Update from a twelve-year nationwide fungaemia surveillance: increasing intrinsic and acquired resistance causes concern

New data from the Danish National Fungaemia Surveillance 2012-15 is reported and epidemiological trends are investigated in a 12-year perspective (2004-15). During 2012-15, 1900 out of 1939 (98%) fungal bloodstream isolates were included. The average incidence was 8.4/100,000 inhabitants and this appears to be stabilizing after the increase to 10.1/100,000 in 2011. The incidence was higher in males than females (10.0 vs 6.8) and in patients above 50 years, mainly driven by an increasing incidence among 80-89 years old males (65.3/100,000 in 2014-15). The proportion of Candida albicans decreased 2004-15 (64.4% to 42.4%) in parallel with a doubling of Candida glabrata (16.5% to 34.6%, p<0.0001). C. glabrata was more common among females (34.0% vs. 30.4% in males). Following an increase in 2004-11 the annual drug use stabilised during the last 2-3 years but remained higher than in other Nordic countries. This was particularly true for the fluconazole and itraconazole use in the primary healthcare sector which exceeded the combined national use of these compounds in each of the other Nordic countries. Fluconazole susceptibility decreased (68.5%, 65.2% and 60.6% in 2004-7, 2008-11 and 2012-15, respectively, p<0.0001) and echinocandin resistance in Candida emerged (0%, 0.6% and 1.7%, respectively, p<0.001). Amphotericin B susceptibility remained high (98.7%). Among 16 (2.7%) echinocandin-resistant C. glabrata isolates (2012-15), 13 harboured FKS mutations and five (31%) were multidrug resistant.The epidemiological changes and the increased incidence of intrinsic and acquired resistance emphasise the importance of continued surveillance and of strengthened focus on antifungal stewardship.