Candidemia in critically ill patients is a significant source of mortality. To identify perioperative risk factors accounting for patient death, we performed a retrospective study of 46 surgical patients with fungemia during the period from 1981 to 1990. Twenty patients survived (43%), and 26 died (57%). Mortality was associated with age older than 46 (p < 0.02, unpaired Student's t-test) and concomitant renal failure, hepatic failure, postoperative shock, or adult respiratory distress syndrome (p < 0.0001, p < 0.0001, and p < 0.05, respectively, chi 2 test). Survival was not influenced by the presence of diabetes, chronic obstructive pulmonary disease, gastrointestinal hemorrhage, pneumonia, alcohol consumption, steroid use, or enteral/parental nutrition. Bacterial speticemia developed in 26 patients (11 lived, 15 died) and typically preceded or was concomitant with the onset of fungal sepsis (88%). Candida albicans was the fungal species most commonly isolated from blood cultures (30 of 46). Its was cultured from other sites in addition to blood in 30 patients. Candidemia carries a higher risk of mortality in older patients and in those with multiple organ dysfunction. Other immunocompromised conditions such as diabetes and steroid use did not increase mortality. These findings suggest that the pathogenicity of Candida sepsis is not solely related to opportunistic superinfections but may reflect failure of other host defense mechanisms. Moreover, the frequent occurrence of bacterial septicemia prior to the development of Candida sepsis further emphasizes the importance of fungal surveillance cultures to detect early fungal colonization in the critically ill.