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Editor's Correspondence
August 10, 2009

Fluconazole Use as an Important Risk Factor in the Emergence of Fluconazole-Resistant Candida glabrata Fungemia—Reply

Arch Intern Med. 2009;169(15):1445. doi:10.1001/archinternmed.2009.244

In reply

We thank Tumbarello and colleagues for their insightful comments. Their article evaluated risk factors, antifungal treatment, and outcomes in 14 patients with fluconazole–less-susceptible Candida glabrata bloodstream infections and 21 patients with fluconazole-susceptible C glabrata bloodstream infections.1 Similar to our results, the authors identified fluconazole use as a significant risk factor for fluconazole–less-susceptible C glabrata isolates. This provides further evidence supporting the role of fluconazole use in the emergence of fluconazole resistance. Their study additionally identified diabetes mellitus as an independent risk factor for fluconazole–less-susceptible isolates, while surgery was found to be an independent risk factor for fluconazole-susceptible isolates. Central venous catheter use was found to be a significant risk factor in both analyses, suggesting that this may be a risk factor for C glabrata bloodstream infections in general, regardless of fluconazole susceptibility. The authors are correct that our study did not evaluate these variables. Central venous catheter use was not included in our analysis because of concern for data accuracy. At our institution, central venous catheters are often placed by house staff, which occurs without an order being placed into the electronic database and therefore would not be captured by the Pennsylvania Integrated Clinical and Administrative Research Database. Diabetes mellitus and general surgery were not evaluated because no studies prior to the time we submitted our manuscript had found an association between these factors and C glabrata bloodstream infections. We agree with Tumbarello and colleagues on the importance of evaluating clinical outcomes in this population. A study is under way to determine whether mortality rates differ in patients with C glabrata bloodstream infections based on fluconazole susceptibility. Lastly, future studies should evaluate interventions designed to curb fluconazole resistance in C glabrata isolates.