Candidemia in a pediatric intensive care unit

Risk Factors and Characteristics of Candidemia After Cardiac Surgery in Pediatric Patients in Central Israel

BACKGROUND

Candidemia is a serious complication in pediatric patients with congenital heart defects (CHD) after cardiac surgery. Information about the epidemiology, clinical characteristics and risk factors for candidemia in this vulnerable population remains limited.

METHODS

This retrospective case-control study was conducted in 2 pediatric intensive care units between 2004 and 2019. All patients <18 years old who developed candidemia following cardiac surgery were included. Each case was matched with 2 control patients based on age and date of surgery. Multivariable logistic regression analysis was conducted to determine the risk factors for postoperative candidemia.

RESULTS

Thirty-five candidemia cases were identified and matched to 70 control cases. The incidence of candidemia was 6.3 episodes per 1000 admissions. The median age for candidemia cases was 4 months. The attributable mortality was 28.5%. The predominant (54%) pathogens isolated were non- albicans Candida species, of which C. parapsilosis isolates demonstrated high resistance to fluconazole (70%). Independent risk factors associated with candidemia included cumulative antibiotic exposure for ≥4 days [OR: -4.3; 95% confidence interval (CI): 1.3-14.6; P = 0.02], the need for total parenteral nutrition or peritoneal dialysis (OR: -6.1; 95% CI: 2-18.8; P = 0.001), male sex (OR: 6.2; 95% CI: 1.9-20.3; P = 0.002) and delayed sternal closure≥2 days (OR: -3.2; 95% CI: 1-11.2; P = 0.05).

CONCLUSIONS

Postoperative candidemia in children with CHD is an uncommon but severe complication. Our study revealed an unexpectedly high frequency of fluconazole-resistant C. parapsilosis as the main cause of non- albicans candidemia. In addition to confirming previously recognized risk factors, our results reveal new potential risk factors such as delayed sternal closure and male sex.

Distribution of candida species and risk factors for invasive candidiasis

Aim: The aim of this study was to investigate the Candida species isolated from the clinical samples of patients in the pediatric intensive care unit and to determine the risk factors for invasive candidiasis. Materials and Methods: Patients with Candida species detected in clinical samples between January 2013 and December 2018 were included in this study. The demographic characteristics of the patients, the use of broad-spectrum antibiotics and immunosuppressive drugs, underlying diseases, blood transfusions, history of surgical operations, whether there is bacterial growth with Candida species in the same clinical sample, parenteral nutrition and invasive interventions were retrospectively analyzed and their relationship with invasive candidiasis was investigated. Results: A total of 91 patients were included in the study. The mean age was 72.3 ± 70.1 months. Among the patients 48.4% had Candida albicans while 51.6% had non-albicans Candida. Candida parapsilosis (n = 18, 19.8%) and Candida tropicalis (n = 14, 15.4%) were the most common non-albicans Candida species. The most common antifungal treatment was fluconazole (n = 34, 59.6%). There was no statistically significant relationship between invasive candidiasis and the underlying disease, central venous and / or urinary catheter, broad-spectrum antibiotic, corticosteroid, gender and surgical operation (p&gt; 0.05). On the other hand, there was a statistically significant relationship between invasive candidiasis and parenteral nutrition, blood transfusion and bacterial growth with Candida species in the same clinical sample (p &lt;0.05). Conclusions: Non-albicans Candida species are more common than Candida albicans in the pediatric intensive care units. Candida parapsilosis is the most common among non-albicans Candida species. Parenteral nutrition, blood transfusion and bacterial growth with Candida species in the same clinical sample increased the risk of invasive candidiasis.

Characteristics, Risk Factors and Predictors for Candidemia in the Pediatric Intensive Care Unit at the University Hospital Centre Zagreb in Croatia: A 9-Year Retrospective Study

BACKGROUND

Candidemia is one of the leading causes of bloodstream infections in the pediatric intensive care unit (PICU). The aim of this study was to define characteristics and risk factors for candidemia in the PICU setting and propose a predictive model to identify the patients at risk.

METHODS

This was a retrospective matched case-control study in the PICU during a 9-year period. Patients with candidemia were studied and matched with control patients without candidemia. Univariate analysis was performed for potential risk factors and multivariate analysis was conducted to determine the prediction score for candidemia.

RESULTS

Forty-two cases of candidemia were matched with 84 control patients. Candida parapsilosis was the most common (71.4%) species. Risk factors independently associated with candidemia were: the use of >2 antibiotics in a maximum period of 4 weeks before the candidemia (odds ratio [OR]: 10.59; 95% confidence interval [CI]: 2.05-54.83), a previous bacterial infection in a maximum period of 4 weeks before the candidemia (OR: 5.56; 95% CI: 1.44-21.5) and the duration of PICU stay of >10 days (OR: 4.22; 95% CI: 1.02-17.41). The proposed predictive scoring system has a sensitivity of 95.24%, specificity of 76.12%, OR 64.0, 95% CI 14.2-288.6, the positive predictive value of 66.67% and the negative predictive value of 96.97%.

CONCLUSIONS

Previously reported risk factors for candidemia have been confirmed and some new have been detected. The presented scoring system can help identify patients who would benefit from prophylactic antifungal therapy.

Characteristics, outcome and risk factors for mortality of paediatric patients with ICU-acquired candidemia in India: A multicentre prospective study

BACKGROUND

The epidemiology, clinical profile and outcome of paediatric candidemia vary considerably by age, healthcare settings and prevalent Candida species. Despite these differences, few comprehensive studies are undertaken. This nationwide study addresses this knowledge gap.

METHODS

487 children who contracted ICU-acquired candidemia at 23 Indian tertiary care centres were assessed for 398 variables spanning demography, clinical characteristics, microbiology, treatment and outcome.

RESULTS

Both neonates (5.0 days; range = 3.0-9.5) and non-neonatal children (7.0 days; range = 3.0-13.0) developed candidemia early after ICU admission. Majority of neonates were premature (63.7%) with low birthweight (57.1%). Perinatal asphyxia (7.3%), pneumonia (8.2%), congenital heart disease (8.4%) and invasive procedures were common comorbidities, and antibiotic use (94.1%) was widespread. C tropicalis (24.7%) and C albicans (20.7%) dominated both age groups. Antifungal treatment (66.5%) and removal of central catheters (44.8%) lagged behind. Overall resistance was low; however, emergence of resistant C krusei and C auris needs attention. The 30-day crude mortality was 27.8% (neonates) and 29.4% (non-neonates). Logistic regression identified admission to public sector ICUs (OR = 5.64), mechanical ventilation (OR = 2.82), corticosteroid therapy (OR = 8.89) and antifungal therapy (OR = 0.22) as independent predictors of 30-day crude mortality in neonates. Similarly, admission to public sector ICUs (OR = 3.62), mechanical ventilation (OR = 3.13), exposure to carbapenems (OR = 2.18) and azole antifungal therapy (OR = 0.48) were independent predictors for non-neonates.

CONCLUSIONS

Our findings reveal a distinct epidemiology, including early infection with a different spectrum of Candida species, calling for appropriate intervention strategies to reduce candidemia morbidity and mortality. Independent factors identified in our regression models can help tackle these challenges.

Candidaemia in a tertiary care centre of developing country: Monitoring possible change in spectrum of agents and antifungal susceptibility

Purpose

Candidaemia is a major cause of morbidity and mortality of hospitalised patients, especially in developing countries. This study was conducted to monitor any change in species distribution and antifungal susceptibility pattern of Candida species causing candidaemia over the last 20 years.

Materials and Methods

The candidaemia cases reported during January 1999 and December 2018 at our centre were reviewed. The yeasts were identified by phenotypic characters (during 1999-2014) and matrix-assisted laser desorption ionisation-time of flight mass spectrometry (MALDI-TOF MS) (during 2014-2018). Antifungal susceptibility testing (AFST) was performed in accordance with the Clinical and Laboratory Standards Institute guidelines.

Results

A total of 602,963 blood samples from patients with suspected sepsis were processed. Candidaemia was diagnosed in 7927 (1.31%) cases. The frequency of cases rose significantly (P = 0.000) in the last quarter of the study. Candida tropicalis (40.1%) was the most common species, followed by Candida albicans (15.2%), Wickerhamomyces anomalus (13.1%), Candida krusei (6.6%), Candida parapsilosis (4.7%) and others. Rare species such as Candida auris, Candida lambica, Candida orthopsilosis, Candida vishwanathii were identified after the introduction of MALDI-TOF. The minimum inhibitory concentrations of amphotericin B rose significantly from the first to last quarter (0.5%-4.9%). Fluconazole resistance was fairly constant at 7.4%-8.8%.

Conclusion

Local epidemiology of candidaemia at our centre was distinct regarding prevalence and change of spectrum of species. The identification of rare species was possible after the introduction of MALDI-TOF. With the emergence of multidrug-resistant C. auris and resistance in other species, routine AFST has become imperative.

Vitamin D-supplemented yogurt drink reduces Candida infections in a paediatric intensive care unit: a randomised, placebo-controlled clinical trial

BACKGROUND

The prevalence of Candida infections in paediatric intensive care units (PICUs) has dramatically increased as a result of resistance to conventional anti-fungal treatments. Because vitamin D has been shown to exhibit fungicidal activity against Candida infection in an in vitro antimicrobial screening, we aimed to investigate the effect of vitamin D on Candida infections in the PICU.

METHODS

Four hundred sixteen eligible children aged between 12 months to 5 years old admitted to the PICU, who were on broad-spectrum antibiotic therapy, participated in the study. Patients were randomly assigned to two study groups, receiving a plain yogurt drink (placebo group) or supplemented with 300 IU day^-1 vitamin D (VD group). Primary outcome was defined as the incidences of Candida colonisation (Candida isolated from rectal swab) 14 days after enrollment. Secondary outcome measures were Candida growth in blood (candidaemia) and urine (candiduria).

RESULTS

The prevalence of candiduria as well as candidaemia was significantly lower in the VD-treated group (26 cases) than in the placebo group (62 cases). The mean (SD) length of PICU stay was obviously lowered in the VD group [11.8 (1.2) days] compared to the placebo group [15.2 (2.3 days)], whereas cases of patient death were similar between the two groups.

CONCLUSIONS

Supplementation of vitamin D effectively reduces infections of Candida in children who were critically ill and on broad-spectrum antibiotic treatment.

Zinc supplementation reduces Candida infections in pediatric intensive care unit: a randomized placebo-controlled clinical trial

Resistance to anti-fungal drugs has become the main cause for increasing incidence rate of Candida infections in pediatric intensive care units (PICU). Zinc supplementation has been shown to exhibit beneficial effects on many pediatric illnesses. This study aimed to investigate the efficacy of zinc supplementation on prevalence of candidemia and candiduria infections in PICU. 724 eligible children between 1 to 5 years old admitted in PICU were randomly assigned into either zinc supplementation group or placebo group. Primary endpoints were the number of Candida infections, length of PICU stay and cases of patient death 14 days after enrollment. Secondary endpoints were the incidence rates of candidemia and candiduria. The incidences of candiduria and candidemia were significantly lower in the zinc group than the placebo group. The length of PICU stay and cases of patient death were obviously lowered in the zinc group compared to the placebo group. In conclusion, zinc supplementation shows beneficial clinical efficacy in reducing Candida infections among PICU patients on broad-spectrum antibiotics with critical illnesses.

Invasive Candidiasis in pediatric patients at King Fahad Medical City in Central Saudi Arabia. A 5-year retrospective study

Objectives:

To identify predisposing factors, species distribution, antifungal susceptibility, and outcome.

Methods:

This study is a retrospective chart review that was conducted at a children’s hospital at King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia. One hundred twenty-nine children with invasive candidiasis who were admitted between January 2010 and January 2015.

Results:

The statistical analysis results have revealed a group of risk factors; prematurity in 37 (28.7%) of patients, low birth weight in 42 (32.6%), central venous catheter in 59 (45.7%), malignancy in 21 (16.3%), immunotherapy in 20 (15.5%), and ventilator support in 60 (46.5%). More than 2-fold mortality rate in patients who had heart vegetation (odds ratio [OR]: 2.9) and patients who had Candida isolated from their blood were more than twice as likely to die as patients with Candida isolated from other sites (OR: 2.2). A total of 48.3% of patients on ventilator died versus 26.1% who were not on ventilator (p=0.009); and 43.8% of patients in the ICU died versus only 24.5% of patients who were not in the ICU (p=0.03). Candida parapsilosis exhibited the highest mortality rate (56.2%).

Conclusion:

Candida albicans is the most common isolate among all Candida species. Gender, low birth weight, prolonged ICU stay, presence of vegetation, positive blood culture, and mechanical ventilation as a strong predictive risk factors for death in children with invasive candidiasis, a finding that could be applied as prophylactic indicator in critically ill children especially neonates.

Candidemia in children: Epidemiology, prevention and management

Candidemia is the leading cause of invasive fungal infections in hospitalised children. The highest rates of candidemia have been recorded in neonates and infants <1 year of age. Candidemia is more frequent in neonates and young infants than in adults, and is associated with better clinical outcomes, but higher inpatient costs. Over the last 10 years, a declining trend has been noted in the incidence of paediatric candidemia in the US and elsewhere due to the hospital-wide implementation of central-line insertion and maintenance bundles that emphasise full sterile barrier precautions, chlorhexidine skin preparation during line insertion, meticulous site and tubing care, and daily discussion of catheter necessity. Additional interventions aiming at reducing gut-associated candidemia are required in immunocompromised and critically ill children.

Antifungal Drugs in Newborns and Children

Invasive fungal infections are a significant cause of morbidity and mortality in infants and children. Early diagnosis is critical, and treatment with the appropriate drug and dose should be initiated promptly. Although an increasing number of studies have examined dosing of antifungals in this population, pediatric safety and efficacy data are lacking.

Failure to Validate a Multivariable Clinical Prediction Model to Identify Pediatric Intensive Care Unit Patients at High Risk for Candidemia

We attempted to validate a previously derived clinical prediction rule for candidemia in the pediatric intensive care unit. This multicenter case control study did not identify significant association of candidemia with most of the previously identified predictors. Additional study in larger cohorts with other predictor variables is needed.

Candida infections in paediatrics: Results from a prospective single-centre study in a tertiary care children's hospital

To describe the epidemiology of invasive Candida infection in a tertiary care paediatric hospital. Prospective single-centre survey on all Candida strains isolated from normally sterile fluids and urines in the period 2005-2015 . A total of 299 ICI were documented in 262 patients. Urinary tract infection represented the most frequent diagnosis (62%), followed by fungaemia (34%) and peritonitis (4%). Fungaemia was most frequent in children with cancer (59%) or in low birth weight neonates (61%), while urinary tract infections were more frequent in patients with urinary tract malformation. C.albicans was the most frequently isolated species (60%) compared with C. non-albicans, but differences were present according to the site of isolation and underlying conditions. Overall 90-day mortality was 7%, 13% in fungaemias, 8% in peritonitis and 2% in urinary tract infections. The rates of invasive Candida infection increased during the study period. Invasive Candida infection is diagnosed with increasing frequency in children. Site of isolation and aetiology are frequently related with the presence of underlying, favouring conditions. Mortality was not negligible, especially in the presence of more invasive infections and specific underlying conditions.

Species-based comparison of disease severity and risk factors for disseminated Candida infections in pediatric patients

Background

Pediatric Candida infections are associated with worse clinical outcomes and increased costs. Yet, it is not definitively known if particular species are associated with more severe illness. Differential risk factor exposures among the species group may also exist. We aimed to determine whether certain Candida species are more strongly associated with worse outcomes, and whether certain risk factors more strongly predispose patients to infection with certain species.

Methods

Microbiology lab records from patients seen from 2003 to 2010 at an urban children’s hospital were reviewed for invasive or disseminated Candida infections. Data on measures of disease severity/outcome and risk factors were abstracted and analyzed to determine differences associated with various Candida species.

Results

Exactly 106 cases of infection were analyzed. Non-albicans species were associated with a significantly longer length of stay postdiagnosis (P=0.03), as well as longer treatment (P=0.02). Candida albicans was associated with a higher number of antihypotensive medications required (P=0.03) and length of mechanical ventilation postdiagnosis (P=0.05). Candida tropicalis was associated with the highest mortality (45.5%). Hypotension, which was found to be significantly associated with concurrent infection, was significantly associated with increased risk of mortality (odds ratio =5.85, P=0.005). Initial choice of antifungal therapy was not associated with differences in eventual patient mortality. Multivariate logistic regression modeling revealed a trend toward C. albicans infection in patients receiving antineoplastic chemotherapy and non-albicans infection in patients with >96 hours mechanical ventilation.

Conclusion

Interspecies differences may exist for Candida in terms of disease severity and risk factors. Underlying morbidity and the role of concurrent infections may play a key role in poor outcomes.

Pediatric Invasive Candidiasis: Epidemiology and Diagnosis in Children

Pediatric patients present with differing underlying conditions and cytotoxic therapeutic protocols, so the differing epidemiology of invasive candidiasis in children versus adults is not surprising. Understanding the Candida species epidemiology is critical, as we often begin empiric therapy or therapy before antifungal susceptibilities are known. Reports with newer molecular diagnostic assays for invasive candidiasis are rare and require more study to develop firm pediatric-specific guidance. Antifungal treatment of pediatric candidiasis is reviewed in the context of larger epidemiologic studies and the few trials completed to date.

Epidemiological and mycological characteristics of candidemia in patients with hematological malignancies attending a tertiary-care center in India

BACKGROUND AND OBJECTIVES

We undertook the present study to ascertain the contributing risk factors and explore the epidemiological and mycological characteristics of opportunistic candidemia among patients with hematological malignancies.

DESIGN AND SETTINGS

Observational cross-sectional study in a tertiary care center.

PATIENTS AND METHODS

Consecutive patients with hematological malignancies reporting to the collaborating medical and pediatric units with a febrile episode were recruited and screened for candidemia by blood culture. Recovered Candida isolates were speciated and antifungal susceptibility testing was performed as per Clinical and Laboratory Standards Institute guideline (CLSI) guidelines M44-A. Further analysis was done for potential risk factors and compared between culture positive and negative patients.

RESULTS

Of 150 patients recruited, the majority (n=27) were between 51 and 60 years and the male to female ratio was 1.63:1. Fifteen patients (10%) were culture positive. The culture positivity was significantly higher in acute lymphocytic leukemia (ALL) than in non-ALL patients (p=0.03). There was significant association of candidaemia with leucopenia, chemotherapeutic drugs, corticosteroids and presence of indwelling devices. Duration of disease (p=0.032) and duration of hospitalization (p=0.003) were significantly prolonged in culture positive patients. C. tropicalis was the commonest isolate (46.67%), with non- Candida albicans outnumbering C. albicans in all categories of hematological malignancies (2.75:1). All isolates of C. albicans were uniformly sensitive to all the azoles, but only 50% were sensitive to amphotericin B and none to nystatin and flucytosine.

CONCLUSIONS

This observational study identifies ALL and chronic lymphocytic leukemia (CLL) as the forms of hematological malignancy predominantly associated with candidemia; specifies risk factors and chemotherapeutic agents predisposing patients towards its occurrence; reports a preponderance of C. tropicalis among the causative agents and finds voriconazole to be the most effective antifungal agent against the recovered isolates. This information could assist in tailoring prophylactic and therapeutic antifungal practices for this infection, according to local epidemiological and mycological characteristics.

Antibiotic overuse as a risk factor for candidemia in an Indian pediatric ICU

OBJECTIVE

To identify risk factors and mycological characteristics of candidemia in Pediatric ICU of a tertiary-care hospital.

METHODS

Patients were screened for candidemia by blood culture. Recovered isolates were speciated and subjected to antifungal susceptibility testing. For every candidemic patient, three controls were matched for age, underlying diagnosis and period of hospitalization. Premature neonates were also matched for birth-weight. Proportion of cases and controls on specific antibiotics or indwelling devices was compared using Chi-square test, while unpaired t-test was used for comparing the number of antibiotics used and the number of days of antibiotic administration. Concordance between susceptibility testing methods was evaluated using Chi-square test.

RESULTS

Significantly wider spectrum of antibiotic coverage was observed among the 28 candidemic patients. While every patient received antibiotic against enteric gram-negative bacilli, antibiotic usage for additional groups of microorganisms was significantly higher among cases. Association of candidemia with increasing use of indwelling devices was also observed. Endogenous colonization was higher in candidemic infants. Candida albicans was the commonest species (n = 18), followed by C. tropicalis (n = 7). Fluconazole and ketoconazole resistance was observed in 10.7 % cases.

CONCLUSIONS

This information on pediatric candidemia could be used to devise locally-tailored strategies for identifying at-risk patients, underline the importance of routine antifungal susceptibility testing and formulate appropriate guidelines for management.

Analysis of Independent Risk Factors for Death Among Pediatric Patients With Candidemia and a Central Venous Catheter in Place

Objective.

To use multivariate analysis to determine risk factors for death among pediatric patients with candidemia and a central venous catheter in place.

Design.

Retrospective cohort study conducted at Santa Casa Complexo Hospitalar, a 1,200-bed teaching hospital in southern Brazil.

Methods.

All cases of candidemia in pediatric patients (age, ≤ 13 years) at our medical center over a 9-year period were reviewed. A diagnosis of sepsis was required for inclusion in the study. Severity of illness was confirmed by the presence of hypotension requiring inotropes and according to the following scores: the Pediatric Risk of Mortality (PRISM) II score, the PRISM III score, and the Pediatric Logistic Organic Dysfunction score. The following 2 outcomes were evaluated: early death, defined as death occurring within 7 days after candidemia was diagnosed, and late death, defined as death 8-30 days after candidemia was diagnosed.

Results.

A total of 61 patients were included in the study, including 14 neonates. Most (63.9%) of these patients were girls, and the median age was 0.3 years. A total of 80.3% of candidemia cases were due to species other than Candida albicans, primarily Candida parapsilosis (32.8% of cases) and Candida tropicalis (24.6% of cases). Using multivariate analysis, we demonstrated that failure to remove the central venous catheter was an independent risk factor for early death among pediatric patients with candidemia. However, patients whose catheters were retained were sicker than patients whose catheters were removed, and catheter removal had no impact on late death. Instead, severity of illness determined using the PRISM III score was also an independent predictor of late death.

Conclusions.

Results from this study suggest that systematic removal of catheters from pediatric patients with candidemia does not reduce the occurrence of late death.

Per-species risk factors and predictors of invasive Candida infections in patients admitted to pediatric intensive care units: development of ERICAP scoring systems

BACKGROUND

Prediction rules for invasive Candida infection (ICI) are available for adult but not for infants and children managed in pediatric intensive care units (PICU).

METHODS

Observational study in 24 PICU with prospective phase (all children admitted during 1 year) and retrospective review of ICI records. Four logistic regression models were performed using ICI by Candida spp., Candida albicans, Candida parapsilosis or Candida tropicalis as dependent variables. Scores were constructed.

RESULTS

One hundred and twenty five ICI (47 C. albicans, 37 C. parapsilosis, 19 C. tropicalis and 22 others) and 1022 controls were included. Incidence (cases/100 PICU admissions): 4.22 (all Candida), 2.44 (C. albicans), 1.41 (C. parapsilosis), 0.19 (C. tropicalis). ICI was associated [Area under the receiver operating characteristics curve (AUC) = 0.764, 95% confidence interval (CI) = 0.719-0.809, P < 0.001] with pre-PICU hospitalization ≥ 15 days [odds ratio (OR) = 3.3; score: +3], fever (OR = 2.6; +2), thrombopenia (OR = 2.0; +1) and parenteral nutrition (OR=2.4; +2). Additionally, the following associations were noted: C. albicans ICI (AUC = 0.716, 95% CI = 0.640-0.792, P < 0.001) with chronic metabolic disease (OR = 10.7; score:+4), surgical digestive process (OR = 2.8; +1), fever (OR = 2.8; +1) and parenteral nutrition (OR = 2.3; +1); C. parapsilosis ICI (AUC = 0.808, 95% CI = 0.739-0.877, P < 0.001) with previous colonization (OR = 7.1; score:+3), tracheostomy (OR = 5.1; +2), parenteral nutrition (OR = 4.3; +2), thrombopenia (OR = 3.6; +1) and previous bacterial infection (OR = 3.0; +1) and ICI by C. tropicalis (AUC = 0.941, 95% CI=0.886-0.995, P < 0.001) with thrombopenia (OR = 53.8; score: +10), neutropenia (OR = 7.2; +1), pre-PICU hospitalization ≥ 15 days (OR = 17.2; +3) and hematologic (OR = 22.4; +4) and cardiovascular infectious processes (OR = 5.5; +1). Specificity was >90% for cut offs of 5 (all Candida), 3 (C. albicans), 3 (C. parapsilosis) and 11 (C. tropicalis).

CONCLUSIONS

Once validated, these scores may help for identification of ICI by specific species allowing adequate empiric/prophylactic treatment.

Probiotic use and prevalence of candidemia and candiduria in a PICU

OBJECTIVES

To compare the prevalence of candidemia and candiduria before and after the introduction of routine use of probiotics in children who received broad-spectrum antibiotics in a PICU.

DESIGN

Retrospective "before and after" study.

SETTING

A 12-bed PICU of a teaching hospital in India.

PATIENTS

Children 3 months to 12 years old, admitted to the PICU over two 9 months' time periods, who received broad-spectrum antibiotics for more than 48 hours.

INTERVENTIONS

Three hundred forty-four patients enrolled between November 2008 and July 2009 after the introduction of routine use of probiotics served as the "probiotic group"; they had received one sachet twice a day of a probiotic mix (EUGI [Wallace Pharma, Goa, India] containing Lactobacillus acidophillus, Lactobacillus rhamnosum, Bifidobacterium longum, Bifidobacterium bifidum, Saccharomyces boulardii, and Streptococcus thermophilus) for 7 days. Three hundred seventy-six children enrolled between February 2007 and October 2007 served as "controls." Blood was sent for bacterial and fungal cultures if clinically indicated and urine catheter/bag specimen was submitted for bacterial and fungal culture twice a week as per unit's protocol.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was growth of Candida in blood (candidemia), and secondary outcomes were growth of Candida in urine (candiduria), nosocomial bloodstream infections, and urinary tract infections. Data were retrieved from the case records. Candidemia was seen in four of 344 patients (1.2%) in the probiotic group and in 14 of 376 (3.7%) in the control group (relative risk, 0.31; 95% CI, 0.10-0.94; p = 0.03). Candiduria was noted in 37 of 344 patients (10.7%) in the probiotic group and 83 of 376 (22%) in the control group (relative risk, 0.48; 95% CI, 0.34-0.7; p = 0.0001). The prevalence of nosocomial bloodstream infection and urinary tract infection in the probiotic and control groups was 20.3% and 26% (p = 0.07) and 14.2% and 19.1% (p = 0.08), respectively.

CONCLUSIONS

Routine use of a mix of probiotics in patients who receive broad-spectrum antibiotics could be a useful strategy to reduce the prevalence of candidemia and candiduria in the PICU.

Invasive candidiasis in pediatric intensive care in Greece: a nationwide study

PURPOSE

To record the practices for prevention and management of invasive candidiasis in the PICU and investigate the epidemiology of candidiasis and its outcome nationwide.

METHODS

A multicenter national study among PICUs throughout Greece. A questionnaire referring to local practices of prevention and management of candidemia was filled in, and a retrospective study of episodes that occurred during 5 years was conducted in all seven Greek PICUs.

RESULTS

Clinical practices regarding surveillance cultures, catheter replacement protocols and antibiotic use were similar, although the case mix differed. In all PICUs prophylactic antifungal treatment was administered in transplant and neutropenic oncology patients. Discrepancy existed between PICUs concerning the first-line antifungal agents and treatment duration of candidemia. Twenty-two candidemias were nationally recorded between 2005 and 2009 with a median incidence of 6.4 cases/1,000 admissions. Median age was 8.2 (0.3-16.6) years. Candida albicans was isolated in 45.4 % of episodes followed by Candida parapsilosis (22.7 %). Common findings were presence of central venous and urinary catheters as well as mechanical ventilation and administration of antibiotics with anti-anaerobic activity in almost all patients with candidemia. Total parenteral nutrition was administered to five (22.7 %) patients. Most of the patients had a chronic underlying disease; five were oncology patients, and two-thirds of those with candidemia were colonized with Candida spp. Lipid amphotericin B formulations were the predominant therapeutic choice (54.5 %). Thirty-day mortality was 18.2 %.

CONCLUSION

This first national study adds information to the epidemiology of candidemia in critically ill children. In these special patients, candidemia has a relatively low incidence and tends toward non-albicans Candida preponderance.

Evaluation of efficacy of probiotics in prevention of candida colonization in a PICU-a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of probiotics in prevention of Candida colonization in a PICU.

DESIGN

Prospective double blinded, randomized controlled trial.

SETTING

PICU of a tertiary care teaching hospital in north India.

SUBJECTS

One hundred fifty children (106 boys, 44 girls), 3 months to 12 yrs old, on broad spectrum antibiotics for at least 48 hrs were randomized using computer-generated random numbers to receive probiotic mix (EUGI) (n = 75) or placebo (n = 75).

INTERVENTION

Patients received one sachet twice a day of either probiotics or placebo for 7 days. Probiotics contained Lactobacillus acidophillus, Lactobacillus rhamnosum, Bifidobacterium longum, Bifidobacterium bifidum, Saccharomyces boulardi, Saccharomyces thermophilus, fructo-oligosaccharides; and placebo-contained lactose packed in similar-looking sachets. Rectal swabs for fungal culture were taken at day 0, 7, and 14 of enrollment. Primary outcome measure was prevalence of rectal colonization with Candida on day 14 postenrollment; secondary outcomes were growth of Candida in urine (candiduria) and blood (candidemia). Patients were followed until completion of 14 days study period or death of patient.

RESULTS

Demographic and clinical variables were comparable in two groups. Prevalence of Candida colonization on day 0 was similar (15 of 75) in both the groups. On day 7, 27.9% (19 of 68) patients in the probiotic group and 42.6% (29 of 68) patients in the placebo group were colonized (relative risk 0.65; 95% confidence interval 0.41-1.05; p = 0.07), whereas, on day 14, colonization was observed in 31.3% (21 of 67) patients in the probiotic group and 50% (34 of 68) in the placebo group (relative risk 0.63; 95% confidence interval 0.41-0.96; p = 0.02). Thus, the relative reduction in prevalence of Candida colonization on day 7 and 14 in the probiotic group was 34.5% and 37.2%, respectively. The increase in number of colonized patients from day 0 to 7 and day 0 to 14 was significant in the placebo group (p = 0.004 and 0.001, respectively) but not in the probiotic group (p = 0.30 and 0.19, respectively; McNemar test). Candiduria was significantly less common in the probiotic group than in the placebo group (17.3% vs. 37.3%; relative risk 0.46; 95% confidence interval 0.26-0.82; p = 0.006). However, prevalence of candidemia did not differ significantly in two groups (1.6% in the probiotic group vs. 6.35% in placebo group; relative risk 0.46; 95% confidence interval 0.08-2.74; p = 0.39).

CONCLUSIONS

Supplementation with probiotics could be a potential strategy to reduce gastrointestinal Candida colonization and candiduria in critically ill children receiving broad spectrum antibiotics.

Role of probiotics in prevention of Candida infection in critically ill children

Candidiasis accounts for 10-20% of bloodstream infections in paediatric intensive care units (PICUs) and a significant increase in morbidity, mortality, and length of hospital stay. Enteric colonisation by Candida species is one of the most important risk factor for invasive candidiasis. The local defence mechanisms may be altered in critically ill patients, thus facilitating Candida overgrowth and candidiasis. Systemic antifungals have been proven to be effective in reducing fungal colonisation and invasive fungal infections, but their use is not without harms. Early restoration or maintenance of intestinal microbial flora using probiotics could be one of the important tools for reducing Candida infection. A few studies have demonstrated that probiotics are able to prevent Candida growth and colonisation in neonates, whereas their role in preventing invasive candidiasis in such patients is still unclear. Moreover, there are no published data on role of probiotics supplementation in the prevention of candidiasis in critically ill children beyond neonatal period. There are gap in our knowledge regarding efficacy, cost effectiveness, risk-benefit potential, optimum dose, frequency and duration of treatment of probiotics in prevention of fungal infections in critically ill children. Studies exploring and evaluating the role of probiotics in prevention of Candida infection in critically ill children are needed.

The morbidity and mortality of patients with fungal infections before and during extracorporeal membrane oxygenation support

OBJECTIVE

To evaluate the prevalence of fungal infections (both pre-cannulation and post-cannulation) while on extracorporeal membrane oxygenation support and the associated morbidity and mortality.

DESIGN

Retrospective cohort study.

PATIENT AND METHODS

The Extracorporeal Life Support Organization database is an international voluntary registry of clinical data for patients placed on extracorporeal membrane oxygenation. The database was queried for all patients on extracorporeal membrane oxygenation from 1997 to 2009. Patient and extracorporeal membrane oxygenation data collected included age, support type, length of support, infection status and organism code, discharge status, complications, and component failures. Outcomes of interest were mortality, extracorporeal membrane oxygenation-related patient complications, and mechanical component failures.

RESULTS

From 1997 to 2009, there were 21,073 patients' extracorporeal membrane oxygenation runs analyzed of which 12,933 were in the neonatal group (0-30 days), 6,073 were in the pediatric group (31 days to <18 yrs old), and 2,067 were in the adult group (≥18 yrs). The prevalence of fungal infection during extracorporeal membrane oxygenation varied by age group and timing of infection and ranged from 0.04% to 5%. Fungal infections pre-extracorporeal membrane oxygenation and on-extracorporeal membrane oxygenation conferred a statistically significant higher relative risk of mortality for all age groups and varied by support type and timing of infection. Extracorporeal membrane oxygenation-related complications and component failures were not statistically significantly affected by infection status.

CONCLUSIONS

Fungal infection before or during extracorporeal membrane oxygenation increases the odds of mortality and the magnitude of this effect is dependent upon age-group and timing of infection. This increased mortality was not the result of increased patient or mechanical complications during extracorporeal membrane oxygenation. For patients with fungal infections pre-extracorporeal membrane oxygenation, 82%-89% demonstrated presumed clearance during extracorporeal membrane oxygenation. Although the risk of mortality increased with fungal infections, it does not appear that fungal infection before or during extracorporeal membrane oxygenation is a contraindication to initiation or continuation of support.

A review of Candida prophylaxis in the neonatal intensive care population

OBJECTIVE

To review the efficacy and safety of antifungal prophylaxis in the neonatal intensive care setting.

DATA SOURCES

English-language literature was accessed using MEDLINE (January 1988- December 2010). The following Medical Subject Heading (MeSH) search terms were used: "amphotericin B," "fluconazole," "nystatin," "itraconazole," "caspofungin," "voriconazole," "Candida," "prevention and control," and "critically ill." Literature was further limited to studies focusing on patient birth to 6 months of age. Abstracts and original research articles were included. Preference was given to published controlled trials. Articles providing descriptions of the safety and effectiveness of antifungal prophylaxis in neonatal intensive care patients were also used in this review.

RESULTS

Twenty-two studies have evaluated the impact of antifungal prophylaxis on Candida colonization or invasive infections in the Neonatal Intensive Care Unit (NICU). The two antifungal agents most commonly studied were nystatin and fluconazole. All of the nystatin studies demonstrated that nystatin is effective at reducing fungal colonization and invasive fungal infections. All of the studies designed to evaluate the impact of fluconazole prophylaxis on fungal colonization demonstrated a reduction in the incidence of fungal colonization with fluconazole prophylaxis. A total of 12 of 16 studies that evaluated the impact of fluconazole prophylaxis on the incidence of invasive fungal infections demonstrated a reduction in invasive fungal infections with fluconazole prophylaxis. Two studies found no difference between fluconazole and nystatin when used for prophylaxis.

CONCLUSION

Antifungal prophylaxis appears to be effective in reducing the incidence of Candida colonization and invasive Candida infections in the NICU. Antifungal prophylaxis also appears to be safe in the NICU population. The impact of antifungal prophylaxis on resistance patterns could be significant and needs to be evaluated long term before widespread prophylaxis can be recommended.

Symptomatic and asymptomatic candidiasis in a pediatric intensive care unit

INTRODUCTION

This study aimed to examine the incidence, epidemiology, and clinical characteristics of symptomatic and asymptomatic candidiasis in a pediatric intensive care unit (PICU), and to determine the risk factors associated with symptomatic candidiasis.

METHODS

This retrospective study included 67 patients from a 7-bed PICU in a tertiary care hospital that had Candida-positive cultures between April 2007 and July 2009. Demographic and clinical characteristics of the patients, Candida isolates, antimicrobial and antifungal treatments, and previously identified risk factors for symptomatic candidiasis were recorded, and symptomatic and asymptomatic patients were compared.

RESULTS

In all, 36 (53.7%) of the patients with Candida-positive cultures had asymptomatic candidiasis and 31 (46.3%) had symptomatic candidiasis. Candida albicans was the most common Candida sp. in the asymptomatic patients (n = 20, 55.6%), versus Candida parapsilosis in the symptomatic patients (n = 15, 48.4%). The incidence of central venous catheter indwelling, blood transfusion, parenteral nutrition, and surgery was higher in the symptomatic patient group than in the asymptomatic patient group (P < 0.5). Surgery was the only independent predictor of symptomatic candidiasis according to forward stepwise multivariate logistic regression analysis (OR: 6.1; 95% CI: 1.798-20.692).

CONCLUSION

Surgery was the only risk factor significantly associated with symptomatic candidiasis and non-albicans Candida species were more common among the patients with symptomatic candidiasis. While treating symptomatic candidiasis in any PICU an increase in the incidence of non-albicans candidiasis should be considered.

Epidemiology and antifungal susceptibility of bloodstream fungal isolates in pediatric patients: a Spanish multicenter prospective survey

Data on fungemia epidemiology and antifungal susceptibility of isolates from children are scarce, leading frequently to pediatric empirical treatment based on available adult data. The present study was designed to update the epidemiological, mycological, and in vitro susceptibility data on fungal isolates from children with fungemia in Spain. All fungemia episodes were identified prospectively by blood culture over 13 months at 30 hospitals. Tests of susceptibility to amphotericin B, flucytosine, fluconazole, itraconazole, posaconazole, voriconazole, anidulafungin, caspofungin, and micafungin were performed at participant institutions by a microdilution colorimetric method. New species-specific clinical breakpoints for fluconazole, voriconazole, and echinocandins were also applied. A total of 203 episodes of fungemia in 200 children were identified. A higher proportion of fungal isolates was from general wards than intensive care units (ICU). Candida parapsilosis (46.8%), Candida albicans (36.5%), Candida tropicalis (5.9%), Candida glabrata (3.9%), and Candida guilliermondii (2.5%) were the leading species. C. parapsilosis was the predominant species except in neonates. C. albicans was the most frequent in neonatal ICU settings (51.9%). Intravascular catheter (79.3%), surgery (35%), prematurity (30%), and neutropenia (11%) were the most frequent predisposing factors. Most Candida isolates (95.1%) were susceptible to all antifungals. When the new species-specific clinical breakpoints were applied, all C. parapsilosis isolates were susceptible to echinocandins except one, which was micafungin resistant. This is the largest published series of fungemia episodes in the pediatric setting. C. parapsilosis is the most prevalent species in Spain, followed by C. albicans and C. tropicalis. Resistance to azole and echinocandin agents is extremely rare among Candida species. The fluconazole resistance rate in Spain has decreased in the last 10 years.

Risk factors and predictors for candidemia in pediatric intensive care unit patients: implications for prevention

BACKGROUND

Candida species are the leading cause of invasive fungal infections in hospitalized children and are the third most common isolates recovered from patients with healthcare-associated bloodstream infection in the United States. Few data exist on risk factors for candidemia in pediatric intensive care unit (PICU) patients.

METHODS

We conducted a population-based case-control study of PICU patients at Children's Hospital of Philadelphia during the period from 1997 through 2004. Case patients were identified using laboratory records, and control patients were selected from PICU rosters. Control patients were matched to case patients by incidence density sampling, adjusting for time at risk. Following conditional multivariate analysis, we performed weighted multivariate analysis to determine predicted probabilities for candidemia given certain risk factor combinations.

RESULTS

We identified 101 case patients with candidemia (incidence, 3.5 cases per 1000 PICU admissions). Factors independently associated with candidemia included presence of a central venous catheter (odds ratio [OR], 30.4; 95% confidence interval [CI], 7.7-119.5), malignancy (OR, 4.0; 95% CI, 1.23-13.1), use of vancomycin for >3 days in the prior 2 weeks (OR, 6.2; 95% CI, 2.4-16), and receipt of agents with activity against anaerobic organisms for >3 days in the prior 2 weeks (OR, 3.5; 95% CI, 1.5-8.4). Predicted probability of having various combinations of the aforementioned factors ranged from 10.7% to 46%. The 30-day mortality rate was 44% among case patients and 14% among control patients (OR, 4.22; 95% CI, 2.35-7.60).

CONCLUSIONS

To our knowledge, this is the first study to evaluate independent risk factors and to determine a population of children in PICUs at high risk for developing candidemia. Future efforts should focus on validation of these risk factors identified in a different PICU population and development of interventions for prevention of candidemia in critically ill children.

Dual candidemia detected by nested polymerase chain reaction in two critically ill children

The use of improved microbiological procedures associated with molecular techniques has increased the identification of Candida bloodstream infections, even if the isolation of more than one species by culture methods remains uncommon. We report the cases of two children presenting with severe gastrointestinal disorders and other risk factors that contribute to Candida infections. In the first patient, C. albicans DNA was initially detected by a nested-amplification and C. tropicalis was found later during hospitalization, while blood cultures were persistently negative. In the second child, there was amplification of C. albicans and C. glabrata DNA in the same samples, but blood cultures yielded only C. albicans. Both patients received antifungal therapy but had unfavorable outcomes. These two cases illustrate that PCR was more successful than culture methods in detecting Candida in the bloodstream of high risk children, and was also able to detect the presence of more than one species in the same patient that might impact therapy when the fungi are resistant to azole compounds.

Invasive candidiasis in pediatric intensive care units

Candidemia and disseminated candidiasis are major causes of morbidity and mortality in hospitalized patients especially in the intensive care units (ICU). The incidence of invasive candidasis is on a steady rise because of increasing use of multiple antibiotics and invasive procedures carried out in the ICUs. Worldwide there is a shifting trend from C. albicans towards non albicans species, with an associated increase in mortality and antifungal resistance. In the ICU a predisposed host in one who is on broad spectrum antibiotics, parenteral nutrition, and central venous catheters. There are no pathognomonic signs or symptoms. The clinical clues are: unexplained fever or signs of severe sepsis or septic shock while on antibiotics, multiple, non-tender, nodular erythematous cutaneous lesions. The spectrum of infection with candida species range from superficial candidiasis of the skin and mucosa to more serious life threatening infections. Treatment of candidiasis involves removal of the most likely source of infection and drug therapy to speed up the clearance of infection. Amphotericin B remains the initial drug of first choice in hemodynamically unstable critically ill children in the wake of increasing resistance to azoles. Evaluation of newer antifungal agents and precise role of prophylactic therapy in ICU patients is needed.

Epidemiology of candidemia at a Children's hospital, 2002 to 2006

BACKGROUND

There are few recent studies evaluating trends in the epidemiology of candidemia including changes in species or utilization of antifungal agents in children.

METHODS

We performed a retrospective case series of candidemia at our children's hospital from 2002 to 2006. Our objectives were to study trends in the rates of candidemia, demographic characteristics, Candida species, antifungal susceptibility, and antifungal utilization. These data were obtained from the electronic medical records.

RESULTS

There were 203 episodes of candidemia in 154 subjects. During the study period, the average rate of candidemia was 5.52 per 1000 patient-discharges and did not change throughout the study. The mean and median ages of subjects were 3 years versus 9 months, respectively, and 38% were less than 3 months of age. Gastrointestinal disorders were a common comorbid condition (33%), especially for subjects with multiple episodes of candidemia. Overall, Candida parapsilosis and Candida albicans caused 43% and 26% of episodes, respectively, and candidemia caused by Candida glabrata (5.3%-23%) and Candida krusei (0%-8.5%) increased during the study. Ninety-eight percent of C. albicans and C. parapsilosis isolates remained susceptible to all antifungal drugs. From 2003-2006, the use of antifungal agents increased from 79 days to 150 days per 1000 hospital-days.

CONCLUSIONS

While antifungal use at our hospital increased, candidemia rates remained stable. C. parapsilosis was the most common species but other non-C. albicans species increased during the study period. Local epidemiology should be monitored in pediatric populations for potential impact on management strategies.

Candida colonization and candidemia in a pediatric intensive care unit

OBJECTIVE

To evaluate role of Candida colonization in development of candidemia and to identify risk factors associated with Candida colonization and candidemia in children treated for severe sepsis or septic shock in a pediatric intensive care unit (PICU) for >5 days.

DESIGN

Prospective observational.

SETTING

PICU of a tertiary care teaching hospital.

SUBJECTS

Of 186 children, aged 1 month to 14 yrs, consecutively admitted to PICU for severe sepsis or septic shock, 65 patients having a stay of >5 days.

INTERVENTIONS

Clinical and demographic data at admission and variables likely to influence Candida colonization were recorded. Oropharyngeal, rectal, and skin (groin) swabs were taken on days 0, 2, 5, and 7 of admission. Blood for fungal culture (two samples 48 hrs apart) was obtained if a patient developed signs of sepsis. The yeast growth was identified by conventional methods. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, and multivariate logistic regression analysis was conducted.

MEASUREMENTS AND MAIN RESULTS

Colonization by Candida species occurred in 45 (69%) patients. Oropharyngeal (52%) and rectal (43%) colonization was more common than skin (34%) colonization. The colonizing species were C. tropicalis (34.2%), C. parapsilosis (28.8%), C. albicans (14.4%), and others. Use of central venous catheters was the only independent predictor of colonization on multivariate logistic regression (OR 4.1; 95% CI 1.01-17.1). Twenty (30.2%) patients developed candidemia; 18 (90%) of them were colonized, 15 (75%) with the same Candida species. Independent predictors of candidemia on multivariate stepwise logistic regression analysis were presence of colonization (OR 5.1; 95% CI 1.01-25.6, p = .048) and Pediatric Risk of Mortality score (OR 1.3; 95% CI 1.02-1.6, p = .034).

CONCLUSIONS

Monitoring for colonization with Candida species in children undergoing treatment for severe sepsis or sepsis shock in PICU for >5 days may offer opportunity for early intervention for prevention of candidemia.

Nosocomial bloodstream infection in a pediatric intensive care unit

OBJECTIVE

To study the incidence of nosocomial blood stream infections (BSI) in a pediatric intensive care unit (PICU) of a tertiary care teaching hospital, identify the organisms responsible and the pattern of antibiotic resistance over one decade.

METHODS

Data was retrieved from the records of PICU and Medical Microbiology laboratory of patients with a positive blood culture after 48 hours of admission to PICU over three time periods viz. 1994-1996, 1999-2001 and 2002-2003. Antibiotic sensitivity pattern was also analyzed.

RESULTS

861 episodes (1994-1996: 282, 1999-2001: 362 and 2002-2003: 217) of nosocomial bloodstream infection were documented in 841 patients, corresponding to 3.63, 5.94 and 4.99 episodes per 100 patient-days, respectively. Gram negative organisms were the predominant isolates; common being Klebsiella pneumoniae (20.1%), Enterobacter species (16.6%) and Acinetobacter species (8.6%). Staphylococcus aureus (16.4%) and yeast species (15.9%) were the major Gram positive isolates. Isolation of Staphylococcus aureus , Klebsiella and Acinetobacter species showed a rising trend while yeast (36.9%, 6.6% and 4.1%) showed a decline over the three time periods studied. An increasing trend of resistance to third generation cephalosporins, aminoglycosides, ciprofloxacin and newer antibiotics including combination of beta-lactam with beta-lactamase inhibitor was noted.

CONCLUSION

The predominant organisms responsible for nosocomial infection in the PICU were Klebsiella pneumoniae , Staphylococcus aureus and Enterobacter species . At present, carbapenems plus vancomycin appear to be the best choice for empiric antibiotic therapy in the PICU in Chandigarh.

Epidemiology of candidemia in a tertiary care centre of north India: 5-year study

BACKGROUND

To determine the distribution of species of Candida and the risk factors associated with candidemia in Indian population for which we conducted a retrospective study for 5 years in a tertiary care centre of North India.

MATERIALS AND METHODS

Blood samples from 7,297 patients aged from 3 days to 85 years, suspected with candidemia, were collected and tested for Candida. The susceptibility patterns toward fluconazole for the year 2005 isolates were tested by micro-dilution assay as described in the CLSI (M27A-2 method).

RESULTS

Most of the episodes have been caused by species other than C. albicans. Non-albicans candidemia was 79%-80% in both female and male populations. The most frequent species isolated from 275 patients in 5 years (January 2001-December 2005) was C. tropicalis (35.3%), followed by C. albicans (21.5%), C. parapsilosis (20%), C. glabrata (17.5%), C. krusei (3.3%), C. haemulonii (1.5%), and C. guilliermondii (1%). C. parapsilosis was the predominant in the fifth year of the study (2004-2005). Dose-dependent susceptibility to fluconazole was observed in 5% (n = 3) of the strains. Antifungal resistance was found in 11.7% (n = 7), which includes only C. glabrata.

CONCLUSION

These results were comparable to those derived from other regions of India. C. tropicalis has been reported as the predominant species involved in the cases of candidemia. But in 2005 it has moved toward C. parapsilosis. No true antifungal resistance is reported. Further epidemiological surveillance is needed.

Invasive candidiasis in pediatric intensive care patients: epidemiology, risk factors, management, and outcome

BACKGROUND

The incidence of candidemia in pediatric patients follows the same pattern of increase as in adults, but the rate of increase is greater. Pediatric patients in critical condition, particularly young infants, are especially vulnerable to invasive Candida infections (ICI), partly because of their age and severe underlying disease and partly because of the invasive procedures used.

DISCUSSION

Central venous catheters and arterial lines, parenteral nutrition, mechanical ventilation and extended use of antimicrobials enhance the risk of ICI. C. albicans continues to be the most prevalent isolate. However, an increasing role of non-C. albicans (NAC) spp., some of which are intrinsically or potentially resistant to antifungal agents, has been observed. NAC spp., particularly C. parapsilosis and C. tropicalis, account for almost half of ICI. The increased use of antifungals in immunocompromised patients, mainly prophylactically, is considered the strongest contributory factor to the changes in species distribution, which have subsequently affected the mortality and choice of empirical treatment.

CONCLUSIONS

Prompt removal of lines and initiation of antifungal treatment are the milestones of management. Conventional amphotericin B remains a commonly used antifungal agent, but its lipid formulations and fluconazole are also used frequently. Novel antifungal agents such as second-generation triazoles and echinocandins exhibit potential as alternative agents in critically ill children with ICI. Although response rates are still far from satisfactory, improved understanding of risk factors, preventive strategies and new treatment options promise a better future outcome.

Distribution and epidemiology of Candida species causing fungemia at a Saudi Arabian hospital, 1996-2004

OBJECTIVES

The objective of this study was to evaluate the Candida species and the change over time in the organisms causing candidemia at Saudi Aramco Medical Services Organization in Saudi Arabia. We also describe the risk factors associated with mortality.

METHODS

This was a retrospective study of candidemia over nine years (1996-2004).

RESULTS

A total of 98 distinct episodes of candidemia were identified over the study period. The annual incidence of candidemia ranged between 0.2 and 0.76 cases/1000 hospital discharges with an incidence per 10 000 patient-days per year of 0.45 to 1.6. The most frequent Candida species were Candida albicans (53%), Candida tropicalis (19%), Candida parapsilosis (16%), and Candida glabrata (7%). In relation to predisposing factors, 83% of candidemia occurred in patients with central venous catheters and 96% had received broad-spectrum antibiotics. Other predisposing factors included complicated abdominal surgeries (22%), total parenteral nutrition (52%), neutropenia (9%), acute renal failure (24%), malignancy (26%) and burns (15%). However, prior fluconazole use was low (8%). The overall crude mortality rate was 43% for all candidemia. Logistic regression analysis identified two independent determinants of death, C. albicans (OR 5.91, 95% CI 1.50, 23.24, p=0.01) and acute renal failure (OR 5.15, 95% CI 1.18, 22.55, p=0.03).

CONCLUSION

The study showed that the rate of candidemia was low in our hospital and that C. albicans was the major species followed by C. tropicalis and C. parapsilosis. Future studies are needed to evaluate the antifungal susceptibility pattern in our hospital.

Oral amphotericin B for the prevention of Candida bloodstream infection in critically ill children

OBJECTIVES

To determine the efficacy of oral amphotericin B for the prevention of Candida bloodstream infection in the pediatric intensive care unit.

DESIGN

Retrospective, nonrandomized, historic-control study.

SETTING

Multidisciplinary pediatric intensive care unit at a university-affiliated children's medical center.

PATIENTS

Study group included all patients admitted to the pediatric intensive care unit from January 1, 1998, to December 31, 1999, who required mechanical ventilation and who were admitted for >7 days. The control group included all patients admitted for >7 days who needed mechanical ventilation from January 1, 1994, to December 31, 1997.

INTERVENTIONS

Oral amphotericin B suspension, 50 mg every 8 hrs, administered to all study group patients soon after initiation of mechanical ventilation and terminating after weaning.

MEASUREMENTS

The rates of Candida bloodstream infection were compared between the study and control groups.

MAIN RESULTS

Candida species were isolated from blood cultures in 5 of 185 (2.1%) and 21 of 196 (10.7%) patients in the study and control groups, respectively (p= .0038). There was also a statistically significant (p= .017) decrease in Candida bloodstream infection rate in all patients admitted to the pediatric intensive care unit for >7 days during the study period compared with the Candida bloodstream infection rate during the control period.

CONCLUSION

Prophylactic administration of oral amphotericin B may lead to a significant decrease in the rate of Candida bloodstream infection in ventilated pediatric intensive care unit patients.

A 9-year Study Comparing Risk Factors and the Outcome of Paediatric and Adults with Nosocomial Candidaemia

Although there are numerous studies of candidaemia in adults, data on paediatrics are still limited. The aim of this study was to compare risk factors, aetiology, therapy, and the outcome of nosocomial candidaemia among paediatric and adult patients in a large Brazilian tertiary hospital (1995-2003). During this period, 78 paediatrics and 113 adults were studied. Species other than Candida albicans caused 78.2% of episodes of candidaemia in paediatrics. Compared to adults, paediatrics received more frequently broad-spectrum antibiotics, vasopressors, blood transfusions, arterial catheter, chest tube, cardiothoracic surgery, mechanical ventilation, and parenteral nutrition. Candidaemia caused by Candida parapsilosis was more common in paediatrics, as was the isolation of Candida spp. from catheters. Amphotericin B treatment was more common in paediatrics. Mortality rate was higher in adults than in paediatrics with nosocomial candidaemia. We reinforce the necessity of continuous epidemiologic surveillance to follow the dynamics of candidaemia.

Randomized comparison between fluconazole and itraconazole for the treatment of candidemia in a pediatric intensive care unit: a preliminary study

OBJECTIVE

Candida bloodstream infections have shown an increase in hospitalized patients, especially those receiving intensive care. The effectiveness of various azoles, especially itraconazole, in treatment of candidemia has not been fully evaluated. Our objective was to compare the efficacy and safety of enterally administered itraconazole vs. fluconazole in treatment of candidemia.

DESIGN

Randomized, double-blind, controlled trial.

SETTING

Pediatric intensive care unit of a referral and teaching hospital.

SUBJECTS

Forty-three pediatric patients with candidemia,

INTERVENTION

Patients received either fluconazole (n = 22) or itraconazole (n = 21), about 10 mg/kg orally or through a gastric tube, and were monitored for clinical and mycological cure (sterile fungal blood culture), blood counts, and liver and renal functions.

MEASUREMENTS AND MAIN RESULTS

The clinical characteristics of two groups were comparable. The cure rate was similar in both the groups: itraconazole 17 of 21 (81%) and fluconazole 18 of 22 (82%). Crude mortality rate (itraconazole 9.5% and fluconazole 13.6%) was also comparable in two groups of patients. The frequency of electrolyte disturbance was very low and similar in both the groups. Blood urea, creatinine, liver enzymes, and serum bilirubin were not adversely affected.

CONCLUSIONS

Itraconazole was as effective as fluconazole in nosocomial candidiasis in children receiving intensive care and was devoid of serious side effects.