Giovanni Scaglione, Marta Colaneri, Martina Offer, Giorgia Montrucchio, Camilla Genovese, Bruno Viaggi, Francesca Dore, Giovanni Tricella, Lidia Dalfino, Gianpaola Monti, Andrea Gori, Emanuele Palomba, Stefano Finazzi, the Italian Group for Evaluation of Interventions in Intensive Care Medicine, Giorgia Montrucchio, Fulvio Agostini, Antonello Di Paolo, Angelo Pan, Gian María Rossolini, Emanuele Russo, Daniela Silengo, Costanza Vicentini, Carla Maria Zotti, Stefano Finazzi, Gianpaola Monti, Emanuele Palomba, Marta Colaneri, Lidia Dalfino, Francesca Dore, Bruno Viaggi
This multicenter study focuses on the latest (2020-2024) trends in candidemia in 155 Italian ICUs, stressing its frequency and lethality, with a shift toward non-albicans, fluconazole-resistant species, namely C. parapsilosis. In this study, resistance to fluconazole prolonged ICU stays without increasing mortality, while non-catheter-related episodes had a more severe prognosis. RATIONALE: Candidemia is the leading fungal bloodstream infection (BSI) in the ICU and carries high mortality. After the COVID-19 pandemic, non-albicans, fluconazole-resistant species increased in Europe, yet contemporary ICU-acquired data are scarce. The primary outcome of this study was to evaluate the incidence of ICU-acquired candidemia per 1,000 "at risk" ICU admissions (ICU length of stay [LOS] ≥ 48 h). Secondary analyses compared ICU-acquired candidemia with ICU-acquired bacterial BSI and assessed species distribution, fluconazole susceptibility, and outcomes by fluconazole resistance and by source of infection. METHODS: Data were drawn from the PROSAFE network, a prospective multicentric observational project conducted across 192 Italian ICUs (2014-2023). RESULTS: Among 179,590 ICU admissions, 95,662 were at risk. ICU-acquired candidemia occurred in 373 patients (3.9‰ of at-risk admissions). Compared with ICU-acquired bacterial BSI, candidemia patients had longer intra-ICU and hospital LOS (32 vs 24 days and 44 vs 36 days, respectively; p < 0.001) and higher mortality (intra-ICU 41.3% vs 28.7%; intra-hospital 50.3% vs 34.1%; p < 0.001). Candida albicans was isolated in 47.2% of episodes, followed by Candida parapsilosis at 33.0%; the latter is often fluconazole-resistant (53.7%). Mortality did not increase in fluconazole-resistant episodes, but ICU LOS did (36 vs 31 days; p = 0.016). Non-catheter-related infections (197/373, 52.8%) had higher intra-hospital mortality rates (57.0% vs 42.9%; p = 0.007). CONCLUSIONS: ICU-acquired candidemia in Italy remains frequent and lethal, with a worrisome shift in epidemiology and resistance; the latter prolongs ICU stay without increasing mortality. Non-catheter-related episodes had a poorer prognosis. Findings support enhanced surveillance, catheter care, and earlier antifungal therapy.