Yoğun Bakım Ünitesinde Nötropenik Olmayan Çocuk Hastalarda Kandidemi

Öz

Amaç: Kandidemi yoğun bakım ünitelerinde yatan kritik hastalarda yüksek morbidite ve mortalite oranına sahiptir. Sağ kalım için doğru anti-fungal tedavinin gecikmeden başlanmasının hayati önemi vardır. Bu çalışmada, kandida türlerinin dağılımını, kandidemi için risk faktörlerini ve yıllar içinde anti-fungal dirençteki değişimi gözden geçirmek için bir Çocuk Yoğun Bakım Ünitesi (ÇYBÜ)’inde gözlenen kandidemi ataklarının 6 yıllık retrospektif analizi yapıldı. Gereç ve Yöntem: Ocak 2014- Ocak 2020 tarihleri arasında XXX Hastanesi ÇYBÜ’inde yatan hastalarda gözlenen kandidemi atakları incelendi. Hastaların demografik ve klinik özellikleri, laboratuvar bulguları, tedavileri ve sonuçları tıbbi kayıtlarından elde edildi. Bulgular: Altı yılda 59 kandidemi atağı (%54,2) olmuştu, tanı anındaki medyan yaş 43 ay (aralık 1-225), medyan hastanede kalış süresi 48 gün (aralık 3-664) idi. Hastaların tümü antibiyotik kullanmıştı, çoğunda komorbidite (%89,8), nazogastrik tüp (84,7), santral venöz kateter (%78,0) ve mekanik ventilasyon (%76,3) vardı. Otuz altı kandidemi epizodunda etken olan kandida türleri tanımlanmıştır; bu atakların %47,2’si C. parapsilosis, %38,9’u C. albicans, %8,3’ü C glabrata, %2,8’i C lusitaniae ve %2,8’i C. tropicalis’den kaynaklanmıştı. Non-albicans kandidemili hastalarda albicans kandidemili hastalara göre hastanede kalış süresi daha uzundu ve bu hastaların tanı anında lökosit sayısı daha yüksekti. Yıllar geçtikçe anti-fungal direnç oranında artış vardı, ancak istatiksel olarak anlamlı fark yoktu. Genel olarak, otuz günlük ölüm oranı%16,9 idi. Sonuç: Belirgin derecede yüksek lökosit sayısı ve uzun hastanede kalış süresi olan kritik hastalarda, başlanacak ampirik antifungal tedavi antifungal direnci olabilen nonalbicans candida'yı kapsamalıdır

Anahtar Kelimeler

• ÇYBÜ
• Kandida
• Kandidemi
• Nonalbikans

Candidemia in Non-neutropenic Pediatric Patients in an Intensive Care Unit

Öz

Aim: Candidemia has high morbidity and mortality rate in critically ill patients hospitalized in intensive care units. Prompt initiation of accurate anti-fungal therapy is essential for survival. In this study, a 6-year retrospective candidemia analysis of pediatric intensive care unit (PICU) was performed to review candida species distribution, risk factors for candidemia and change in the antifungal resistance in years. Material and Method: The candidemia episodes of children followed in the PICU of XXX Hospital between January 2014 and January 2020 were analyzed. The demographic and clinical characteristics, laboratory findings, treatments and outcomes of the patients were obtained from the medical records. Results: Fifty-nine episodes of candidemia (54.2% female) were reported in six years, median age at diagnosis was 43 months (range 1-225), median hospital stay was 48 days (range 3-664). All patients had used broad-spectrum antibiotics, majority had comorbidities (89.8%), nasogastric tube (84.7), central venous catheter (78.0%), and on mechanic ventilation (76.3%). Type of candida species was identified in 36 episodes of candidemia; 47.2% of these episodes were caused by C. parapsilosis, 38,9% by C. albicans, 8.3% by C. glabrata (8.3%), 2.8% by C. lusitaniae, and 2.8% by C. tropicalis. Length of hospital stay was longer among patients with nonalbicans candidemia, and these patients had higher leucocyte count at diagnosis. The rate of antifungal resistance increased over the years. Overall, thirty-day mortality rate was 16.9%. Conclusion: For critically ill patients with markedly elevated leucocyte count and long hospital stay, empiric antifungal treatment should cover nonalbicans candida with antifungal resistance.

Anahtar Kelimeler

• PICU
• Candida
• Candidemia
• nonalbicans

Kaynakça

1. 1. Warris A, Pana ZD, Oletto A, et al. Etiology and Outcome of Candidemia in Neonates and Children in Europe: An 11-year Multinational Retrospective Study. Pediatr Infect Dis J 2020; 39 (2):114-20.
2. 2. Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, Edmond MB. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis 2004; 39 (3):309-17.
3. 3. Tsay SV, Mu Y, Williams S, et al. Burden of Candidemia in the United States, 2017. Clin Infect Dis 2020; 71 (9): e449-53.
4. 4. Ulu Kilic A, Alp E, Cevahir F, Ture Z, Yozgat N. Epidemiology and cost implications of candidemia, a 6-year analysis from a developing country. Mycoses 2017; 60 (3):198-203.
5. 5. Benedict K, Roy M, Kabbani S, et al. Neonatal and Pediatric Candidemia: Results From Population-Based Active Laboratory Surveillance in Four US Locations, 2009-2015. J Pediatric Infect Dis Soc 2018; 7 (3):e78-85.
6. 6. Lausch KR, Schultz Dungu KH, Callesen MT, et al. Pediatric Candidemia Epidemiology and Morbidities: A Nationwide Cohort. Pediatr Infect Dis J 2019;38 (5):464-9.
7. 7. Playford EG, Marriott D, Nguyen Q, et al. Candidemia in nonneutropenic critically ill patients: risk factors for non-albicans Candida spp. Crit Care Med. 2008;36 (7):2034-9.
8. 8. Zaoutis TE, Prasad PA, Localio AR, et al. Risk factors and predictors for candidemia in pediatric intensive care unit patients: implications for prevention. Clin Infect Dis. 2010;51:e38.

9. 9. Pana ZD, Kotzadamis D, Roilides E. Invasive Candidiasis in Pediatric Intensive Care Unit: More Challenges. Pediatr Infect Dis J. 2018;37 (12):1309-11.
10. 10. Andes DR, Safdar N, Baddley JW, et al. Impact of treatment strategy on outcomes in patients with candidemia and other forms of invasive candidiasis: a patient-level quantitative review of randomized trials. Clin Infect Dis. 2012;54 (8):1110-22.
11. 11. Dutta A, Zaoutis TE, Palazzi DL. An update on the epidemiology of candidemia in children Curr Fungal Infect Rep. 2012;6:296.
12. 12. Garey KW, Rege M, Pai MP, et al. Time to initiation of fluconazole therapy impacts mortality in patients with candidemia: a multi-institutional study. Clin Infect Dis 2006; 43 (1):25-31.
13. 13. Kollef M, Micek S, Hampton N, Doherty JA, Kumar A. Septic shock attributed to Candida infection: importance of empiric therapy and source control.Clin Infect Dis 2012;54 (12):1739-46.
14. 14. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36 (5):309-32.
15. 15. Shin JH, Kim M-N, Jang SJ, et al. Detection of amphotericin B resistance in Candida haemulonii and closely related species by use of the Etest, Vitek-2 yeast susceptibility system, and CLSI and EUCAST broth microdilution methods. J Clin Microbiol 2012; 50 (6):1852-5.
16. 16. Toda M, Williams SR, Berkow EL, et al. Population-Based Active Surveillance for Culture-Confirmed Candidemia - Four Sites, United States, 2012-2016. MMWR Surveill Summ. 2019;68 (8):1-15.
17. 17. Palazzi DL, Arrieta A, Castagnola E, et al. Candida speciation, antifungal treatment and adverse events in pediatric invasive candidiasis: results from 441 infections in a prospective, multi-national study. Pediatr Infect Dis J. 2014;33(12):1294-6.
18. 18. Kazak E, Akin H, Ener B, et al. An investigation of Candida species isolated from blood cultures during 17 years in a university hospital. Mycoses. 2014;57(10):623-9.
19. 19. Gürcüoglu E, Ener B, Akalın H, et al. Epidemiology of nosocomi-al candidaemia in a university hospital: a 12-year study. Epide-miol Infect. 2010; 138 (9): 1328-35.
20. 20. Kullberg BJ, Arendrup MC. Invasive Candidiasis.N Engl J Med. 2015;373 (15):1445-56.
21. 21. Clancy CJ, Nguyen MH. Finding the “missing 50%” of invasive candidiasis: how nonculture diagnostics will improve understanding of disease spectrum and transform patient care. Clin Infect Dis 2013; 56 (9):1284–92.
22. 22. Hope WW, Castagnola E, Groll AH, et al. ESCMID* guideline for the diagnosis and management of Candida diseases 2012: prevention and management of invasive infections in neonates and children caused by Candida spp. Clin Microbiol Infect. 2012;18 Suppl 7:38.
23. 23. Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62 (4):e1-50.
24. 24. Fierro JL, Prasad PA, Fisher BT, et al. Ocular manifestations of candidemia in children. Pediatr Infect Dis J. 2013;32 (1):84-6.