Factors Associated with Severe Presentation and Mortality in ICU-Acquired Candidaemia: A 20-Year Single-Centre Retrospective Cohort

Background/Objectives: The risk factors for the severe presentation (severe sepsis or septic shock) are not fully understood in ICU-acquired candidaemia. The primary objective of this study was to evaluate risk factors for the severe presentation (severe sepsis or septic shock) and mortality in patients with candidaemia in ICUs. Secondarily, we compared 28-day mortality between patients treated with fluconazole and those treated with an echinocandin. Methods: A retrospective cohort design was employed in a single-center ICU setting, encompassing a study period from 2004 to 2023. Adult patients who had Candida growth in blood cultures taken 48 h after admission to the ICU were included in the study. Risk factors for the severe presentation (severe sepsis and septic shock) and mortality were evaluated in the 141 patients included in the study. The treatment comparison between fluconazole and echinocandins was performed in 113 patients (with 48-h rules) and 125 patients (without 48-h rules). Results: Among 141 patients, 77 (54.6%) died within 28 days. We found that in the multivariable model, APACHE II score, TPN use, steroid use, and concomitant bacteremia were associated with severe presentation. Each one-point increase in APACHE II score was associated with higher risk of severe presentation (adjusted OR 1.146, 95% CI 1.056–1.242; p = 0.001). TPN use and steroid use were also associated with higher risk (adjusted OR 3.297, 95% CI 1.265–8.590; p = 0.015; and adjusted OR 6.067, 95% CI 1.486–24.768; p = 0.012, respectively). Concomitant bacteraemia was associated with lower odds of severe presentation. Patients with severe presentation (severe sepsis or septic shock) had a higher risk of 28-day mortality than patients with sepsis (adjusted OR 8.06, 95% CI 2.60–25.00; p < 0.001). In the primary cohort (n = 113; overlap weights), 28-day mortality was 49.2% with fluconazole and 52.1% with echinocandin (OR 1.12, 95% CI 0.37–3.45; p = 0.838). Results were consistent in the 125-patient cohort without the 48-h rule (OR 1.40, 95% CI 0.51–3.81; p = 0.508). Conclusions: Each one-point increase in APACHE II score on admission, TPN use, and steroid use was associated with severe presentation in ICU-acquired candidaemia. The severity of the clinical presentation at the onset of candidaemia (presence of severe sepsis or septic shock) was strongly associated with 28-day mortality. No difference in 28-day mortality was detected between fluconazole and echinocandin treatment, but this comparison was imprecise and cannot inform antifungal choice.