Changing epidemiology and risk factors for candidemia in critically ill patients

Year 2021, , 97 - 102, 01.01.2021

Zuhal Yeşilbağ , Yasemin Tekdöş Şeker , Kübra Avcı Sevtap Şenoğlu , Zafer Çukurova Gülsüm Oya Hergünsel

https://doi.org/10.28982/josam.871514

Cited By: 1

Abstract

Background/Aim: Candidemia is a common cause of bloodstream infections in critically ill patients, resulting in high mortality and morbidity. This retrospective case-control study was designed to identify epidemiological characteristics and risk factors for candidemia in an intensive care unit.
Methods: A total of 166 patients hospitalized in the intensive care unit between January 2013 and December 2017 were included in this case-control study. Candidemia was defined as at least one positive blood culture for Candida spp. with fever or other clinical findings consistent with infection. Patients who acquired candidemia more than 48 hours after admission represented the case group (n=83). Control group (n=83) consisted of case-matching patients who were hospitalized during the same period and did not develop candidemia.
Results: In the candidemia group Candida albicans (57.8%) was the most common species, followed by Candida glabrata (13.3%) and Candida parapsilosis (12%). The rate of C. albicans decreased from 69.2% to 50% during the five-year study period. Out of 83 candidemia infections, 36 (43.4%) were associated with central venous catheters. C. parapsilosis had an increasing rate in parallel with central venous catheter-associated candidemia rates. When comparing cases and controls, in univariate analysis, Sequential Organ Failure Assessment (SOFA) score, blood transfusion, central venous catheter placement, intubation, gastrointestinal surgery and total parenteral nutrition were significantly more common in the candidemia group (P<0.05 for each). The rate of the patients whose Candida scores were higher or equal to 3, was significantly higher in candidemia group (P=0.03). According to the multivariate analysis, SOFA scores (P<0.001, OR:1.25, 95% CI:1.15-1.37), gastrointestinal surgery (P=0.03, OR:2.60, 95% CI:1.10-6.12), central venous catheter (P=0.04, OR:2.62, 95% CI:1.05-6.57) and total parenteral nutrition (P=0.02, OR:2.61, 95% CI:1.12-6.06) were independent risk factors for candidemia, while enteral feeding (P=0.02, OR:0.27, 95% CI:0.09-0.80) was protective against.
Conclusion: The result of our study is an evidence of the changing epidemiology of candidemia, which showed a shift towards non-albicans Candida spp. over the years. The increasing rate of C. parapsilosis and central venous catheter-associated candidemia has highlighted the need for more attention to the central line care and hand hygiene. Our study also revealed that critically ill patients with high SOFA score, gastrointestinal surgery, central venous catheter, and total parenteral nutrition have an elevated risk for developing candidemia. Unless necessary, limitation of total parenteral nutrition, and ensuring the earlier implementation of enteral feeding may be protective from candidemia.

Keywords

Candidemia, epidemiology, intensive care unit, risk factors

References

• 1. Gazendam RP, van de Geer A, Roos D, van den Berg TK, Kuijpers TW. How neutrophils kill fungi. Immunol Rev. 2016;273:299–311.
• 2. Invasive Candidiasis Statistics. Centers for Diseases and Prevention. https://www.cdc.gov/fungal/diseases/candidiasis/invasive/statistics.html Accessed 12 September 2020
• 3. Tsay S, Williams S, Mu Y, Epson E, Johnston H, Farley MM, et al. National burden of candidemia, United States. Open Forum Infect Dis. 2018;5(Suppl 1):142-3.
• 4. Annual Epidemiological Report 2016-Healthcare-associated infections acquired in intensive care units. European Centre for Disease Prevention and Control. https://www.ecdc.europa.eu/sites/default/files/documents/AER_for_2016-HAI_0.pdfAccessed 12 September 2020
• 5. Annual Epidemiological Report 2017-Healthcare-associated infections acquired in intensive care units. European Center for Disease Prevention and Control. https://www.ecdc.europa.eu/sites/default/files/documents/AER_for_2017-HAI.pdf Accessed 30 September 2020
• 6. Wisplinhoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, Edmond MB.Nosocomial bloodstream infections in US hospitals: analysis of 24179 cases from a prospective nationwide surveillance study. Clin Infect Dis. 2004;39:309–17.
• 7. Clinical and Laboratory Standards Institute. (2008). Reference method for broth dilution antifungal susceptibility testing of yeasts. Approved Standard, 3rd ed. CLSI Document M27-A3. CLSI, Wayne, PA.
• 8. Clinical and Laboratory Standards Institute(2012). Reference method for broth dilution antifungal susceptibility testing of yeasts. 4th Informational Supplement. CLSI Document M27-S4. CLSI, Wayne, PA.
• 9. Meyer E, Geffers C, Gastmeier P, Schwab F. No increase in primary nosocomial candidemia in 682 German intensive care units during 2006 to 2011. Euro Surveill. 2013;13;18(24):20505.
• 10. Gonzalez de Molina FJ, Leon C, Ruiz-Santana S, Saavedra P, CAVA I Study Group. Assessment of candidemia-attributable mortality in critically ill patients using propensity score matching analysis. Crit Care. 2012;14;16(3):R105
• 11. Kett DH, Azoulay E, Echeverria PM, Vincent JL. Extended prevalence of infection in ICU study (EPIC II) group of investigators. Candida bloodstream infections in intensive care units: analysis of the extended prevalence of infection in intensive care unit study. Crit Care Med. 2011;39:665–70.
• 12. Bassetti M, Giacobbe DR, Vena A, Trucchi C, Ansaldi F, Antonelli M, et al. Incidence and outcome of invasive candidiasis in intensive care units (ICUs) in Europe: results of the EUCANDICU project. Crit Care. 2019;14;23(1):219.
• 13. Pfaller MA, Andes DR, Diekema DJ, Horn DL, Reboli AC, Rotstein C, et al. Epidemiology and outcomes of invasive candidiasis due to non-albicans species of Candida in 2,496 patients: data from the Prospective Antifungal Therapy (PATH) registry 2004–2008. PLoS One. 2014;9(7):e101510.
• 14. Jia X, Li C, Cao J, Wu X, Zhang L. Clinical characteristics and predictors of mortality in patients with candidemia: a six-year retrospective study. Eur J Clin Microbiol Infect Dis. 2018;37(9):1717-24.
• 15. Tan TY, Hsu LY, Alejandria MM, Chaiwarith R, Chinniah T, Chayakulkeeree M, et al. Antifungal susceptibility of invasive Candida bloodstream isolates from the Asia- Pacific region. Med Mycol. 2016;54(5):471–7
• 16. TukenmezTigen E, Bilgin H, Perk Gurun H, Dogru A, Ozben B, Cerikcioglu N, et al. Risk factors, characteristics, and outcomes of candidemia in an adult intensive care unit in Turkey. Am J Infect Control. 2017;45(6):61-3.
• 17. Yılmaz Karadağ F, Ergen P, Aydın Ö, Doğru A, Tandır B, Vahaboğlu MH. Evaluation of epidemiological characteristics and risk factors affecting mortality in patients with candidemia. Turk J Med Sci. 2016;46(6):1724-8.
• 18. Mermutluoglu C, Deveci O, Dayan S, Aslan E, Bozkurt F, Tekin R. Antifungal susceptibility and risk Factors in patients with candidemia. Eurasian J Med. 2016;48:199-203.
• 19. Arslan F, Caskurlu H, Sari S, Dal HC, Turan S, Sengel BE, et al. Risk factors for noncatheter-related Candida bloodstream infections in intensive care units: A multicenter case-control study. Med Mycol Med Mycol. 2019;57(6):668-74.
• 20. San Miguel LG, Cobo J, Otheo E, Sanchez-Sousa A, Abraira V, Moreno S. Secular trends of candidemia in a large tertiary-care hospital from 1988 to 2000: emergence of Candida parapsilosis. Infect Control HospEpidemiol. 2005;26:548-52.
• 21. Kaaniche FM, Allela R, Cherif S, ben Algia N. Invasive candidiasis in critically ill patients. Trend AnaesthCrit Care. 2016;11:1-5.
• 22. Shigemura K, Osawa K, Jikimoto T, Yoshida H, Hayama B, Ohji G, et al. Comparison of the clinical risk factors between Candida albicans and Candida nonalbicans species for bloodstream infection. J Antibiot (Tokyo). 2014;67(4):311-4.
• 23. Wang L, Tong Z, Wang Z, Xu L, Wu Y, Liu Y, et al. Single-center retrospective study of the incidence of, and risk factors for, non-C. albicans invasive candidiasis in hospitalized patients in China. Med Mycol. 2014;52(2):115-22.
• 24. Gürsoy S, Koçkar T, Atik SU, Önal Z, Önal H, Adal E. Autoimmunity and intestinal colonization by Candida albicans in patients with type 1 diabetes at the time of the diagnosis. Korean J. Pediatr. 2018;61:217–20.
• 25. Al-Dorzi HM, Sakkijha H, Khan R, Aldabbagh T, Toledo A, Ntinika P, et al. Invasive Candidiasis in Critically Ill Patients: A Prospective Cohort Study in Two Tertiary Care Centers. J Intensive Care Med. 2018;1:885066618767835.
• 26. Erdem F, Ertem GT, Oral B, Karakoc E, Demiroz AP, Tulek N. Epidemiological and microbiological evaluation of nosocomial infections caused by Candida species. Mikrobiyol Bul. 2012;46:637-48.
• 27. Das I, Nightingale P, Patel M, Jumaa P. Epidemiology, clinical characteristics and outcome of candidemia: experience in a tertiary referral center in the UK. Int J Inf Dis. 2011;15:759-63.
• 28. Nucci M, Anaissie E. Revisiting the source of candidemia: skin or gut? Clin Infect Dis. 2001;33:1959-67.
• 29. Charles PE, Dalle F, Aube H, Doise JM, Quenot JP, Aho LS, et al. Candida spp. colonization significance in critically ill medical patients: a prospective study. Intensive Care Med. 2005;31(3):393-400.
• 30. Agvald-Ohman C, Klingspor L, Hjelmqvist H, Edlund C. Invasive candidiasis in long-term patients at a multidisciplinary intensive care unit: Candida colonisation index, risk factors, treatment and outcome. Scand J Infect Dis. 2008;40(2):145-53.
• 31. León C, Ruiz-Santana S, Saavedra P, Almirante B, Nolla-Salas J, AlvarezLerma F, et al. A bedside scoring system (Candida score) for early antifungal treatment in nonneutropenic critically ill patients with Candida colonization. Crit Care Med. 2006;34:730-7.
• 32. León C, Ruiz-Santana S, Saavedra P, Galván B, Blanco A, Castro C, et al. Usefulness of the “Candida score” for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients: a prospective multicenter study. Crit Care Med. 2009;37:1624-33.