1.02–1.06, p < 0.001), severe hepatic failure (OR 3.25, 95% 1.31–8.08, p 0.011), SOFA score at the onset of IC (OR 1.11 per point, 95% CI 1.04–1.17, p 0.001), and septic shock (OR 2.12, 95% CI 1.24–3.63, p 0.006) were associated with increased 30-day mortality in a secondary, exploratory analysis.

Conclusions

The cumulative incidence of IC in 23 European ICUs was 7.07 episodes per 1000 ICU admissions. Future in-depth analyses will allow explaining part of the observed between-center variability, with the ultimate aim of helping to improve local infection control and antifungal stewardship projects and interventions.

Invasive candidiasis (IC) can develop in adult patients admitted in intensive care units (ICUs), with a significant impact on morbidity, mortality, and healthcare costs [1,2,3,4]. The most frequent clinical forms of IC in critically ill patients are candidemia and intra-abdominal candidiasis (IAC), which affect up to 5% of all ICU admissions [2, 5].

In the last 10 years, other series addressed specifically the cumulative incidence of IC in the ICU setting [6,7,8,9,10]. The majority of those studies was limited to candidemia, some were limited to one or a few countries, and some occasionally included cases not representing true infections but colonization [6,7,8,9,10].

The aim of the present multinational study was to expand our knowledge of the cumulative incidence of ICU-acquired IC in Europe.

The present multicenter, retrospective study was conducted from January 2015 to December 2016 in 23 ICUs in 22 large tertiary care European hospitals (9 in Italy, 4 in France, 2 in Greece, 1 in Belgium, 1 in Czech Republic, 1 in Germany, 1 in Ireland, 1 in Portugal, 1 in Spain, 1 in The Netherlands, and 1 in the UK). All patients who developed an episode of candidemia or a microbiologically documented IAC [11] during their stay in the ICU (at least 48 h after admission) were included in the study.

The primary objective of the study was to assess the cumulative incidence of ICU-acquired IC in European ICUs. Secondary objectives were (i) to assess the independent impact of center-level factors on the cumulative incidence of ICU-acquired IC and (ii) to assess factors associated with crude 30-day mortality in patients with ICU-acquired IC.

The entire EUCANDICU project consists of two phases: (i) a first study describing the cumulative incidence of ICU-acquired IC in Europe, reported in the present paper; (ii) a second, case-control study to assess patient-level predictors of ICU-acquired IC, which will be conducted and published subsequently.

Definitions

ICU-acquired IC was defined as candidemia or IAC with signs and symptoms of infection developing at least 48 h after ICU admission. Candidemia and IAC were defined according to previously published definitions [6, 11]. More in detail, candidemia was defined as the presence of at least one positive blood culture for Candida spp. in patients with signs and symptoms of infection. IAC was defined as the presence of at least one of the following: (i) Candida detection by direct microscopy or growth in culture from necrotic or purulent intra-abdominal specimens obtained by percutaneous aspiration or during surgery; (ii) growth of Candida from the bile or intra-biliary duct devices, plus biopsy of intra-abdominal organs; (iii) growth of Candida from blood cultures in the presence of secondary or tertiary peritonitis in the presence of no other pathogens; (iv) growth of Candida from drainage tubes inserted less than 24 h before culture sampling [11]. In case of multiple episodes of IC in the same patient, a subsequent event was considered as independent if developing at least 30 days after the last positive culture related to the previous episode. Crude 30-day mortality was defined as death within 30 days from the onset of signs and symptoms of ICU-acquired IC. All patients suitable for inclusion were identified starting from the laboratory databases of the participating hospitals, and subsequent review of clinical records.

Statistical analysis

The cumulative incidence of ICU-acquired IC was measured as the number of episodes per 1000 ICU admissions. The impact of center-level factors on the cumulative incidence of ICU-acquired IC was assessed by means of a multivariable generalized Poisson mixed model with center as a random intercept, after having verified the absence of overdispersion in count data. Subgroup analyses were also conducted according to the type of ICU-acquired IC (candidemia and IAC).

Demographic and clinical characteristics of patients are presented with number and percentage for categorical variables and median and interquartile range (IQR) for continuous variables. Their possible association with crude 30-day mortality was firstly tested through univariable logistic regression. Then, factors potentially associated with the outcome in univariable comparisons (p < 0.10) were included in an initial multivariable regression model and further selected for the final multivariable model (model A) by means of a stepwise backward procedure based on the Akaike information criterion. Only the first IC episode per patient was considered for this analysis. Variables included in model A were also included in an additional multivariable mixed logistic regression model (model B), with center as a random intercept.

All the analyses were conducted using R Statistical Software 3.5.2 (R Foundation for Statistical Computing, Vienna, Austria). Mixed models were built using the glmer function in the lme4 package.

Primary analysis—cumulative incidence

During the study period, the 23 ICUs (median number of beds 18, interquartile range 14–43) had 80,645 admissions and 570 episodes of ICU-acquired IC, corresponding to an incidence of 7.07 episodes per 1000 ICU admissions (6.67 and 7.47 in 2015 and 2016, respectively). Separated, non-mutually exclusive incidences of candidemia and IAC were 5.52 and 1.84 episodes per 1000 ICU admissions, respectively. As shown in Table 1, in subgroup comparisons, admission to a surgical ICU was associated with lower incidence when compared with a medical ICU (cumulative incidence ratio 0.10, 95% CI 0.01–0.76 for surgical vs. medical, p 0.022). The observed random effects variance testified to the presence of between-center variability in the cumulative incidence of IC that was unexplained by the explored, fixed center-level predictors (Table 1 legend). A graphic representation of the cumulative incidence of IC is also available in Fig. 1.

Cumulative incidence of ICU-acquired invasive candidiasis. IAC, intra-abdominal candidiasis; IC, invasive candidiasis; ICU, intensive care unit

Full size image

Secondary analysis—predictors of mortality

An additional, secondary analysis of predictors of mortality was conducted in the subgroup of patients for whom patient-level clinical data was registered (mostly cases of IC meeting the following inclusion criterion for the future case-control study: availability of controls with the same length of ICU stay without IC). In this regard, clinical data were available for 330/570 cases of IC (58%). The median age of patients was 66 (IQR 55–75), and 60% were males (198/330). Candidemia, IAC, and IAC plus candidemia accounted for 65% (215/330), 29% (97/330), and 5% (18/330) of episodes, respectively. C. albicans was the most frequently isolated species (189/330, 57%), followed by C. glabrata (68/330, 21%) and C. parapsilosis (42/330, 13%). Crude 30-day mortality was 42% (137/330). Table 2 shows univariable and multivariable analyses of predictors of crude 30-day mortality. In the final multivariable model (model A), age (odds ratio [OR] 1.04 per year, 95% CI 1.02–1.06, p < 0.001), severe hepatic failure (OR 3.25, 95% 1.31–8.08, p 0.011), SOFA score at the onset of IC (OR 1.11 per point, 95% CI 1.04–1.17, p 0.001), and septic shock (OR 2.12, 95% CI 1.24–3.36, p 0.006) were associated with increased 30-day mortality. As reported in the legend of Table 2, the additional multivariable model with center as random intercept (model B) confirmed the results obtained in model A.

This is the largest multinational study assessing the cumulative incidence of ICU-acquired IC in Europe to date. Based on our report, the incidence of IC in European ICUs was 7.07 episodes per 1000 ICU admissions, with crude 30-day mortality of 42%.

Our results are similar to those of the large point-prevalence EPIC II study, which previously reported a prevalence of 6.87 episodes of candidemia per 1000 ICU patients, although we recorded a slightly lower cumulative incidence of candidemia (5.52 episodes per 1000 ICU admissions) [6]. In addition, our analysis indicated two center-level factors that may influence local incidences: (i) the type of ICU, with medical ICUs being associated with increased incidence vs. surgical ICUs in subgroup comparisons, and (ii) the presence of random between-center variability, although likely relying in part on unexplored but exhaustive center-level factors. It is also worth noting that some unexplored center-level factors (e.g., cumulative days at risk, antifungal prophylaxis policies), together with the low number (and thus low generalizability) of ICU wards included in the subgroup comparison surgical vs. medical (3 vs. 5, respectively), might have influenced the unexpected but significant observation of a lower cumulative incidence of IC in surgical ICUs, which calls for future confirmatory studies specifically addressing this aspect.

In a secondary analysis, we confirmed the importance of baseline factors (age, severe hepatic failure) and severity of disease/clinical presentation (SOFA score, septic shock) in unfavorably influencing the prognosis of ICU-acquired IC [2, 12]. However, we could not explore the impact on mortality of both source control and antifungal therapy performed/administered beyond 24 h after the onset of IC. Dedicated studies and models aimed at primarily evaluating these variables are necessary to comprehensively assess their effect.

An important limitation of our study is the limited number of assessed, potential center-level predictors of cumulative incidence. Further studies with a higher number of participating ICUs are necessary for allowing inclusion of more variables in the model. Other main limitations of our study are the lack of a control group (patients without IC) for assessing patient-level predictors of IC and the inherent possibility of having considered some contamination as IAC. As regards the former, it should be noted that the main goal in which we were interested in this first phase was to provide a center-level perspective on the cumulative incidence of ICU-acquired IC, by describing its burden and assessing the possible effect of fixed and random center-level predictors. Although it will ultimately add to the discussion, the assessment of patient-level predictors is an independent and different analysis, which will be the core of the future case-control study. As regards the possibility of including contaminations, it is worth noting that we used a consensus definition for minimizing the number of contaminations misidentified as IAC [11]. Another limitation is that most data came from a few countries (e.g., 9/23 participating ICUs are in Italy), thus preventing us from reliably assessing the existence of any possible between-country variability impacting on the cumulative incidence of ICU-acquired IC. Finally, it should be acknowledged that the impact on mortality of some covariates (e.g., COPD) may depend on their degree of severity, which was not registered.

Global incidence of IC in 23 European ICUs was 7.07 episodes per 1000 ICU admissions. Future in-depth analyses will allow explaining part of the observed between-center variability, with the ultimate aim of helping to improve local infection control and antifungal stewardship interventions.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

CI:

Confidence intervals

COPD:

Chronic obstructive pulmonary disease

IAC:

Intra-abdominal candidiasis

IC:

Invasive candidiasis

ICU:

Intensive care unit

OR:

Odds ratio

SOFA:

Sequential organ failure assessment

Not applicable.

Endorsement

The EUCANDICU project was endorsed by the Critically Ill Patients Study Group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).

Funding

None.

Affiliations

1. Infectious Diseases Clinic, Department of Medicine University of Udine and Santa Maria Misericordia Hospital, Piazzale Santa Maria della Misericordia 15, 33100, Udine, Italy
   • Matteo Bassetti
   • , Antonio Vena
   • , Alessia Carnelutti
   • , Maria Merelli
   •  & Maddalena Peghin
2. Department of Health Sciences, University of Genoa, Genoa, Italy
   • Matteo Bassetti
   • , Daniele R. Giacobbe
   • , Filippo Ansaldi
   • , Cristiano Alicino
   • , Alessio Mesini
   •  & Valentino Tisa
3. Health Planning unit, Azienda Ligure Sanitaria della Regione Liguria (A.Li.Sa.), Liguria Region, Italy
   • Cecilia Trucchi
   •  & Filippo Ansaldi
4. Health Planning unit, Policlinic San Martino Hospital - IRCCS, Genoa, Italy
   • Cecilia Trucchi
   •  & Filippo Ansaldi
5. Department of Intensive Care and Anesthesiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
   • Massimo Antonelli
6. Clinical Microbiology and ATB Centre, Institute of Medical Biochemistry and Laboratory Diagnostics, General University Hospital, Prague, Czech Republic
   • Vaclava Adamkova
7. Department of Medical Microbiology, Medical Faculty of Palackeho University, Olomouc, Czech Republic
   • Vaclava Adamkova
8. Medical Direction, Santa Corona Hospital, ASL 2 Regional Health System of Liguria, Pietra Ligure, Italy
   • Cristiano Alicino
9. Department of Critical Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece
   • Maria-Panagiota Almyroudi
   •  & George Dimopoulos
10. Département d’Anesthésie-Réanimation, CHU Bichat-Claude Bernard, HUPNVS, APHP, Paris, France
    • Enora Atchade
    •  & Philippe Montravers
11. Department of Diagnostics and Public Health, Infectious Disease Unit, University of Verona, Verona, Italy
    • Anna M. Azzini
12. First Division, Cotugno Hospital, AO dei Colli, Naples, Italy
    • Novella Carannante
13. Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
    • Silvia Corcione
14. Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
    • Andrea Cortegiani
15. Department of Anesthesiology and Intensive Care Medicine, Heidelberg University Hospital, Heidelberg, Germany
    • Simon Dubler
16. Servicio de Cuidados Críticos y Urgencias, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain
    • José L. García-Garmendia
17. Department of Anesthesia and Intensive Care, University Hospital of Modena, Modena, Italy
    • Massimo Girardis
18. Department I of Internal Medicine, University Hospital of Cologne and Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
    • Oliver A. Cornely
19. Infectious Diseases Unit, Department of Medical and Surgical Science, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
    • Stefano Ianniruberto
20. Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
    • Bart Jan Kullberg
    •  & Jeroen Schouten
21. Department of Laboratory Medicine and National Reference Centre for Mycosis, University Hospitals of Leuven, Leuven, Belgium
    • Katrien Lagrou
22. Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
    • Katrien Lagrou
23. Bichat-Réanimation médicale et des maladies infectieuses, Medical ICU, Paris, France
    • Clement Le Bihan
24. Infectious Diseases Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
    • Roberto Luzzati
25. Department of Intensive Care Medicine, University Hospital Brussels (UZB), Jette, Belgium and Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
    • Manu L. N. G. Malbrain
26. C.H. Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
    • Ana J. Marques
27. Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James’s Hospital, Dublin, Ireland
    • Ignacio Martin-Loeches
28. Hospital Clinic, IDIBAPS,CIBERes, universidad de Barcelona, Barcelona, Spain
    • Ignacio Martin-Loeches
29. Department of Emergency and Intensive Care Medicine, Centro Hospitalar Universitário São João, Faculdade de Medicina da Universidade do Porto e Grupo de Infecção e Sépsis, Porto, Portugal
    • José-Artur Paiva
30. Department of Biopathology and Medical Biotechnologies, Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico P. Giaccone, University of Palermo, Palermo, Italy
    • Santi Maurizio Raineri
31. Department of Infectious Diseases, Manchester University NHS Foundation Trust, Wythenshawe Hospital; and Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
    • Riina Rautemaa-Richardson
32. Infectious Diseases Department, Ospedale Civile SS. Giovanni e Paolo, Venice, Italy
    • Pierluigi Brugnaro
33. Intensive Care Department, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
    • Herbert Spapen
34. G. Gennimatas General Hospital of Thessaloniki, Thessaloniki, Greece
    • Polychronis Tasioudis
35. Université Paris Diderot/Hopital Bichat-Réanimation Medicale et Des Maladies Infectieuses, Paris, France
    • Jean-François Timsit
36. UMR 1137-IAME Team 5-DeSCID: Decision SCiences in Infectious Diseases, Control and Care, Inserm/Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
    • Jean-François Timsit
37. Institute of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
    • Mario Tumbarello
38. Department of Intensive Care, University Medical Center Groningen, Groningen, the Netherlands
    • Charlotte H. S. B. van den Berg
39. Pole Anesthésie-Réanimation-SAMU, Rouen University Hospital, Rouen, France
    • Benoit Veber
40. Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
    • Mario Venditti
41. Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Service de réanimation médico-chirurgicale, Hôpital Tenon, 75020, Paris, France
    • Guillaume Voiriot
42. Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
    • Joost Wauters
43. Université de Paris, INSERM UMR 1152, Paris, France
    • Philippe Montravers

Contributions

MB, PM, DRG, FA, CT, and AV made substantial contributions to the study concept and design, acquisition of data, analysis and interpretation of data, first drafting of the manuscript, and critical revision of the manuscript for important intellectual content. All the other authors made substantial contributions to the acquisition of data and critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Matteo Bassetti.

Ethics approval and consent to participate

Specific informed consent for this study was not necessary because of the retrospective nature of the analyses. The study was approved by the Ethics Committee of the coordinating center (Regional Ethics Committee of Friuli-Venezia-Giulia Region, parere CEUR-2017-Os-033-ASUIUD).

Consent for publication

Not applicable.

Competing interests

Outside the submitted work, MB reports grants and personal fees from Pfizer, grants and personal fees from MSD, grants and personal fees from Cidara, personal fees from Astellas, and personal fees from Gilead. DRG reports personal fees from Stepstone Pharma GmbH and an unconditioned grant from MSD Italia. GD reports personal fees from Pfizer, Infectopharm, and EU/FP7/Magic Bullet and a grant for his institution from MSD. JLGG reports a formative grant from MSD, a formative grant from Fresenius, and payment for lecture from Astra Zeneca. BJK reports grants for his institution from Amplyx, Astellas, and Cidara. KL has received research grants from Gilead, MSD, and Pfizer; consultancy fees from Gilead, Pfizer, Abbott, MSD, and SMB Laboratoires Brussels; travel support from Pfizer, Gilead, and MSD; and speaker fees from Gilead, Roche, and Abbott. JFT has received grants for his institution from Pfizer and MSD and personal fees from BioMérieux and participated in advisory board for MSD, Bayer, 3 M, and Gilead. PM reports personal fees from Pfizer and MSD. The other authors declare that they have no competing interests.

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