Changes in Incidence and Antifungal Drug Resistance in Candidemia: Results from Population-Based Laboratory Surveillance in Atlanta and Baltimore, 2008-2011

  1. Angela Ahlquist Cleveland1,*,
  2. Monica M. Farley2,
  3. Lee H. Harrison3,
  4. Betsy Stein2,
  5. Rosemary Hollick3,
  6. Shawn R. Lockhart1,
  7. Shelley S. Magill4,
  8. Gordana Derado1,
  9. Benjamin J. Park1, and
  10. Tom M. Chiller1

Author Affiliations

  1. 1Mycotic Diseases Branch, Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

  2. 2Georgia Emerging Infections Program, Atlanta Veterans Affairs Medical Center and Emory University, Atlanta, Georgia, USA

  3. 3Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA

  4. 4Surveillance Branch, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
  1. *Corresponding author: Angela Ahlquist Cleveland, MPH, 1600 Clifton Road, MS C-09, Atlanta, GA 30333, Telephone: (404) 639-0124, Fax: (404) 929-2843, E-mail
  1. Alternate Corresponding author: Tom M. Chiller, MD, 1600 Clifton Road, MS C-09, Atlanta, GA 30333, Telephone: (404) 639-4753, Fax: (404) 929-2843, E-mail address:



Candidemia is common and associated with high  morbidity and mortality; changes in population-based incidence rates have not been reported.


We conducted active, population-based surveillance in metropolitan Atlanta, Georgia, and Baltimore City/ County, Maryland (combined population 5.2 million), during 2008-2011. We calculated candidemia incidence and antifungal drug resistance compared to prior surveillance (Atlanta: 1992-1993; Baltimore: 1998-2000).


We identified 2,675 cases of candidemia with 2,329 isolates during 3 years of surveillance. Mean annual crude incidence per 100,000 person-years was 13.3 in Atlanta, and 26.2 in Baltimore. Rates were highest among adults aged ≥65 years (Atlanta, 59.1; Baltimore, 72.4), and infants (aged <1 year) (Atlanta, 34.3; Baltimore, 46.2). In both locations compared to prior surveillance, adjusted incidence significantly declined for infants of both black and white race (Atlanta, black risk ratio (RR): 0.26, 95% confidence interval [CI]: [0.17-0.38]; white RR: 0.19, 95% CI: [0.12-0.29]; Baltimore, black RR: 0.38, 95% CI: [0.22-0.64], white RR: 0.51, 95% CI: [0.29-0.90]). Prevalence of fluconazole resistance (7%) was unchanged compared to prior surveillance; 32 (1%) isolates were echinocandin-resistant, and nine (eight C. glabrata) were multi-drug resistant to both fluconazole and an echinocandin.


We describe marked shifts in candidemia epidemiology over the past two decades. Adults aged ≥ 65 years replaced infants as the highest incidence group; adjusted incidence has declined significantly in infants. Use of antifungal prophylaxis, improvements in infection control, or changes in catheter insertion practices may be contributing to these declines. Further surveillance for antifungal resistance and efforts to determine effective prevention strategies are needed.

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