Nosocomial candidemia in a university hospital in Taiwan.

The incidence of nosocomial candidemia increased 27-fold over the past 13 years at National Taiwan University Hospital. In order to investigate its predisposing factors, clinical manifestations and prognostic determinants, a prospective observational study of nosocomial candidemia was undertaken at the hospital. From 1 May 1994 to 30 April 1995, 118 consecutive adult patients with 120 Candida spp blood isolates were analyzed. Clinical presentations included fever (100%) with a median duration of 3 days, diarrhea within 7 days of candidemia (27.9%) and macronodular skin emboli (7.6%). Laboratory studies showed worsening azotemia (35.6%), elevation of aminotransferase (28.3%), leukocytosis (27.1%) and thrombocytopenia (23.3%). Use of multiple antibiotics, retained vascular catheters and parenteral nutritional support were the three most common predisposing factors for candidemia. C. albicans was the most common isolate (50%), followed by C. tropicalis (20%), C. glabrata (14%), C. parapsilosis (9.2%). C. guilliermondii (2.5%), and C. Krusei (1.7%). C. tropicalis was more frequently the cause of candidemia in patients with leukemia and neutropenia, while C. glabrata was more commonly seen in patients receiving fluconazole prophylaxis. A severity scoring system adopted from prospective bacteremia studies proved to be highly predictive of mortality in candidemic patients. The overall case fatality rate was 70/118 (59.3%), and 51/70 (72.9%) were attributable to candidemia. In a multivariate analysis, the prognostic factors adversely influencing outcome were: higher severity scores, no removal of the catheter, persistent candidemia and lack of antifungal therapy.