Skip to main content Accessibility help

Prospective Observational Study of Candidemia in São Paulo, Brazil: Incidence Rate, Epidemiology, and Predictors of Mortality

  • Arnaldo L. Colombo (a1), Thaís Guimarães (a1) (a2), Ligia R. B. F. Silva (a1) (a3), Leila Paula de Almeida Monfardini (a1), Anna Karenine B. Cunha (a1) (a2), Patrícia Rady (a1), Thelma Alves (a1) and Robert C. Rosas (a1) (a4)...



Studies conducted in tertiary care hospitals of different European countries and the United States have shown incidence rates of candidemia ranging from 0.17 to 0.76 and 0.28 to 0.96 per 1,000 admissions, respectively. So far, only 1 study has evaluated the incidence rates of candidemia in tertiary care hospitals in Latin American countries.


To evaluate the epidemiology of candidemia in 4 tertiary care hospitals in São Paulo, Brazil.


Multicenter, laboratory-based surveillance of candidemia.


A total of 7,038 episodes of bloodstream infection were identified, and Candida species accounted for 282 cases (4%). The incidence rate of candidemia was 1.66 candidemic episodes per 1,000 hospital admissions. Candida albicans was the most frequently isolated Candida species in all hospitals, but Candida species other than C. albicans accounted for 62% of isolates, including predominantly Candida parapsilosis and Candida tropicalis. Azole resistance was restricted to only 2% of all Candida isolates (1 isolate of Candida glabrata and 4 isolates of Candida rugosa). Candidemia was mostly documented in surgical patients with long durations of hospital stay. The crude mortality rate was 61%, and advanced age and high Acute Physiology and Chronic Health Evaluation II score were both conditions independently associated with risk of death.


We observed in our series a higher incidence rate of candidemia than that reported in European countries and the United States. Advanced age and a high Acute Physiology and Chronic Health Evaluation II score were factors associated with a higher probability of death in candidemic patients. Fluconazole-resistant Candida strains are still a rare finding in our case-based study of candidemia.


Corresponding author

Division of Infectious Diseases, R. Botucatu, 740 Vila Clementino, São Paulo SP, Brazil (


Hide All
1. Wisplinghoff, H, Bischoff, T, Tallent, SM, Seifert, H, Wenzel, RP, Edmond, MB. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis 2004;39:309317.
2. Wey, SB, Mori, M, Pfaller, MA, Woolson, RF, Wenzel, RP. Hospital-acquired candidemia: the attributable mortality and excess length of stay. Arch Intern Med 1988;148:26422645.
3. Gudlaugsson, O, Gillespie, S, Lee, K, et al. Attributable mortality of nosocomial candidemia, revisited. Clin Infect Dis 2003;37:11721177.
4. Abi-Said, D, Anaissie, E, Uzun, O, Raad, I, Pinzcowski, H, Vartivarian, S. The epidemiology of hematogenous candidiasis caused by different Candida species. Clin Infect Dis 1997;24:11221128.
5. Hope, W, Morton, A, Eisen, DP. Increase in prevalence of nosocomial non-Candida albicans candidaemia and the association of Candida krusei with fluconazole use. J Hosp Infect 2002;50:5665.
6. Trick, WE, Fridkin, SK, Edwards, Jr, Hajjeh, RA, Gaynes RP;National Nosocomial Infections Surveillance System Hospitals. Secular trend of hospital-acquired candidemia among intensive care unit patients in the United States during 1989-1999. Clin Infect Dis 2002;35:627630.
7. Garbino, J, Kolarova, L, Rohner, P, Lew, D, Pichna, P, Pittet, D. Secular trends of candidemia over 12 years in adult patients at a tertiary care hospital. Medicine (Baltimore) 2002;81:425433.
8. Colombo, AL, Nucci, M, Park, BJ, et al. Epidemiology of candidemia in Brazil: a nationwide sentinel surveillance of candidemia in eleven medical centers. J Clin Microbiol 2006;44:28162823.
9. Kurtzman, CP, Fall, JW. The Yeasts: A Taxonomic Study. New York, NY: Elsevier; 1998:.250357.
10. National Committee for Clinical Laboratory Standards (NCCLS). Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts;Approved Standard. Wayne, PA: NCCLS; 2002;22:151. Document M27-A2.
11. Nguyen, MH, Clancy, CJ, Yu, VL, et al. Do in vitro susceptibility data predict the microbiologic response to amphotericin B? Results of a prospective study of patients with Candida fungemia. J Infect Dis 1998;177:425430.
12. Odds, FC, Motyl, M, Andrade, R, et al. Interlaboratory comparison of results of susceptibility testing with caspofungin against Candida and Aspergillus species. J Clin Microbiol 2004;42:34753482.
13. Denning, DW. Echinocandin antifungal drugs. Lancet 2003;362:11421151.
14. Marchetti, O, Bile, J, Fluckiger, U, et al. Epidemiology of candidemia in Swiss tertiary care hospitals: secular trends, 1991-2000. The Fungal Infection Network of Switzerland (FUNGINOS). Clin Infect Dis 2004;38:311320.
15. Eggimann, P, Garbino, J, Pittet, D. Epidemiology of Candida species infections in critically ill non-immunosuppressed patients. Lancet Infect Dis 2003;3:685702.
16. Kao, AS, Brandt, ME, Pruitt, WR, et al. The epidemiology of candidemia in two United States cities: results of a population-based active surveillance. Clin Infect Dis 1999;29:11641170.
17. Diekema, DJ, Messer, SA, Brueggemann, AB, et al. Epidemiology of candidemia:3-year results from the emerging infections and the epidemiology of Iowa organisms study. J Clin Microbiol 2002;40:12981302.
18. Richet, H, Roux, P, Des Champs, C, Esnault, Y, Andremont, A. Candidemia in French hospitals: incidence rates and characteristics. The French Candidemia Study Group. Clin Microbiol Infect 2002;8:405412.
19. Viudes, A, Permán, J, Cánton, E, Úbeda, P, López-Ribot, JL, Gobernado, M. Candidemia at a tertiary-care hospital: epidemiology, treatment, clinical outcome and risk factors for death. Eur J Clin Microbiol Infect Dis 2002;21:767774.
20. Hajjeh, RA, Sofair, AN, Harrison, LH, et al. Incidence of bloodstream infections due to Candida species and in vitro susceptibilities of isolates collected from 1998 to 2000 in a population-based active surveillance program. J Clin Microbiol 2004;42:15191527.
21. Colombo, AL, Nucci, M, Salomao, R, et al. High rate of non-albicans candidemia in Brazilian tertiary care hospitals. Diagn Microbiol Infect Dis 1999;34:281286.
22. Cuenca-Estrella, M, Rodero, L, Garcia-Effron, G, Rodriguez-Tudela, JL. Antifungal susceptibilities of Candida spp. isolated from blood in Spain and Argentina, 1996-1999. J Antimicrob Chemother 2002;49:981987.
23. Silva, V, Diaz, MC, Febre, N. Invasive fungal infections in Chile: a multicenter study of fungal prevalence and susceptibility during a 1-year period. Med Mycoi 2004;42:333339.
24. Colombo, AL, Perfect, J, DiNubile, M, et al. Global distribution and outcomes for Candida species causing invasive candidiasis: results from an international randomized double-blind study of caspofungin versus amphotericin Bfor the treatment of invasive candidiasis. Eur J Clin Microbiol Infect Dis 2003;22:470474.
25. Colombo, AL, Melo, ASA, Rosas, RFC, et al. Outbreak of Candida rugosa candidemia: an emerging pathogen that may be refractory to amphotericin Btherapy. Diagn Microbiol Infect Dis 2003;46:253257.
26. Almirante, B, Rodriguez, D, Park, BJ, et al. Epidemiology and predictors of mortality in cases of Candida bloodstream infection: results from population-based surveillance, Barcelona, Spain, from 2002 to 2003. Barcelona Candidemia Project Study Group. J Clin Microbiol 2005;43:18291835.
27. Pappas, PG, Rex, JH, Lee, J, et al. A prospective observational study of candidemia: epidemiology, therapy, and influences on mortality in hospitalized adult and pediatric patients. NIAID Mycoses Study Group. Clin Infect Dis 2003;37:634643.
28. Tortorano, AM, Peman, J, Bernhardt, H, et al. Epidemiology of candidaemia in Europe: results of 28-month European Confederation of Medical Mycology (ECMM) hospital-based surveillance study. The ECMM Working Group on Candidaemia. Eur J Clin Microbiol Infect Dis 2004;23:317322.
29. Viscoli, C, Girmenia, C, Marinus, A, et al. Candidemia in cancer patients: a prospective, multicenter surveillance study by the Invasive Fungal Infection Group (IFIG) of the European Organization for Research and Treatment of Cancer (EORTC). Clin Infect Dis 1999;28:10711079.
30. Nucci, M, Colombo, AL, Silveira, F, et al. Risk factors for death in patients with candidemia. Infect Control Hosp Epidemiol 1998;19:846850.
31. Pfaller, MA, Diekema, DJ, Messer, SA, Boyken, L, Holiis, RJ, Jones, RN. In vitro susceptibilities of rare Candida bloodstream isolates to ravuconazole and three comparative antifungal agents. Diagn Microbiol Infect Dis 2004;48:101105.
32. Colombo, AL, Nakagawa, Z, Valdetaro, F, Branchini, ML, Russano, EJ, Nucci, M. Susceptibility profile of 200 bloodstream isolates of Candida spp. collected from Brazilian tertiary care hospitals. Med Mycol 2003;41:235239.
33. Antunes, AG, Pasqualotto, AC, Diaz, MC, d'Azevedo, PA, Severo, LC. Candidemia in a Brazilian tertiary care hospital: species distribution and antifungal susceptibility patterns. Rev Inst Med Trop Sao Paulo 2004;46:239241.


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed