Candidemia In Patients Research Articles

ANTIFUNGAL DRUG RESISTANCE PATTERN AMONG BIOFILM PRODUCING STRAINS OF CANDIDA SPECIES ISOLATED FROM BLOODSTREAM INFECTIONS

Background & objectives: The emergence of drug resistant Candida species has become an important cause of health care associated infections. Antimicrobial resistance is very high in biolm-producing Candida strains. This study was carried out with an aim to study species distribution of Candida isolates among candidemia patients, biolm formation as a virulence factor and their antifungal susceptibility pattern. A total ofMethods: 100 consecutive Candida isolates obtained from blood culture samples were included in the study. Identication of the isolates were done by conventional method and VITEK 2. The antifungal susceptibility were done by VITEK 2 and E test method. Biolm formation was detected using Congo red agar medium, Test tube method and Microtitre plate method. Of the total 100 Candida isolates evaluated, Candida albicansResults: (n=34 isolates) was most common followed by C. tropicalis (n=20 isolates). A larger number of Candida spp. (71%) produced biolm. Biolm production by NAC was signicantly more frequent (75.75%) than that by C. albicans (61.76%). Antifungal resistance rates for Fluconazole (30.98%), Amphotericin B (15.49%) and Flucytosine (11.26%) were higher among the biolm producing strains. All the strains of C. krusei were resistant to Fluconazole and Flucytosine and all strains of C. auris were found resistant to uconazole. Interpretation & Conclusion: Speciation of Candida becomes important as the prevalence of NAC is increasing. Biolm formation exhibits increased resistance to commonly available antifungal therapies. These data has become necessary to reduce the net effect of the increasing severity of Candida infections, drug resistance, and economic burden.

Prevalence, risk factors, treatment and outcome of multidrug resistance Candida auris infections in Coronavirus disease (COVID-19) patients: A systematic review.

Background Candida auris is an emerging multidrug‐resistant pathogen in intensive care settings (ICU). During the coronavirus disease 19 (COVID‐19) pandemic, ICU admissions were overwhelmed, possibly contributing to the C. auris outbreak in COVID‐19 patients.ObjectivesThe present systematic review addresses the prevalence, underlying diseases, iatrogenic risk factors, treatment and outcome of C. auris infections in COVID‐19 patients.MethodsMEDLINE, Scopus, Embase, Web of Science and LitCovid databases were systematically searched with appropriate keywords from 1 January 2020 to 31 December 2021.ResultsA total of 97 cases of C. auris were identified in COVID‐19 patients. The pooled prevalence of C. auris infections (encompassing candidemia and non‐candidemia cases) in COVID‐19 patients was 14%. The major underlying diseases were diabetes mellitus (42.7%), hypertension (32.9%) and obesity (14.6%), followed by the iatrogenic risk factors such as a central venous catheter (76.8%%), intensive care unit (ICU) stay (75.6%) and broad‐spectrum antibiotic usage (74.3%). There were no significant differences in underlying disease and iatrogenic risk factors among C. auris non‐candidemia/colonisation and C. auris candidemia cases. The mortality rate of the total cohort is 44.4%, whereas, in C. auris candidemia patients, the mortality was 64.7%.ConclusionThis study shows that the prevalence of C. auris infections remains unchanged in the COVID‐19 pandemic. Hospital‐acquired risk factors may contribute to the clinical illness. Proper infection control practices and hospital surveillance may stop future hospital outbreaks during the pandemic.

Candidemia before and after the COVID-19 pandemic: An analysis of risk factors and outcomes in patients with candidemia

Background: An increase in candidemia has been observed throughout the world since the start of the COVID-19 pandemic. Patients with COVID-19 may have different risk factors, clinical presentations, and outcomes compared to patients without COVID-19. Methods: We conducted a retrospective chart review of all inpatients with candidemia at a large, academic medical center from April 30, 2019, to February 19, 2021. The first case of COVID-19 was detected at our institution March 2020 and patients were sorted into pre– versus post–COVID-19 pandemic groups. Data regarding clinical characteristics, risk factors, and outcomes were collected. The rate of candidemia per 10,000 patient days was calculated from January 2013 through February 2021. Results: In total, 202 patients were identified with candidemia: 92 cases were identified before the pandemic and 110 cases were identified after the pandemic began. Moreover, 33 (16.3%) patients were diagnosed with COVID-19 during the admission and 169 (83.7%) did not have COVID-19. Patients with COVID-19 were significantly more likely to be older (median, 64.5 vs 54.8 years; P = .0006) and to have a higher body mass index (32.8 vs 29.1; P = .03) than patients without COVID-19. Patients with COVID-19 were less likely have some of the traditional risk factors (eg, abdominal surgery, total parenteral nutrition, history of injecting drugs) for candidemia compared to patients without COVID-19. Patients with COVID-19 were significantly more likely to require ICU care (97.0% vs 67.5%; P < .001) and to require mechanical ventilation (90.9% vs 53.9%; P < .001), and they had higher mortality at 30 days (66.7% vs 31.4%; P < .001). A multivariate logistic regression model showed that COVID-19 (OR, 2.53; 95% CI, 1.09–5.90) and higher age (OR 1.45, 95% CI, 1.11–1.91) were significant predictors of 30 day mortality. Using a Poisson regression model, the incidence rate ratio for candidemia per month after the start of the COVID-19 pandemic was 2.09 (95% CI, 1.85–2.36; P < .0001) compared to the years prior. Conclusions: Rates of candidemia significantly increased after the start of the COVID-19 pandemic. Patients with candidemia in the post–COVID-19 era tend to have nontraditional risk factors, to be more critically ill, and to have increased mortality compared to patients in the pre–COVID-19 era. COVID-19 and higher age were independent predictors of mortality. More studies are needed to further define risk factors for candidemia in patients with COVID-19.Funding: NoneDisclosures: None

Risk Factors and Clinical Characteristics of Patients with Ocular Candidiasis.

Ocular candidiasis is a critical and challenging complication of candidemia. The purpose of this study was to investigate the appropriate timing for ophthalmologic examinations, risk factors for complications of ocular lesions, and their association with mortality. This retrospective cohort study applied, using multiple logistic regression analysis and Cox regression models, to cases of candidemia (age ≥ 18 years) for patients who underwent ophthalmologic consultation. Of the 108 candidemia patients who underwent ophthalmologic examination, 27 (25%) contracted patients had ocular candidiasis, and 7 experienced the more severe condition of endophthalmitis, which included subjective ocular symptoms. In most cases, the initial ophthalmologic examination was performed within one week of the onset of candidiasis with a diagnosis of ocular candidiasis, but in three cases, the findings became apparent only after a second examination within 7–14 days after onset of candidiasis. The independent risk factor extracted for the development of ocular candidiasis was the isolation of C. albicans (OR, 4.85; 95% CI, 1.58–14.90), unremoved CVC (OR, 10.40; 95% CI, 1.74–62.16), and a high βDG value (>108.2 pg/mL) (HR, 2.83; 95% CI = 1.24–6.27). Continuous ophthalmologic examination is recommended in cases of candidemia with the above risk factors with an initial examination within 7 days of onset and a second examination 7–14 days after onset.

Risk factors and lethality associated with Candidemia in severe COVID-19 patients.

Candidemia remained important in the intensive care units (ICU) during the COVID-19 pandemic. This study aimed to investigate the clinical and laboratory data on candidemia in COVID-19 patients. The baseline characteristics, as well as laboratory and clinical findings of candidemia and non-candidemia patients, were compared. Candidemia was defined as the isolation of Candida spp. from blood cultures. The isolates were identified by VITEK® 2 (bioMérieux, France) commercial method. Antifungal susceptibility was assessed using the E-test method. Univariate and multiple binary logistic regression analyses were performed to compare the variables. In total, 126 patients with the COVID-19 disease were included. Candidemia was diagnosed in 44 (35%) of the patients. The number of patients with diabetes mellitus and chronic renal failure was higher in the candidemia group. In the candidemia group, the duration of ICU stay of patients, the 30-day mortality rate, mechanical ventilation therapy, and systemic corticosteroids (Prednisone) usage were significantly higher in candidemia patients. Moreover, the median white blood cell, neutrophils, and lactate dehydrogenase were higher in the candidemia group.Univariate and multiple binary logistic regression analyses were performed to compare the variables. Isolated species were identified as Candida albicans (n=12, 41%), Candida parapsilosis (n=7, 24%), Candida glabrata (n=6, 21%), Candida tropicalis (n=3, 10%), and Candida dublinensis (n=1, 3%). In total, three isolates of six C. glabrata species had dose-dependent sensitivity to fluconazole, and one C. parapsilosis was determined to be resistant. The COVID-19 patients who are admitted to ICU have many risk factors associated with candidemia. The most common risk factors for the development of candidemia were mechanical ventilation, diabetes mellitus, neutrophilia, and low hemoglobin level. The most frequently isolated species was C. albicans. Moreover, caspofungin was found to be the most effective drug in vitro. No significant resistance pattern was detected against the isolated species. It should be noted that risk-stratified antifungal prophylaxis in the ICU is possible.

Candidemia in patients with head and neck cancer: mortality and a novel risk factor.

Candidemia is a bloodstream infection (BSI) by Candida spp. and is associated with high mortality. However, there have been few reports about BSI in head and neck cancer (HNC). We aimed to evaluate the impact of candidemia in patients with HNC and compared it with bacteremia. A multicenter retrospective study. We retrospectively analyzed 83 BSI episodes in HNC (2011 to 2020) and divided them into the candidemia and bacteremia groups. We then compared the survival rate and risk factors for candidemia between the groups. The overall cumulative incidence (risk) of candidemia in BSI was 12 out of 83 episodes (14.5%). The 1-year mortality for the bacteremia and candidemia groups was 33.3% and 58.3%, respectively (log-rank p = 0.041). Broad-spectrum antibiotics (odds ratio [OR]: 29.5; 95% confidence interval [CI], 2.49-350), mucositis (OR 11.0; 95% CI, 1.52-80.1), and malignant wounds (OR 79.5; 95% CI 1.33-4737) were significant risk factors for candidemia in HNC. Candidemia causes high mortality in patients with HNC. To our knowledge, malignant wounds have not been previously reported as a risk factor for candidemia. For early diagnosis and treatment of candidemia, risk factors should be considered, and antifungal therapy started earlier.

A quality improvement initiative to improve the appropriateness of candidemia management by the implementation of a comprehensive candidemia care bundle at a tertiary care hospital in South India: Results of a quasi-experimental study.

Management of candidemia in developing countries like India encounters laxity in appropriate clinical management and challenges in terms of healthcare capacity, despite its association with high morbidity and mortality. Our study aims to evaluate the impact of a comprehensive candidemia care bundle implementation on appropriateness of therapy and major clinical outcomes.The single-center, quasi-experimental study conducted at a south Indian tertiary care center included adult patients diagnosed with candidemia. Following a retrospective review of candidemia patients of the pre-implementation period (January 2013–December 2015), the hospital antifungal stewardship team instituted a clinical pharmacist driven comprehensive candidemia care bundle for candidemia patients during the post-implementation period (October 2017–2019) and its impact on appropriateness of antifungal prescriptions and inpatient mortality was evaluated.The study included 175 patients with candidemia, comprising of 103 patients in the pre-implementation period and 72 patients in the post-implementation period. Appropriateness of antifungal prescriptions rose to 65% during post-implementation period from 30% observed in pre-implementation phase (P = .0005). The inhospital mortality rate reduced from 40% in the pre-implementation phase to 36% in the post-implementation phase, recording a 10% reduction over 2 years post-implementation (P = .26). No significant difference was observed in terms length of stay (P = .17).Our study demonstrates the successful implementation of an antifungal stewardship led comprehensive care bundle in a low middle income countries setting. The results of our study will have profound implications in improving the appropriateness of management of candidemia and feasibility of scaling up to wider settings could be explored.

Screening for Ocular Candidiasis Among Patients With Candidemia: Is It Time to Change Practice?

Ocular candidiasis (OC) complicates approximately 10% of candidemia and carries potentially severe morbidity. There are conflicting recommendations about the need for routine funduscopic examinations of candidemic patients. Indirect funduscopy is accurate and safe in diagnosing OC, and positive findings change recommended treatment. However, conclusive evidence that treatment changes improve outcomes is lacking. Bringing perspectives as infectious diseases physicians and ophthalmologists, we review controversies about OC and endorse routine screening during candidemia. We acknowledge difficulties in obtaining inpatient ophthalmologic consults and recommend studies to evaluate digital fundus photography and teleophthalmology as an alternative to funduscopic examinations by ophthalmologists in asymptomatic patients.

The Incidence of Ocular Complications in Candidemic Patients and Implications for the Practice of Routine 
Eye Exams

BackgroundOcular candidiasis is a known complication of candidemia. Given the poor ocular penetration of echinocandins, there is some concern that the increasing use of echinocandins may portend an increased incidence of ophthalmic complications. We examined the changing trends in antifungal prescribing patterns and the incidence of ophthalmic complications after candidemia.MethodsPatients with blood cultures positive for Candida species between January 2014 and June 2020 who underwent screening fundoscopic examination by an ophthalmologist were analyzed. The χ2 analysis was used to compare antifungal prescriptions and ocular exam findings before and after 2016. Trend analysis was also performed to assess temporal changes in prescribing practices and eye exam findings.ResultsThere were 226 candidemia cases during the study period, 129 (57.1%) of which underwent screening eye exams. From 2014 to 2015, 24 of 37 (64.5%) patients received eye-penetrating antifungals compared to 36 of 92 (39.1%) from 2016 to 2020 (P = .008). Overall, 30 of 129 (23.3%) patients had abnormal eye exams with the prevalence of abnormal findings being 7 of 37 (18.9%) before 2016 compared to 23 of 92 (25%, P = .46) thereafter. A trend analysis revealed an increase in abnormal eye findings over the study period (P = .008). Of the 30 patients who had abnormal eye exams, 9 (30%) had a change in systemic antifungal therapy from echinocandins to eye-penetrating antifungals. Echinocandin use was associated with abnormal eye findings. ConclusionsPrescription of eye-penetrating antifungals for candidemia has trended down since 2016. This was associated with a concomitant increase in abnormal findings on screening fundoscopy. Abnormal eye exams were not uncommon throughout our study period.

Incidence of Candidemia Is Higher in COVID-19 versus Non-COVID-19 Patients, but Not Driven by Intrahospital Transmission.

There is scarce information on the actual incidence of candidemia in COVID-19 patients. In addition, comparative studies of candidemia episodes in COVID-19 and non-COVID-19 patients are heterogeneous. Here, we assessed the real incidence, epidemiology, and etiology of candidemia in COVID-19 patients, and compared them with those without COVID-19 (2020 vs. 2019 and 2020, respectively). We also genotyped all C. albicans, C. parapsilosis, and C. tropicalis isolates (n = 88), causing candidemia in both groups, providing for the first time a genotypic characterization of isolates gathered in patients with either COVID-19 or non-COVID-19. Incidence of candidemia was higher in patients with COVID-19 than non-COVID-19 (4.73 vs. 0.85 per 1000 admissions; 3.22 vs. 1.14 per 10,000 days of stay). No substantial intergroup differences were found, including mortality. Genotyping proved the presence of a low number of patients involved in clusters, allowing us to rule out rampant patient-to-patient Candida transmission. The four patients, involved in two clusters, had catheter-related candidemia diagnosed in the first COVID-19 wave, which demonstrates breaches in catheter management policies occurring in such an overwhelming situation. In conclusion, the incidence of candidemia in patients with COVID-19 is significantly higher than in those without COVID-19. However, genotyping shows that this increase is not due to uncontrolled intrahospital transmission.

Retrospective Evaluation of Risk Factors for Invasive Candida Infections in a Medical Intensive Care Unit.

We aimed to detect the risk factors for invasive candida infections by evaluating the fungal strains cultivated from samples taken in a medical intensive care unit (ICU). We investigated fungal growths between January 1, 2016, and December 1, 2018, retrospectively. All reported fungal growths and demographic characteristics, clinical features, treatments and outcomes of the patients with fungal growths were recorded. Fungal growths were reported from 384 different samples obtained from 179 ICU patients. The most common strain was determined to be C. albicans (47.9%).The incidence of non-albicansCandida strains was increased over the years (2016 - 44%, 2017 - 52.5%, 2018 - 49%), most significantly C. glabrata (7.7% to 14.6%). The most common strain was C. parapsilosis (57.9%) in patients with candidemia, and infection was more severe among them. Fluconazole resistance was rare. When patients with and without fungal growth were compared, a significant difference was found between groups in terms of age, acute physiology and chronic health evaluation II (APACHE II) score, length of ICU and hospital stay, ICU and hospital mortality (p<0.001, p =0.011, p<0.001, p=0.031, p =0.016). Candida score was significantly higher in candidemic patients (3.0 vs 0.0 p<0.001). Among fungal growths in samples from critically ill patients, the incidence of non-albicans Candida strains was gradually increasing. Older age, higher APACHE II score, and longer hospital and ICU stay were associated with fungal growths.

Development of a Simple DNA Extraction Method and Candida Pan Loop-Mediated Isothermal Amplification Assay for Diagnosis of Candidemia.

To reduce the morbidity and mortality of candidemia patients through rapid treatment, the development of a simple, rapid molecular diagnostic method that is based on nucleic acid extraction and is superior to conventional methods for detecting Candida in the blood is necessary. We developed a multiplex Candida Pan/internal control (IC) loop-mediated isothermal amplification (LAMP) assay and a simple DNA extraction boiling protocol using Chelex-100 that could extract yeast DNA in blood within 20 min. The Chelex-100/boiling method for DNA extraction showed comparable efficiency to that of the commercial QIAamp UCP Pathogen Mini Kit using Candida albicans qPCR. In addition, the Candida Pan/IC LAMP assay showed superior sensitivity to that of general Candida Pan and species qPCRs against clinical DNA samples extracted with the QIAamp UCP Pathogen Mini Kit and Chelex-100/boiling method. The Candida Pan/IC LAMP assay followed by Chelex-100/boiling-mediated DNA extraction showed high sensitivity (100%) and specificity (100%) against clinical samples infected with Candida. These results suggest that the Candida Pan/IC LAMP assay could be used as a rapid molecular diagnostic test for candidemia.

Epidemiology and Outcome of Candidemia in ICU, Mashhad, a 6-Year Multi-Center Study

Background and aim: candidemia is a state that usually happens in immunocompromised patients. Thus it is more prevalent in ICU patients. This status brings mortality and morbidity; however, the outcome is various in different ICU care settings. The aim of this study is to assess epidemiology of outcome of candidemia in ICU in Mashhad during a 6-year period. Method: in a cross-sectional study between 2012 and 2018 in different ICU centers affiliating with Mashhad University of Medical Sciences, data of candidemia patients were extracted from hospital information system. These data were demographic, past medical history, result of the culture, and antifungal treatment. Result: totally, 55 patients (22 men and 33 women) were included in the study. The mean age of the patients was 45.9±1.9 years. Furthermore, the mean duration of hospitalization and the mean duration of ICU care were 43 and 37 days, respectively. Five patients had a history of immunosuppressive treatment and four patients were prescribed antifungal treatment in their past medical history (all with fluconazole and none with Itraconazole). Eighteen patients received caspofungin, eleven Amphotericin B treatment, and two fluconazole with no significant difference in outcome of the patients regarding antifungal type. In case of coincident antibiotic treatment, Carbapenems were prescribed in 43 patients, Glycopeptides in 48 patients, 25 patients had Cephalosporin treatment, and 13 patients had Fluoroquinolone treatment with no significant difference regarding the antibiotic type. Conclusion: The mortality percent of candidemia in ICU was 69.1 within mean time of 37 days. Furthermore, there was no significant difference in outcome of the patients regarding using Caspofungin or Amphotericin. Timely initiation of antifungal regarding to the culture result may bring better outcomes.

Characteristics and Incidence of Candidemia in Hospitalized Coronavirus 2019 (COVID-19) Patients

Management of Coronavirus 2019 (COVID-19) with high-dose corticosteroids and interleukin-2 inhibitors has potential benefits, but is associated with immunosuppression and risk of secondary infections. This single-center, retrospective, cohort study evaluated the incidence of candidemia and associated risk factors in hospitalized COVID-19 patients. Twenty-three patients developed candidemia and were matched to 77 non-candidemic COVID-19 controls. The primary outcome was incidence of candidemia. Secondary outcomes included time to first positive fungal blood culture and antifungal initiation, antifungal treatment duration, fungal isolate identification, candidemia risk factors, in-hospital mortality, Intensive Care Unit (ICU) and hospital Length of Stay (LOS) and mechanical ventilation duration. Candidemia incidence was 0.7% (23/3101). Mean time from hospital admission to first positive fungal blood culture was 26.2±14.3 days, with systemic antifungal therapy initiated in 19 patients; seven started antifungal therapy the same day cultures were drawn and 12 within 24 h of preliminary culture results positive for yeast. The remaining four patients expired prior to culture results. Mean duration of antifungal therapy was 9.7±6.6 days. Candida albicans was the most frequently identified isolate. Candidemic patients were more likely to be admitted to the ICU, receive high-dose corticosteroid, renal replacement therapy, mechanical ventilation, central line, tocilizumab and broad-spectrum antimicrobials. They also had higher mortality (82% vs. 22%, p<0.0001) and longer ICU LOS (25 vs 0 days, p<0.0001), hospital LOS (39 vs 10 days, p<0.0001) and mechanical ventilation days (19 vs 0 days, p<0.0001). Candidemia occurrence is rare in COVID-19 patients, but can result in worse clinical outcomes such as high mortality and longer hospital stay. Clinicians should attempt to minimize risk factors and perform routine workup for systemic candida infections in COVID-19 patients in the ICU, on mechanical ventilation and with multiple risk factors.

Characteristics and Outcomes of Candidemia in Patients with Durable Left Ventricular Assist Device Support.

There are limited data on the characteristics and clinical course of fungal infections in patients on durable left ventricular assist device (LVAD) support. We sought to further characterize the epidemiology and outcomes of LVAD patients with fungemia. We performed a retrospective review of patients receiving LVAD support from January 2012 through June 2020 at a large academic institution. Among 336 patients on LVAD support, five (1.4%) were diagnosed with fungemia during the study period. Three patients had diabetes with mean hemoglobin A1c 7.1% (R 6.6, 7.4). Fever and leukocytosis (mean white blood count 17.0 thousand/µL [R 12.5, 29.9]) were the most common symptoms. Fungemia was diagnosed early after LVAD implantation (mean 14.4 support days [R 2, 19]). All patients were infected with Candida species, and four isolates were susceptible to fluconazole. Central nervous system outcomes included an ischemic stroke, subarachnoid hemorrhage, and malignant hemorrhagic stroke. Two patients were successfully transplanted, and two patients on destination therapy remain on suppressive fluconazole. In conclusion, fungemia is a rare and severe complication in LVAD patients occurring early postimplant.

306. Association of Antibiotic Use and Development Secondary Infection from Clostridium difficile, Multidrug-Resistant Bacteria, and Candida in Hospitalized Patients with History of COVID-19

BackgroundThere is increasing evidence that patients hospitalized with COVID-19 receive unnecessary antibiotics. The consequences of antibiotic overuse as it relates to antimicrobial resistance and development of secondary infections remains uncertain. The objective of this study is to compare antibiotic prescription patterns in patients with a history of COVID-19 to those without a history of COVID-19 and determine if there are differences in the frequency of secondary infections from Clostridioides difficile (C. difficile), multidrug-resistant (MDR) bacteria, and candida infections. MethodsThis study is a single-center, retrospective cohort study of 18,757 adults hospitalized during the COVID-19 pandemic from March 1, 2020 to March 31, 2021. Patients were stratified as COVID-19 positive, throughout all hospitalizations subsequent to the date of initial positivity, or COVID-19 negative. Differences in antibiotic practice patterns between the two groups were quantified using days of therapy per 1000 patient days (DOT/1000 PD). The frequency of C. difficile infection, MDR-bacteria, and candida infections were assessed among the two groups. ResultsDuring the 12-month study period, on average, the COVID-19 positive group received 21.81% more antibiotics than COVID-19 negative patients, with up to 56.15% increase seen in the first month of the pandemic (Table 1, Figure 1) The COVID-19 positive group had an increased frequency of Candidemia (0.73% versus 0.18%, p< .00001) and decreased isolation of ESBL organisms (1.17% versus 1.87%, p< 0.01416) compared to the COVID-19 negative group. There were no significant differences in frequency of C. difficile infection, isolation of other MDR-organisms, or Candida auris between the two groups. (Table 2)Table 1. Antibiotic days of therapy in COVID-19 positive and COVID-19 negative patients. Figure 1. Antibiotic days of therapy in total cohort, COVID-19 positive, and COVID-19 negative patients. Table 2. Frequency of secondary infections in COVID-19 positive and COVID-19 negative patients ConclusionPatients with a history of COVID-19 infection received an average of 21.81% more antibiotics, have higher rates of candidemia, but lower rates of ESBL infection than those without a history of COVID-19 infection. The potential increase in antibiotic exposure could account for the increase in candidemia in patients with a history of COVID-19. Future studies include investigating the decrease in ESBL infections seen, perhaps due to receipt of broad antibiotics in COVID-19 patients that target ESBL bacteria. Disclosures Shruti K. Gohil, MD, MPH, Medline (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnycke (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Susan S. Huang, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)

988. Is There Value of Infectious Diseases Consultation in Candidemia? A Single Center Retrospective Review From 2016-2019

BackgroundCandidemia is the second most common cause of healthcare-associated bloodstream infections in the US with mortality of approximately 25%. Studies demonstrate lower candidemia mortality with infectious diseases consultation (IDC). We evaluated effects of IDC on mortality and guideline-adherence at our institution to determine if mandatory IDC was warranted.MethodsWe retrospectively reviewed adults hospitalized with candidemia (≥ 1 blood culture positive for Candida) between 1/1/2016-12/31/2019. Exclusion criteria included age < 19 years, polymicrobial blood culture, or death or hospice within 48 hours. Primary outcome was all-cause 30-day mortality. Secondary outcomes included guideline-adherence and treatment choice. Guideline-adherence was assessed with a modified EQUAL Candida score (Table 1). Descriptive statistics were performed.Table 1. Original vs Modified EQUAL Candida Score Abbreviations. CVC: central venous catheter, BCx: blood cultureResultsOf 187 patients reviewed, 92 episodes of candidemia with 94 species of Candida were included. Patient characteristics are shown in Table 2. Central venous catheters (CVCs) were present in 66 (71.7%) patients and were the most common infection source (N=38 [41.3%]) followed by intra-abdominal (N=23 [25%]). The most isolated species were Candida glabrata (40/94 [42.6%]) and C. albicans/dublienensis (35/94 [37.2%]). 30-day mortality was 21.7%. IDC was performed in 84 (91.3%) cases. Outcomes are in Table 3. Mortality was not different between IDC vs no IDC (18 [21.4%] vs 2 [25%]); other comparisons were numerically different but not significant: repeat blood culture (98.8% vs 87.5%), echocardiography (70.2% vs 50%), CVC removal (91.7% vs 83.3%), and initial treatment echinocandin (67.9% vs 50%). All patients received antifungal therapy. IDC resulted in more ophthalmology consultations (77.4% vs 12.5%, p< 0.01). Mean modified EQUAL Candida score was higher with IDC (17.4 vs 13.9, p< 0.01).Table 2. Patient Characteristics Abbreviations. TPN: total parenteral nutrition, ICU: intensive care unit, AIDS: acquired immunodeficiency syndromeTable 3. Outcomes Abbreviations. NS: non-significant, CVC: central venous catheterConclusionIDC was common in candidemic patients and not associated with significant differences in outcomes. Current antimicrobial stewardship and consultation practices at our center do not warrant mandated IDC for candidemia.Disclosures Trevor C. Van Schooneveld, MD, FACP, BioFire (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Insmed (Individual(s) Involved: Self): Scientific Research Study Investigator; Merck (Individual(s) Involved: Self): Scientific Research Study Investigator; Rebiotix (Individual(s) Involved: Self): Scientific Research Study Investigator

291. Epidemiology of Candidemia Rates during COVID-19 and Comparison of Outcomes in Candidemia Between COVID-19 and Non-COVID-19 Patients

BackgroundFungemia is associated with high rates of morbidity, mortality and increase in length of hospital stay. Several studies have recognized increased rates of candidemia since the COVID-19 pandemic. MethodsA retrospective cohort study was conducted at a tertiary healthcare system in Detroit, Michigan to evaluate the impact of the COVID-19 pandemic on incidence of candidemia. The “pre COVID-19” timeframe was defined as January – May 2019 while the “during COVID-19” timeframe was January – May 2020. To compare incidence and patient characteristics between cohorts, t-tests and chi-square analysis was used. Additional sub-analysis was performed in candidemia patients during COVID-19 timeframe comparing outcomes of patients based on COVID-19 status. A Fisher Exact and Satterthwaite Test were used for analysis of categorical and continuous variables, respectively. ResultsOverall, 46 cases of candidemia were identified in both the pre COVID-19 and during COVID-19 periods. Pre COVID-19, the average number of cases was 3.0 ± 1.2 per month. The incidence more than doubled during COVID-19 to 6.2 ± 4.2 cases per month (p = 0.14) (Figure 1). No significant differences in patient demographics were detected between cohorts, however, patients in the COVID-19 cohort had higher rates of corticosteroid use, mechanical ventilation and vasopressors (Table 1). In the 2020 period, 31 patients developed candidemia and 12 (38.7%) patients tested SARS-CoV-2 positive. On average, COVID-19 patients developed candidemia 12.1 days from admission, compared to 17.8 days in the COVID-19 negative cohort (p = 0.340). Additionally, COVID-19 patients with candidemia coinfection were significantly more likely to expire; 83.3% (n=10) COVID-19 patients expired compared to 36.8 (n=7) in the COVID-19 negative cohort (p = 0.025) (Table 2). Figure 1. Incidence of Candidemia in the Pre-COVID-19 (January 2019 – May 2019) and During COVID-19 (January 2020-May 2020) periods Table 1. Characteristics of Candidemia patients in the pre-COVID (January 2019-May 2019) and during-COVID periods (January 2020-May 2020) Table 2. Characteristics of Candidemia patients in the SARS-COV-2 negative and SARS-COV-2 positive cohorts from January 2020-May 2020 ConclusionThe prevalence of fungemia markedly increased during the COVID-19 surge. Increased use of corticosteroids and broad spectrum antimicrobials, prolonged use of central venous catheters and prolonged ICU length of stay likely contributed to this increase. Patients who developed candidemia co-infection with COVID-19 were found to have poorer outcomes as compared to those who were SARS-CoV-2 negative or untested. Disclosures All Authors: No reported disclosures

316. Use of (1-3)-β-D-Glucan Assay for Diagnosis of Candidemia in Patients Hospitalized with SARS-CoV-2 Infection

BackgroundCandidemia is a rare but serious complication of SARS-CoV-2 hospitalization. Combining non-culture and culture-based diagnostics allows earlier identification of candidemia. Given higher reported incidence during COVID-19 surges, we investigated the use of (1-3)-β-D-glucan (BDG) assay at our institution in those who did and did not develop candidemia.MethodsRetrospective study of adults admitted to The Mount Sinai Hospital between March 15-June 30 2020 for SARS-CoV-2 infection, with either ≥1 BDG assay or positive fungal blood culture. Data was collected with the electronic medical record and Vigilanz. A BDG value ≥ 80 was used as a positivity cutoff. Differences in mortality were assessed by univariate logistic regression using R (version 4.0.0). Statistical significance was measured by P value < .05.ResultsThere were 75 patients with ≥1 BDG assay resulted and 28 patients with candidemia, with an overlap of 9 between the cohorts. Among the 75 who had BDG assay, 23 resulted positive and 52 negative. Nine of 75 patients developed candidemia. Of the 23 with a positive assay, 5 developed candidemia and 18 did not. Seventeen of the 18 had blood cultures drawn within 7 days +/- of BDG assay. Four patients with candidemia had persistently negative BDG; 2 had cultures collected within 7 days +/- of BDG assay. With a cut-off of >80, the negative predictive value (NPV) was 0.92. When the cut-off increased to >200, NPV was 0.97 and positive predictive value (PPV) was 0.42. Average antifungal days in patients with negative BDG was 2.6 vs. 4.2 in those with a positive. Mortality was 74% in those with ≥1 positive BDG vs. 50% in those with persistently negative BDGs. There was a trend towards higher odds of death in those with positive BDG (OR = 2.83, 95% CI: 1.00-8.90, p < 0.06).ConclusionThere was substantial use of BDG to diagnose candidemia at the peak of the COVID-19 pandemic. Blood cultures were often drawn at time of suspected candidemia but not routinely. When cultures and BDG were drawn together, BDG had a high NPV but low PPV. High NPV of BDG likely contributed to discontinuation of empiric antifungals. The candidemic COVID-19 patients had high mortality, so further investigation of algorithms for the timely diagnosis of candidemia are needed to optimize use of antifungals while improving mortality rates. Disclosures All Authors: No reported disclosures

Modified Pitt bacteremia score for predicting mortality in patients with candidaemia: A multicentre seven-year retrospective study conducted in Japan.

BackgroundSeveral severity indexes have been reported for critically ill patients. The Pitt bacteremia score (PBS) is commonly used to predict the risk of mortality in patients with bacteraemia.ObjectivesTo develop a scoring system for predicting mortality in candidaemia patients.MethodsMedical records at five Japanese tertiary hospitals were reviewed. Factors associated with mortality were analysed using logistic regression modelling. The discriminatory power of scoring models was evaluated by assessing the area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI) and integrated discrimination improvement (IDI).ResultsIn total, 422 candidaemia patients were included. Higher PBS, dialysis and retainment of central venous catheter were independent risk factors for all‐cause 30‐day mortality. However, among the five PBS components, fever was not associated with mortality; therefore, we developed a modified version of the PBS (mPBS) by replacing fever with dialysis. AUC for PBS and mPBS were 0.74 (95% confidence interval [CI]: 0.68–0.80) and 0.76 (95% CI: 0.71–0.82), respectively. The increase in predictive ability of mPBS for 30‐day mortality was statistically significant as assessed by NRI (0.24, 95% CI: 0.01–0.46, p = .04) and IRI (0.04, 95% CI: 0.02–0.06, p = .0008). When patients were stratified by mPBS into low (scores 0–3), moderate (4–7) and high risk (≥8), there were significant differences among the survival curves (p < .0001, log‐rank test), and 30‐day mortality rates were 13.8% (40/290), 36.8% (28/76) and 69.4% (34/49), respectively.ConclusionsmPBS can be a useful tool for predicting mortality in candidaemia patients.