Candida krusei fungaemia: antifungal susceptibility and clinical presentation of an uncommon entity during 15 years in a single general hospital.

Background: Candida krusei fungaemia is an uncommon entity described in immunocompromised patients previously exposed to azole agents.
Methods: From 1988 to 2003, 13 episodes of C. krusei fungaemia (2.3% of all fungaemias) were detected in our institution and compared with 39 Candida albicans controls. Susceptibility testing was carried out with the modified microdilution method according to NCCLS recommendations.
Results: Underlying conditions were: HIV infection (4), haematological malignancies (4), organ transplantation (2), abdominal surgery (2) and lactose intolerance (1). Nine patients (69%) were not neutropenic. In comparison with C. albicans, patients with C. krusei infection had more commonly received antifungal agents (54% versus 15%, P = 0.006), had a haematological disease (31% versus 3%, P = 0.03), or a transplant (15% versus 3%, P = 0.08), were on corticosteroids (47% versus 13%, P = 0.01) and were neutropenic (31% versus 0%, P < 0.001). Patients with C. albicans had more surgical interventions (41% versus 15%, P = 0.09) and bladder catheters (61% versus 31%, P = 0.05). The most common origin for C. albicans was a catheter (41% versus 0%; P = 0.006) whereas for C. krusei the most common origin was unknown (69% versus 20%; P = 0.001). C. krusei presented more commonly with skin lesions in neutropenic patients (23% versus 5%; P = 0.05). Multivariate analysis of these differential characteristics showed that the only factor that independently predicted the presence of C. krusei fungaemia was the administration of antifungal agents before the fungaemia (RR: 6.4; P=0.009; 95%CI 1.6-25.99). Overall mortality of C. krusei fungaemia was 38% (C. albicans 49%). Except for voriconazole (MIC90 0.125 mg/L), azoles and 5-flucytosine had poor activity against C. krusei, whereas amphotericin (MIC90 1 mg/L) and LY-303366 (MIC90 0.06 mg/L) showed good activity.
Conclusion: C. krusei fungaemia incidence remains low despite widespread use of azoles. It may occur outside the setting of cancer patients with previous antifungal use. The presence of skin lesions should be a warning sign.