Abstract
As part of a national surveillance programme initiated in 2004, fungal blood isolates from 2016–2018 underwent species identification and EUCAST susceptibility testing. The epidemiology was described and compared to data from previous years. In 2016–2018, 1454 unique isolates were included. The fungaemia rate was 8.13/100,000 inhabitants compared to 8.64, 9.03, and 8.38 in 2004–2007, 2008–2011, and 2012–2015, respectively. Half of the cases (52.8%) involved patients 60–79 years old and the incidence was highest in males ≥70 years old. Candida albicans accounted for 42.1% of all isolates and Candida glabrata for 32.1%. C. albicans was more frequent in males (p = 0.03) and C. glabrata in females (p = 0.03). During the four periods, the proportion of C. albicans decreased (p < 0.001), and C. glabrata increased (p < 0.001). Consequently, fluconazole susceptibility gradually decreased from 68.5% to 59.0% (p < 0.001). Acquired fluconazole resistance was found in 4.6% Candida isolates in 2016–2018. Acquired echinocandin resistance increased during the four periods 0.0%, 0.6%, 1.7% to 1.5% (p < 0.0001). Sixteen echinocandin-resistant isolates from 2016–2018 harboured well-known FKS resistance-mutations and one echinocandin-resistant C. albicans had an FKS mutation outside the hotspot (P1354P/S) of unknown importance. In C. glabrata specifically, echinocandin resistance was detected in 12/460 (2.6%) in 2016–2018 whereas multidrug-class resistance was rare (1/460 isolates (0.2%)). Since the increase in incidence during 2004–2011, the incidence has stabilised. In contrast, the species distribution has changed gradually over the 15 years, with increased C. glabrata at the expense of C. albicans. The consequent decreased fluconazole susceptibility and the emergence of acquired echinocandin resistance complicates the management of fungaemia and calls for antifungal drug development.
Highlights
Candidaemia is the most common manifestation of fungaemia and of invasive candidiasis [1]
Prior antifungal use has been shown to lead to a higher proportion of candidaemia with non-C. albicans species, especially C. glabrata following azole and C. parapsilosis following echinocandin exposure [1]
Azole antifungal agents are recommended as prophylaxis for certain patient groups in Denmark depending on their underlying disease and risk factors—especially in the intensive care unit (ICU), in haematological patients, in low-birth-weight neonates, and in lung and liver transplant recipients [3]
Summary
Candidaemia is the most common manifestation of fungaemia and of invasive candidiasis [1]. The impact of antibiotic use was supported by a Danish study on ICU patients, which found that exposure to ciprofloxacin-containing antibiotics increased the risk of invasive Candida infections [20]. Denmark has experienced a larger shift in species proportion from Candida albicans to Candida glabrata than the other Nordic countries and has had the highest consumption of antifungal drugs in both the primary and hospital sector [19]. Prior antifungal use has been shown to lead to a higher proportion of candidaemia with non-C. albicans species, especially C. glabrata following azole and C. parapsilosis following echinocandin exposure [1]. Azole antifungal agents are recommended as prophylaxis for certain patient groups in Denmark depending on their underlying disease and risk factors—especially in the ICU, in haematological patients, in low-birth-weight neonates, and in lung and liver transplant recipients [3]. We report the most recent national data on the epidemiology of fungaemia including antifungal susceptibility over a 15-year perspective
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