Dr Chan Ka Hing Jacky, Department of Medicine, Tseung Kwan O Hospital
Editor’s note: Congratulations to Dr Chan who passed the CCM Exit Exam in May 2009!
Objective: Candidaemia is a common bloodstream infection in hospitals. The incidence has been stable or increasing in the past decade according to worldwide literature. Intensive care unit patient has been recognized as a particular group at risk of Candida infection. Data on candidaemia in local ICU is however lacking. This study looked into the epidemiology and trend of ICU candidaemia from 1999 to 2008 in a regional hospital of Hong Kong. Bloodstream infection due to Candida albicans and non-albicans species and in different patient groups would be compared.
Methods: Clinical records of all patients with positive blood cultures of Candida species in Queen Elizabeth Hospital intensive care unit from 1999 to 2008 were retrieved from Department of Microbiology. Patient demographics, distribution of Candida species, underlying medical conditions and surgery, management, clinical outcome and mortality were analysed.
Results: 90 ICU patients had candidaemia in this decade. Annual incidence rates of nosocomial candidaemia ranged from 4.8 to 21.1 per 1000 admissions and 0.9 to 3.2 per 1000 patient days. It remained similar from 1999 to 2005 followed by surge since 2006. 86 patients entered the retrospective review as 4 clinical records were disposed. 61.6% of patients were male and 51.2% were older than 60 years of age. Candida albicans (67.4%) was the most common species, followed by Candida tropicalis (16.3%) and Candida parapsilosis (8.1%). Mean duration from ICU admission to candidaemia was 10.6 days and the mean length of stay in ICU was 23.5 days. Use of immunosuppressant (16.3%), diabetes (15.1%), malignancy (14.0%) and chronic kidney disease (14.0%) were common associated medical conditions. 54.7% of patients had operations done and abdominal surgery was the most common. 79.1% of patients were diagnosed to have sepsis on ICU admission. All had antibiotics given and 14% had prophylactic antifungal agents. All had inotropic or vasopressor support and central line use. 98.8% had mechanical ventilation, 87.2% had packed cells transfusion, 68.6% had renal replacement therapy and 32.6% had TPN use. Mean APACHE II score was 28.8. Mortality reached 79.1% and was even higher in those with central line not removed and antifungal treatment not given.
Conclusion: Nosocomial candidaemia was associated with significant morbidity and high mortality. Its incidence remained similar till 2005 and had been rising in recent years. Early recognition of high risk patients, source removal and prompt antifungal use were of paramount importance.
References
[1] Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Crit Care Med 1999; 27: 887-892
[2] Wisplinghoff H, Bischoff T, Tallent SM, et al. Nosocomial bloodstream infections in US hospitals: analysis of 24179 cases from prospective nationwide surveillance study. Clin Infect Dis 2004; 39: 309-317
[3] Fridkin SK, Jarvis WR. Epidemiology of nosocomial fungal infections. Clin Microbiol Rev 1996; 9: 499-511
[4] Cortizo-Vidal S., Santiago I., Villami-Cajoto I., Rodriguez-Otero L., Martinez-Lamas L., Aguilera- Guirao A., García-Riestra C., García-Zaabarte Á. Incidence of candidaemia: 5-year results from emerging infections in patients from the intensive care unit of a tertiary hospital. Abstract number P1788, 18th European Congress of Clinical Microbiology and Infectious Diseases
[5] Wey SB, Mori M, Pfaller MA, Wollson RF, Wenzel RP. Risk factors for hospital acquired candidaemia: a matched case-control study. Arch Intern Med 1989; 149: 2349-53
[6] Bross J, Talbot GH, Maislin G, Hurwitz S, Strom BL. Risk factors for hospital acquired candidaemia: a case control study. Am J Med 1989; 87: 614-20
[7] Nguyen HM, Peaock JE, Morris AJ, et al. The changing face of candidaemia: emergence of non-candida albicans species and anti-fungal resistance. Am J Med 1996; 100: 617-23
[8] Genuth, S, Alberti, KG, Bennett, P, et al. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003; 26:3160
[9] ME Bougnuox, G Kac, P Aegerter, JY Fagan. Candidaemia and candiduria in criticially ill patients admitted to intensive care units in France: incidence, modecular diversity, management and outcome. Intensive Care Med 2008; 34: 292-299
[10] Vardakaz KZ, Michalopoulos A, Kiriakidou KG, Siampli EP, Samonis G, Falagas ME. Candidaemia: incidence, risk factors, characteristics and outcomes in immunocompetent critically ill patients. Clin Microbiol Infect. 2009 Jan 10.
[11] Yapar N, Uysal U, Yucesoy M, Cakir N, Yuce A. Nosocomial bloodstream infections associated with Candida species in a Turkish University Hospital. Mycoses 2006, Mar; 49(2): 134-138
[12] Luzzati R, Allegranzi B, Antozzi L, Masala L, Pegoraro E, Azzini A, Cincia E. Secular trends in nosocomial candidaemia in non-neutropenic patients in an Italian tertiary hospital. Clin Microbiol Infect. 2005 Nov; 11(11): 908-913
[13] S schelenz, WR Gransden. Candidaemia in a London teaching hospital: analysis of 128 cases over a 7-year period. Mycoses 2003 (46): 390-396
[14] WE Trick, SK Fridkin, JR Edwards, RA Hajjeh, RP Gaynes. Secular trends of hospital acquired candidaemia among intensive care unit patients in the United States during 1989-1999. Clinical Infectious Disease 2002 (35): 627-630
[15] Blot SI, Vandewoude KH, Hoste EA, Colardyn FA. Effects of nosocomial candidaemia on outcomes of critically ill patients. Am J Med 113: 480-485
[16] Bassetti M, Righi E, Costa A, Fasce R, Molinari MP, Rosso R, Pallavicini FB, Viscoli C. Epidemiological trends in nosocomial candidemia in intensive care. BMC Infect Dis. 2006 Feb 10; 6: 21
[17] Berrouane YF, Herwaldt LA, Pfaller MA. Trends in anti-fungal use and epidemiology of nosocomial yeast infections in a university hospital. J Clin Microbiol 1999; 37: 531-517
[18]. Vazquez JA, Peng G, Sobel JD, et al. Evolution of antifungal susceptibility among candida species isolates recovered from human immunodeficiency virus infected women receiving fluconazole prophylaxis. Clin Infect Dis 2001; 33: 1069-75
[19] Swinne D, Watelle M, Van der Flares M, Nolard N. In vitro activities of voriconzaole and other anti-fungal agents against clinical isolates of candida glabrata and candida krusei. Eur J Clin Microbiol Infect Dis 2004; 23: 619-24
[20] Parkinson T, Falconer DJ, Hitchcock CA. Fluconazole resistance due to energy-dependent drug efflux in candida glabrata. Antimicrob Agents Chemother 1995; 39: 1696-9
[21] Ricard Jorda-Marcos, Franciscop Alvarez-Lerma, Maite Jurado, Mercedes Palomar, Juan Nolla-Salas, Maria A Leon, Cristobal Leon and the EPCAN Study Group. Risk factors for candidaemia in critically ill patients: a prospective surveillance study. Mycosis 2007, 50: 302-310
[22] Pittet D, Monod M, Suter P, Frenk E, Auckenthaler R. Candida colonization and subsequently infection in critically ill surgical patients. Ann Surg 1994; 220: 751 – 758
[23] Magill SS, Swobodac SM, Johnson EA, et al. The association between anatomic site of candida colonization and mortality in critically ill surgical patients. Diagn Mircrobiol Infect Dis 2006; 55: 293-301
[24] Alvarez-Lerma F, Nolla-Salas J, Leon C, et al. Candiduria in criticallt ill patients admitted to intensive care medical units. Intensive Care Med 2003; 29: 2161 – 2169
[25] SP toya, DE Schraufnagel, GE Tzelepis. Candiduira in intensive care units: association with heavy colonization and candidaemia. Journal of Hospital Infection (2007) 66, 201-206
[26] Slotman GJ, Saphiro R, Moffa SM. Fungal sepsis: multisite colonization versus fungaemia. Am Surg 1994; 60: 107-13
[27] Nolla-Sala J, Sitges-Serra A, Leon-Gil C, et al. Candidaemia in non-neutropenic critically ill patients: analysis of prognostic factors and assessment of systemic antifungal therapy. Intensive Care Med 1997; 23: 23-30
[28] Rex JH, Bennet JE, Sugar AM, et al. Intravascular catheter exchange and duration of candidaemia. Clin Infect Dis 1995; 21: 994-6
[29] Pfaller MA. Nosocomial candidasis: emerginig species, reservoirs, and modes of transmission. Clin Infect Dis 1996; 22(S2): S89-94
[30] Eggimann P, Francioli P, Bille J, et al. Fluconazole prophylaxis prevents intra-abdominal candiddasis in high risk surgical patients. Crit Care Med 1999; 27: 1066-72
[31] Montravers P, Gauzit R, muller C, Marmuse JP, Fichelle A, Desmonts JM. Emergence of antibiotics-resistant bacteria in cases of peritonitis after intraabdominal surgery affects the efficacy of empirical antimicrobial therapy. Clin Infect Dis 1996; 23: 286-94
[32] Baker MS, Hinthron D, Lai SM, Ellerbeck EF. Diabet Med 2005 Sep; 22(9): 1252 – 7
[33] Sung JM, Ko WC, Huang JJ. Candidaemia in patients with dialysis-dependent acute renal failure: aetiology, predisposing and prognostic factors. Nephrol Dial Transplant 2001 Dec; 16(12): 2348 -56
[34] Edwards JE Jr. International conference for the development of a consensus on the management and prevention of severe candidal infections. Clin Infect Dis 1997; 25: 43-59
[35] Kwok M Ho, Jeffrey Lipman, Geoffrey J Dobb, Steven AR Webb. The use of prophylactic fluconazole in immunocompetent high-risk surgical patients: a meta-analysis. Critical Care 2005. 9: R701-R717
[36] Pasqualotto AC, Nedel WL, Machado TS, Severo LC. A comparative study of risk factors and outcome among outpatient-acquired and nosocomial candidaemia. J Hosp Infect 2005 Jun; 60(2): 129-34
[37] Geert J. Wanten, Mihai G. Netea, Ton H. Naber, Jo H. Curfs, Liesbeth E. Jacobs, Trees J. Verver-Jansen, and Bart-Jan Kullberg. Parenteral Administration of Medium- but Not Long-Chain Lipid Emulsions May Increase the Risk for Infections by Candida albicans. Infect Immun. 2002 November; 70(11): 6471-6474
[38] JK Chow, Yehuda Carmeli, Janet A Young, Susan Hadley. Risk factors for albicans and non albicans candidaemia in the intensive care unit. Crit Care Med 2008 Vol 36, No 5
[39] EG Playford, Q Nguyen, M Slavin, S Chen, D Marriott, D Ellis, TC Sorrell. Candidaemia in non-neutropenic critically ill patients: risk factors for non-albicans cnadida spp. Crit Care Med 2008 Vol 36, No 7
[40] P Munoz, A Burillo, E Bouza. Criteria used when initiating antifingal therapy against Candida spp. in the intensive care unit. Int J of Antimicrob Agents 2000 August 15: 83-90
[41] C Leon, S Ruiz-Santana, P Saavedra, B Almirante, J Nolla-Salas, F, Alvarez-Lerma, J Garnacho-Monero, M Angeles Leon. A bedside scoring system (candida score) for early antifungal treatment in non-neutropneic critically ill patients with candida colonization. Crit Care Med 2006 Vol 34, No 3
[42] Hauser AB, Stinghen AE, Kato S, Bucharles S, Aita C, Yuzawa Y, Pecoits-Filho R. Characteristics and causes of immune dysfunction related to uremia and dialysis. Perit Dial Int. 2008 Jun; 28 Suppl 3: S183-7
[43] Peter G Pappas, Carol A Kauffmann, David Andes, Daniel K Benjamen, Thierry F. Calandra. Clinical Practice Guidelines for the Management of candidasis. Clinical Infectious Disease 2009; 48: 503-535
[44] Brad J Spellberg, Scott G Filler, JE Edwards, Jr. Current treatment strategies for disseminated candidasis. Clinical Infectious Disease 2006; 42: 244-51
[45] Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clinical Infectious Disease 2004; 38: 161-89