Contemporary Trends in Candidemia: Mortality, Species, and Antifungal Resistance Across Three Periods (2017-2025) in Houston, Texas

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Abstract Background Candida species distribution has changed and antifungal resistance has increased since COVID-19. We determined whether these trends contributed to changes in candidemia mortality. Methods In a retrospective cohort study of patients with candidemia in Houston, TX, we compared clinical characteristics, species, and resistance between three periods (P1, 2017-2019; P2, 2020-2022; P3, 2023-2025) and assessed contribution to mortality. We compared 30-day mortality in candidemia vs bacteremia. Results Among 1275 patients with candidemia (1386 episodes), 30-day mortality increased from P1 to P2 (19.7% vs 31.9%, p<0.001) and remained above baseline in P3 (29.8%, p<0.001 vs P1). In contrast, 30-day mortality increased from P1 to P2 in patients with Enterobacterales (7.4% vs 9.5%, p=0.004) and Staphylococcus aureus bacteremia (9.5% vs 14.3%, p<0.001) but returned to baseline in P3 (both p>0.05 vs P1). Mean age (62.7±16.0 vs 66.1±14.8, p=0.002) and median Elixhauser Comorbidity Index (8 [IQR 5-12] vs 11 [IQR 6-15], p<0.001) increased from P1 to P3 among candidemia patients. Proportion of ICU-onset candidemia increased from P1 to P2 (31.3% vs 40.6%, p=0.02). Proportion of C. auris increased from P1 to P3 (0.5% vs 20.5%, p<0.001). In multivariable analyses, age (OR 1.03, 95%CI 1.02-1.04) and ICU-onset candidemia (OR 2.08, 95%CI 1.46-2.98) were associated with increased mortality. In univariable analyses, C. auris and antifungal resistance were not associated with increased mortality. Conclusions Increased post-candidemia mortality was associated in part with demographic changes and not with species or resistance changes. Factors underlying the persistent increase in post-candidemia mortality are unclear.

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