Prognostic factors of Candida spp. bloodstream infection in adults: A nine-year retrospective cohort study across tertiary hospitals in Brazil and Spain

BACKGROUND: Mortality rates among adults with candidemia vary widely in different geographical settings. Studies directly comparing epidemiology and clinical practices between countries are scarce and could bring insights into improving clinical outcomes. METHODS: Retrospective cohort including adults with candidemia diagnosed in five tertiary hospitals from Brazil and Spain between 2010-2018. Adequate therapeutic management included appropriate antifungal therapy and central-venous-catheter (CVC) removal within 48 h of fungemia. Primary endpoints were mortality rates at 14 and 30 days. Secondary endpoints were prognostic factors associated with 30-day mortality. FINDINGS: Overall, 720 patients were included, being 323 from Spain. Spanish patients received echinocandins more often (52·5% vs. 39·3%, p = 0.001), initiated antifungals earlier [2 (0-7) vs. 2 days (0-16), p<0.001], and had faster CVC-removal [1 (0-42) vs. 2 days (0-38), p = 0.012]. Mortality was higher among Brazilians at 14 days (35·8% vs. 20·1%, p<0.001), and at 30 days (51·9% vs. 31·6%, p < 0.001). Factors associated with mortality included: age [OR 1·02, 95%CI (1·008-1·032), p = 0·001], neutropenia [OR 3·24, 95%CI (1·594-6·585), p = 0·001], chronic pulmonary disease [OR 2·26, 95%CI (1·495-3·436), p < 0·001], corticosteroids [OR 1·45, 95%CI (1·018-2·079), p = 0·039], Pitt-Score>1 [OR 2·56, 95%CI (1·776-3·690), p < 0·001], and inadequate therapeutic management [OR 2·84, 95%CI (1·685-4·800), p < 0·001]. Being from Spain [OR 0·51, 95%CI (0·359-0·726), p < 0·001] and C. parapsilosis [OR 0·36, 95%CI (0·233-0·568), p < 0·001] were protective. INTERPRETATION: Higher mortality rates were observed in Brazil. Factors associated with 30-day mortality included mainly epidemiological characteristics and inadequate therapeutic management. Thus, effective and prompt antifungals combined with CVC-removal still need to be emphasized in order to improve the prognosis of adults with candidemia. FUNDING: Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP 2017/02203-7); CAPES Foundation (PDSE 88881.187981/2018-01).