In recent years, some studies have reported that the incidence of candedimia is increasing in many hospitals around the world. Our data show that in our hospital the incidence of candidemia has increased steadily in the past three years in parallel with medical technological advances. The incidence is somewhat higher than that reported for centers in Denmark (0.41 case per 1000 admissions) , Israel (0.50 case per 1000 admissions) , China (0.53 cases per 1000 admissions) , and much lower than that reported in Brazil (1.87 cases per 1000 admissions) . The differences in candidemia rates between countries may reflect differences in demographic characteristics, variations in health care practice, patterns using blood cultures and long duration of antibacterial usage as well as the resistance situation.
Neonates and infants have historically been populations with some of the highest rates of candidemia [23–29]. In our study, BSI by candida species occurred more frequently among males, mainly in those over 65 years old. The reasons for the shift in burden from neonates to adults are likely multifactorial; some contribution may be due to changes in the prevalence of risk factors in the adult population. Increases in common risk factors such as ICU admission [30, 31], or numbers of patients receiving immunosuppressive therapies  may have resulted in increase in the overall pool of patients at high risk for candidemia. The difference in the distribution of cases between genders could be related to the predominant presence of male patients in units where the use of invasive devices, broad-spectrum antibiotics, extensive surgical procedures, or advanced life support is frequently used.
Over the past 20 years, a shift towards non-albicans Candida species has been reported previously from the USA, Europe and Australia, although the precise pattern of causative species varies across countries . The findings from our surveillance are partially supportive of these reports. We observed a significant predominance of non-albicans Candida species (76.7%), with C. tropicalis being the most common isolate (28.6%), followed by C. albicans (23.3%), C. parapsilosis (19.5%) and C. glabrata (8.3%). Traditionally, C. tropicalis has been the second most common Candida species recovered from blood . Similarly, as previously reported at a hospital in China, C. albicans (57.8%) continued to play a dominant role in candidemia, followed by C. tropicalis (12.8%) . In our report, C. tropicalis surpassed the other Candida species to become the most common species, we recognize that this finding may simply be a result of the small sample size, and the further studies with larger sample size are needed to verify it. It is worth mentioning that eight C. pelliculosa, seven C. famata and two C. haemulonii isolates were recovered during the study period, suggesting the diversity of the etiologic agents. ARTEMIS DISK Global antifungal surveillance also found an increase of the involvement of less-common Candida species during the 10.5-year study period and showed that species identification is important to diagnosis and surveillance .
As already reported . non-albicans Candida species were predominant in patients with haematological malignancies (83.3%), a finding in accordance with the global results of the ECMM survey ; moreover, C. tropicalis was frequently isolated in this group of patients, the prevalence of C. tropicalis among patients with haematological malignancies is consistent with previous reports .
The antifungal susceptibility patterns revealed that voriconazole has excellent in vitro activity overall against Candida species. Successful salvage therapy with voriconazole for the treatment of candidemia in patients intolerant or refractory to other antifungal agents has been reported . Some studies showed that voriconazole may be a suitable agent for salvage therapy of invasive candidiasis, even in the setting of previous azole exposure and C. krusei infection [36, 38]. Most publications on antifungal resistance over the past 10 years have been concerned with resistance to triazole antifungals, especially fluconazole, itraconazole, and ketoconazole. For ketoconazole, it showed the exsitence of a sensitivity of 38.1% of strains studied, lower than the other three azoles. Ketoconazole resistance was observed in 50% of C. albicans and C. parapsilosis, respectively. Itraconazole resistance was observed for 30.5% of all Candida species and was also highest among C. glabrata (90.9% resistance), this sensitivity decline was similar to that previously published in Iowa Organisms Study . In recent years, resistance to azole antifungal agents among Candida spp. is still uncommon. In Iceland, 97.3% of the Candida spp. isolates tested were susceptible to fluconazole . A similar data has been reported from North India . In contrast to other reports, antifungal resistance was a notable finding in our study and was mainly restricted to fluconazole. Our proportion of fluconazole-resistant isolates (53.9%) was higher than the rates observed with spain (9.8%) . We propose two potential reasons, first, the number of isolates in this study is still not high enough, therefore the rate of azole resistance is higher than clinical reports. Second, the increasing use of fluconazole as antifungal therapy leads to a reduction in susceptibility and the appearance of resistant strains. Some reportes have demonstrated that candidemia due to non-albicans species increased and that was apparently correlated with an increasing use of azoles for prophylaxis or empirical treatment , in our study, almost all patients received empirical therapy, 65(45.9%) patients were treated with fluconazole, followed by voriconazole (18.8%), and caspofungin (11.3%). For the latter reason, it would be convenient to carry out antifungal susceptibility studies in order to establish the in vitro activities of antifungal agents against local isolates and also to detect shifts toward resistance as early as possible. When analyzed by species, apart from the intrinsically fluconazole-resistant species (C. krusei), the highest rate of resistance to fluconazole was for C. glabrata and C. tropicalis (more than 50%), which was consistent with other studies in whom the greatest resistance to fluconazole also showed C. glabrata (36%) . Furthermore, discrepancies in vitro susceptibility to FLC rate of different strains studied in this single-center study could be associated to differences in species distribution of isolates tested in this study.
In the present study we decided to analyze prognostic factors in patients with candidemia, we found that complicated abdominal surgery, presence of CVC, neutropenia, candidemia due to C. tropicalis, poor treatment with fluconazole were predictors of mortality in the univariate analysis. Of all the variables significantly associated with mortality in the univariate analysis, presence of CVC was the only predictive factor of mortality in the multivariate analysis. This is in agreement with the findings of a hospital population-based surveillance study . In a study of pediatric candidemia, Candidemia-associated mortality has been found to be 31-72% . Similarly, the crude 30-day mortality rate in our study was 26% for all patients with candidemia, which is in concordance with rates reported from Chinese tertiary-care centers, ranging from 26.4% to 33.3% [21, 34]. A possible explanation for the relatively low mortality of nosocomial candidemia is the increase in empirical and/or pre-emptive use of fluconazole for presumed invasive candidiasis. Furthermore, although the hospital is a tertiary care hospital it rarely has patients with solid organ or bone marrow transplants. Thus, on average the patients in our hospital are less sick than in other hospitals. In our study, C. tropicalis was the species associated with the highest mortality rate (50%), besides being raised among the elderly, mortality is particularly high among patients with cancer (66.7% for haematological malignancies) as reported previously [33, 45, 46]. Certainly the severity of the underlying medical conditions has greatly influenced the crude mortality rate in these patient populations.