Utilization of Intensive Care Interventions in Critically Ill Patients With Candidemia Versus Bacteremia: A Multicenter Retrospective Cohort Study

OBJECTIVES: Candida species are one of the most common causes of ICU-onset bloodstream infection (BSI). Yet, there is no robust guidance on when to initiate empiric antifungals for ICU patients suspected of BSI. We compared patients with ICU-onset candidemia vs. ICU-onset bacteremia to determine which patients may benefit from empiric antifungals.

DESIGN: We compared characteristics between patients with bacteremia vs. candidemia at time of culture. We determined risk factors for death and constructed a multivariable regression to determine if candidemia is an independent risk factor for death.

SETTING/PATIENTS: We included ICU patients from a hospital system in Houston, Texas (n = 8 hospitals) with a BSI from 2016 to 2023 and validated our findings using ICU patients with a BSI in the publicly available Medical Information Mart for Intensive Care (MIMIC)-IV cohort.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Of 1509 total patients in our primary cohort, 290 (19.2%) had candidemia and 1219 (80.8%) had bacteremia. Patients with candidemia were more likely to be on invasive mechanical ventilation (72.8% vs. 52.8%; p < 0.001), vasopressors (39.3% vs. 24.0%; p < 0.001), and continuous renal replacement therapy (15.2% vs. 9.4%; p = 0.006) at the time of culture. They contracted infection later in ICU stay than bacteremia patients (7.2 vs. 5.0 d; p < 0.001) and were more likely to die within 30 days of culture (unadjusted odds ratio [OR], 1.62; 95% CI, 1.25-2.09). After adjusting for ICU interventions (invasive mechanical ventilation, vasopressors, and continuous renal replacement therapy) and baseline parameters, candidemia was not independently associated with mortality compared with bacteremia in our primary cohort (OR, 1.21; 95% CI, 0.92-1.60) but was in the MIMIC-IV cohort (OR, 1.48; 95% CI, 1.003-2.17).

CONCLUSIONS: Patients with significant ICU resource utilization are at increased risk for candidemia. Our data suggest that when initiating empiric antibiotics in patients requiring high-resource ICU care, empiric antifungal therapy should be considered.