Invasive Candidiasis Statistics

How common is invasive candidiasis?

Candidemia is one of the most common bloodstream infections in the United States.1 During 2013–2017, the average incidence was approximately 9 per 100,000 people; however, this number varies substantially by geographic location and patient population. CDC estimates that approximately 25,000 cases of candidemia occur nationwide each year.2

Candidemia is the most common form of invasive candidiasis, but it does not represent all forms of invasive candidiasis because the infection can occur in the heart, kidney, bones, and other internal organs without being detected in the blood. In fact, the true burden of invasive candidiasis might be twice as high as the estimate for candidemia.

Public health surveillance for candidemia in the United States

CDC performs surveillance for Candida bloodstream infections candidemia through the Emerging Infections Program (EIP), a network of 10 state health departments and their collaborators in local health departments, academic institutions, other federal agencies, public health and clinical laboratories, and healthcare facilities.

Active, population-based surveillance for candidemia is being conducted in 10 EIP sites: California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee (Table 1). CDC and its partners recruit laboratories and hospitals serving the counties under surveillance to submit reports of candidemia that develops in  patients living within the surveillance area.

Table 1: Description of Emerging Infections Program sites where candidemia surveillance is being conducted
Emerging Infections Program site Current candidemia surveillance ongoing since (year) Area under surveillance
California 2017 Alameda County
Colorado 2017 5 counties in Metropolitan Denver
Connecticut 2019 Statewide
Georgia 2008 8 counties in Metropolitan Atlanta
Maryland 2008 Baltimore City and County
Minnesota 2017 7 counties in Minneapolis-St. Paul Metropolitan area
New Mexico 2017 Bernalillo County
New York 2016 Monroe County
Oregon 2011 3 counties in Metropolitan Portland
Tennessee 2011 17 counties that incorporate Knoxville and surrounding areas

Through this program, CDC monitors epidemiologic trends in candidemia and performs species confirmation and antifungal susceptibility testing on all available Candida bloodstream isolates to meet these public health needs:

  • Track incidence of candidemia and estimate the total burden
  • Identify new risk factors for candidemia
  • Detect the emergence and spread of antifungal resistance
  • Understand and describe specific genetic mutations associated with resistance
  • Identify areas where candidemia prevention and intervention strategies can be focused

CDC also collects data on healthcare-associated infections, including central line-associated Candida infections through the National Healthcare Safety Network (NHSN), the largest healthcare-associated infection reporting system in the United States.

Candidemia trends in the United States

CDC’s active, population-based surveillance for candidemia has been ongoing since 2008. Candidemia incidence declined during 2009–2013 and then stabilized at approximately 9 cases per 100,000 population during 2013-2017 (Figure 1). However, there are notable differences by site. It is possible that the observed declines in candidemia during 2008–2013 are related to healthcare delivery improvements such as those involving catheter care and maintenance.Increases in incidence in certain surveillance areas may be due to increases in the number of candidemia case related to injection drug use, which has recently been re-emerging as a risk factor for candidemia.4,5

Download data tables for Figure 1, Figure 2, Figure 3, and Figure 4 Cdc-excel[XLS – 44 KB]

Figure 1: Candidemia incidence rates per 100,000 people by site and surveillance year, 2009–2017

Candidemia incidence rates per 100,000 person-years by area and surveillance period

Demographic trends
There have been important changes in the rates of candidemia by age group. Rates have decreased significantly in infants, but remain high compared with other groups.6,7 The reasons for the decline in candidemia rates in infants are not fully understood but might be related to factors such as fluconazole prophylaxis in high-risk pre-term babies or improved infection control practices, such as hand hygiene and catheter care. Candidemia rates are typically highest among people aged 65 and older (Figure 2). Candidemia rates are approximately twice as high in blacks as in non-blacks (Figure 3). The reasons for the difference in incidence by race may have to do with difference in underlying conditions, socioeconomic status, or other factors.

Figure 2: Candidemia incidence rates per 100,000 person-years, by age group, 2009–2017

Candidiasis age group incidence per 100,000 persons 2009-2017

Figure 3: Candidemia incidence rates per 100,000 person-years, by age group, 2009–2017

Candidemia incidence rates per 100,000 person-years, by age group, 2009–2017

Trends in species distribution
Up to 95% of all invasive Candida infections in the United States are caused by five species of Candida: C. albicans, C. glabrata, C. parapsilosis, C. tropicalis, and C. krusei. The proportion of infections caused by each species varies by geographic region and by patient population.8 C. albicans is the most common species causing invasive Candida infection, although the proportion of Candida infections caused by C. albicans has decreased during the last 20 years.9-11 Altogether, non-C. albicans species cause approximately two-thirds of candidemia cases in the United States.3,9 In some locations, C. glabrata is the most common species. An emerging species called C. auris is also an increasing cause of invasive Candida infections in United States since 2016.

Trends in antifungal resistance
Some types of Candida are increasingly resistant to the first-line and second-line antifungal medications, such as fluconazole and the echinocandins (anidulafungin, caspofungin, and micafungin). About 7% of all Candida bloodstream isolates tested at CDC are resistant to fluconazole (Figure 4). More than 70% of these resistant isolates are the species Candida glabrata or Candida krusei.9,12 CDC’s surveillance data indicate that the proportion of Candida isolates that are resistant to fluconazole has remained fairly constant over the past 20 years.9,13,14 Echinocandin resistance, however, appears to be emerging, especially among Candida glabrata isolates. Approximately 3% of Candida glabrata isolates are resistant to echinocandins, but the percentage may be higher in some hospitals. This is especially concerning because echinocandins are the first-line treatment for Candida glabrata, which already has high levels of resistance to fluconazole.12

Figure 4: Antifungal resistant Candida spp. isolates by year, 2009–2017

Candidiasis resistance for fluconazole, echinocandin, and multi-drug from 2009-2017

Deaths due to invasive candidiasis

Invasive Candida infections are often associated with high rates of morbidity and mortality, as well as increases in cost and length of hospital stay. CDC’s surveillance data indicate that the in-hospital all-cause (crude) mortality among people with candidemia is approximately 25%. However, because people who develop invasive candidiasis are typically already sick with other medical conditions, it can be difficult to determine the proportion of deaths directly attributable to the infection. One study estimated the mortality attributable to candidemia to be 19–24%.15

Invasive candidiasis outbreaks

Most cases of invasive candidiasis are not associated with outbreaks. However, sporadic outbreaks of C. parapsilosis infection have been reported for decades, including clusters of invasive candidiasis in neonatal intensive care units likely transmitted via healthcare workers’ hands.16-18 Recently, an emerging species called C. auris has caused outbreaks of invasive infections around the world likely because of its ability to colonize patient skin and persist on healthcare surfaces. Of concern, it is commonly resistant to antifungal medications, and some disinfectants used in healthcare settings do not kill C. auris. Read more about C. auris.

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