Abstract
The urinary tract is considered an uncommon source of Candida bloodstream infection (CBSI). We aimed to determine the source of CBSI in hospitalized patients, and to compare clinical and microbiological features of CBSI originating in the urinary tract (U-CBSI) and non-urinary CBSI (NU-CBSI). Of 134 patients with CBSI, 28 (20.8%) met criteria for U-CBSI, 34 (25.3%) had vascular catheter-related CBSI and 21 (15.6%) had a gastrointestinal origin. Compared to NU-CBSI patients, patients with U-CBSI were older with higher rates of dementia. Bladder catheterization for urinary retention and insertion of ureteral stents or nephrostomies were risk factors for U-CBSI. Fifty percent of U-CBSI cases occurred within 48 h of hospital admission, versus 16.9% of NU-CBSI (p < 0.0001). The mortality rate was lowest for CBSI originating in the urinary tract and highest for CBSI of undetermined origin. CBSI of undetermined origin remained associated with higher mortality in a Cox regression model that included age, Candida species, Pitt bacteremia score and neutropenia as explanatory variables. U-CBSI may be increasing in frequency, reflecting extensive use of bladder catheters and urologic procedures in elderly debilitated patients. Distinct clinical features are relevant to the diagnosis, treatment and prevention of U-CBSI.
Highlights
Candida species are among the most frequent causes of bloodstream infections in hospitalized patients [1,2,3,4], and are associated with the highest case-fatality rate of all common nosocomial pathogens [1,5]
We defined urinary source (U-)Candida bloodstream infection (CBSI) based on criteria proposed by Cuervo et al [17], with modification: An episode of candidemia fulfilling at least two of the following criteria, concomitant with the onset of candidemia: 1. Signs and symptoms of upper urinary tract infection; 2. transurethral instrumentation; 3. recovery of the same
Neutropenia was present in 16 patients (11.9%) (Tables 1 and S2)
Summary
Candida species are among the most frequent causes of bloodstream infections in hospitalized patients [1,2,3,4], and are associated with the highest case-fatality rate of all common nosocomial pathogens [1,5]. Candida bloodstream infection (CBSI) is thought to arise endogenously from the gastrointestinal tract, with the skin being a less frequent source of infection [8]. While Candida spp. are frequently isolated from the urine of hospitalized patients, the urinary tract is regarded as an infrequent source of CBSI in adults [9]. Patients with candiduria typically have multiple comorbidities, notably diabetes mellitus, malignancy and recent antibiotic treatment, and most have indwelling bladder catheters [9,10]. The frequency of candidemia among patients with candiduria ranged from 1.3%
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