The changing face of nosocomial candidemia: epidemiology, resistance, and drug therapy.

The changing epidemiology and therapy of nosocomial candidemia are discussed. The frequency of nosocomial bloodstream infections by Candida species has risen dramatically in the past two decades. The arrival of antifungal drugs with better tolerability than conventional amphotericin B has resulted in widespread use of systemic antifungal therapy. With the introduction of new systemic antifungals, however, there have been major shifts in the epidemiology of candidal bloodstream infections toward species with less susceptibility to the available antifungal agents. Reports of in situ antifungal resistance are also becoming more common. Strategies for preventing the emergence of resistance have been suggested but have not undergone clinical trials. Antifungal susceptibility testing is becoming an increasingly important tool in the management of nosocomial candidemia. Treatments that have been undergoing investigation for use in these infections include combination therapies, lipid-based amphotericin B formulations, cytokines as adjuvant therapy, and novel antifungal agents such as voriconazole, SCH56592, and echinocandins. New antifungals in development may offer enhanced activity against pathogenic Candida species with less toxicity than amphotericin B. Antifungal susceptibility testing will play a major role in determining the treatment of resistant infections.