OBJECTIVES: Timely initiation of antifungal therapy in septic or critically ill (CrILL) patients with candidemia is crucial, and real-world treatment and outcomes data in such patients are limited.  We examined treatment patterns and outcomes for septic/CrILL inpatients with candidemia. METHODS: This retrospective study of electronic health record data from 7/2005-3/2012 used Cerner’s Health Facts. Adult inpatients with ≥1 blood culture positive for any species of Candidaand sepsis/CrILL were studied. CrILL was defined as ≥1 organ system dysfunction plus intensive care unit exposure. Timing of initial antifungal therapy relative to the index blood culture draw (BCx), length-of-stay following first antifungal order (AF-LOS), mortality, and measures of resource utilization were explored using descriptive statistics. Chi-square was used for proportional, and t-test for continuous data comparisons. RESULTS: Of 1,288 candidemia patients with sepsis/CrILL, 266 initiated antifungal therapy prior to BCx, 150 within 24h of BCx, 590 after 24h, and  282 received no antifungal therapy.  The mortality rates were 39.9%, 30.7%, 29.7%, and 51.1%, respectively. (P<0.001). Initial antifungal therapies in those treated ≤24h of BCx were: fluconazole in 54.0%, echinocandin in 39.3%, other azoles in 3.3%, and amphotericin B in 3.3%.  In patients treated within 24h after BCx with fluconazole (n=81) or echinocandin (n=59), occurrence of bacteremia was high (71% vs. 75%); echinocandin patients had a higher mean number of organ system dysfunctions than fluconazole patients (1.8 vs. 1.5, P=0.04). In the ≤24h treated groups, AF-LOS (fluconazole 20.8, echinocandin 22.1 days; P=0.63) and mortality (fluconazole 25.9%, echinocandin 32.2%; P=0.42) was similar, as were total charges (approximately US$76,000). CONCLUSIONS: A large proportion of inpatients with candidemia and sepsis/CrILL failed to receive antifungal therapy within 24h of the first positive BCx, with an adverse mortality effect. Nonetheless, patients treated within 24h have high mortality and resource utilization.