Evaluation of the prognostic factors for candidemia in a medical intensive care unit

Yıl 2020, Cilt: 4 Sayı: 10, 870 - 874, 01.10.2020

Seher Kır , Buğra Kaan Bahceci

https://doi.org/10.28982/josam.804426

Öz

Aim: Infections with Candida species are an important cause of morbidity and mortality in intensive care units (ICUs). The studies about the prognostic factors related with candidemia in ICU patients are limited and lacking in our country. The aim of this study is to evaluate the epidemiology and prognostic factors for candidemia in adult patients admitted to a medical ICU.
Methods: This is a retrospective cohort study. A total of 693 patients who were followed for more than 48 hours in our 16-bedded medical ICU between 2016 October-2019 March were evaluated retrospectively and 60 candidemia patients were included in the study. The patients were divided into two groups according to ICU mortality (survivor vs. non-survivor) and compared to determine possible prognostic factors among Candida infection risk factors.
Results: The total incidence of candidemia was 46 per 1000 admissions. The most common fungal isolate was Candida albicans (57.5%). The 30-day mortality was 71.7% and ICU-mortality was 78.3%. There was no difference for age, gender, co-morbid diseases, SOFA and APACHE II scores, Glasgow Coma Score, immunosuppressive treatments (steroid or chemotherapy), septic shock, neutropenia, acute hepatic or renal failure, need for vasopressors, hemodialysis, erythrocyte transfusion and total parenteral nutrition between groups. No relationship was found between the time of initiation of antifungal therapy and mortality (P=0.268). Survivors had shorter ICU stay and hospital stay before ICU, and lower Charlson Comorbidity Index scores than non-survivors (P=0.039, P=0.008, P=0.02, respectively). Length of hospital stay before ICU, need for invasive mechanical ventilation and hypoalbuminemia were the prognostic factors for ICU mortality of candidemia patients (P=0.034, P=0.013, P=0.029, respectively).
Conclusion: We reported the highest incidence rate of candidemia and one of the highest mortality rates in critically ill patients with candidemia. Confirming to most of the previous reports, Candida albicans (57.5%) was the most common isolate in our study. We evaluated reported risk factors for invasive candidiasis as a prognostic indicator for candidemia in ICU patients, and found that the length of hospital stay, invasive mechanical ventilation and hypoalbuminemia were prognostic indicators.

Anahtar Kelimeler

Candidemia, mortality, critical care, prognostic factors

Medikal yoğun bakım ünitesinde kandidemi ile ilişkili prognostik faktörlerin değerlendirilmesi

Öz

Amaç: Candida türleri ile enfeksiyonlar, yoğun bakım ünitelerinde (YBÜ) önemli bir morbidite ve mortalite nedenidir. YBÜ hastalarında kandidemi ile ilişkili prognostik faktörlerle ilgili çalışmalar sınırlı sayıdadır ve ayrıca ülkemizde YBÜ'lerde kandidemi ile ilgili yeterli klinik çalışma bulunmamaktadır. Bu çalışmanın amacı, medikal bir YBÜ'ye kabul edilen yetişkin hastalarda kandideminin epidemiyolojisi ve prognostik faktörlerini değerlendirmektir.
Yöntemler: Bu çalışma retrospektif kohort bir çalışmadır. 2016 Ekim-2019 Mart tarihleri arasında 16 yataklı yoğun bakım ünitemizde 48 saatten fazla takip edilen 693 hasta retrospektif olarak değerlendirildi ve 60 kandidemili hasta çalışmaya dahil edildi. Hastalar YBÜ mortalitesine göre (sağ kalan ve ölen) iki gruba ayrıldı ve Candida enfeksiyon risk faktörleri arasından olası prognostik faktörleri belirlemek için karşılaştırıldı.
Bulgular: Toplam kandidemi insidansı 46 hasta/1000 başvuru olarak bulundu. En sık görülen mantar izolatı Candida albicans'tı (%57,5). Hastaların 30 günlük mortalitesi %71,7 ve YBÜ mortalitesi %78,3 olarak bulundu. Yaş, cinsiyet, eşlik eden hastalıklar, SOFA ve APACHE II skorları, Glasgow koma skoru, immünsüpresif tedaviler (steroid veya kemoterapi), septik şok, nötropeni, akut karaciğer veya böbrek yetmezliği, vazopresör ihtiyacı, hemodiyaliz, eritrosit transfüzyonu ve total parenteral beslenme bakımından gruplar arasında fark yoktu. Antifungal tedaviye başlama zamanı ile mortalite arasında ilişki bulunamadı (P=0.268). Sağ kalanlar YBÜ öncesinde daha kısa YBÜ yatış ve hastanede kalış süresine sahipti ve hayatta kalmayanlara göre Charlson Komorbidite İndeksi puanları daha düşüktü (sırasıyla P=0,039, P=0,008, P=0,02). Kandidemi hastalarının YBÜ mortalitesi için prognostik faktörler olarak YBÜ öncesi hastanede kalış süresi, invazif mekanik ventilasyon ihtiyacı ve hipoalbüminemi saptandı (sırasıyla P=0,034, P=0,013, P=0,029).
Sonuç: Kandidemili kritik hastalarda en yüksek kandidemi insidans oranını ve en yüksek ölüm oranlarından birini bildirdik. Daha önceki raporların çoğunu doğrular şekilde çalışmamızda en sık Candida albicans (%57,5) izolatı saptandı. YBÜ hastalarında kandidemi için prognostik bir gösterge olarak invaziv kandidiyaz için bildirilen risk faktörlerini değerlendirdik. Bunlardan hastanede kalış süresi, invazif mekanik ventilasyon ve hipoalbüminemi prognostik birer gösterge olarak bulundu.

Anahtar Kelimeler

Kandidemi, mortalite, yoğun bakım, prognostik faktörler

Kaynakça

• 1. Bassetti M, Giacobbe DR, Vena A, Wolff M. Diagnosis and Treatment of Candidemia in the Intensive Care Unit. Semin Respir Crit Care Med. 2019;40(4):524–39.
• 2. Ding R, Ji Y, Liu B, Zhao D, Zhang X, Zhang Z, et al. Risk factors for mortality in cases of intensive care unit-acquired candidemia: a 5.5-year, single-center, retrospective study. Int J Clin Exp Med. 2018;11:9950–7.
• 3. Tukenmez Tigen 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.
• 4. Gonzalez de Molina FJ, Leon C, Ruiz-Santana S, Saavedra P, the CAVA I Study Group. Assessment of candidemia-attributable mortality in critically ill patients using propensity score matching analysis. Crit Care. 2012;16:R105.
• 5. Yapar N, Akan M, Avkan-Oguz V, Ergon CM, Hancer M, Doluca M. Risk factors, incidence and outcome of candidemia in a Turkish intensive care unit: a five-year retrospective cohort study. Anaesth Pain & Intensive Care. 2014;18(3):265–71.
• 6. Epelbaum O, Chasan R. Candidemia in the Intensive Care Unit. Clin Chest Med. 2017;38(3):493–509.
• 7. 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.
• 8. Andes DR, Safdar N, Baddley JW, Playford G, Reboli AC, Rex JH, 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.
• 9. Kawano Y, Togawa A, Nakamura Y, Mizunuma M, Yamasaki R, Hoshino K, et al. Prognostic factors for candidaemia in intensive care unit patients: a retrospective analysis. Singapore Med J. 2017;58(4):196–200.
• 10. Guinea J. Global trends in the distribution of Candida species causing candidemia. Clin Microbiol Infect. 2014; 20 (6): 5–10.
• 11. Li F, Zhou M, Zou Z, Li W, Huang C, He Z. A risk prediction model for invasive fungal disease in critically ill patients in ICU. Asian Nurs Res. 2018;12(4):299. doi: 10.1016/j.anr.2018.11.004.
• 12. Arslan F, Caskurlu H, Sari S, Cankar Dal H, Turan S, Erturk B, et al. Risk factors for noncatheter-related Candida bloodstream infections in intensive care units: A multicenter case-control study. Med Mycol. 2019;57(6):668–74.
• 13. Falcone M, Tiseo G, Tascini C, Russo A, Sozio E, Raponi G, et al. Assessment of risk factors for candidemia in non-neutropenic patients hospitalized in Internal Medicine wards: A multicenter study. Eur J Intern Med. 2017;41:33–8.
• 14. da Silva RB, Neves RP , Hinrichsen SL, de Lima-Neto RG. Candidemia in a public hospital in Northeastern Brazil: Epidemiological features and risk factors in critically ill patients. Rev Iberoam Micol. 2019;36(4):181–5.
• 15. Leroy O, Gangneux JP, Montravers P, Mira JP, Gouin F, Sollet JP, et al. Epidemiology, management, and risk factors for death of invasive Candida infections in critical care: A multicenter, prospective, observational study in France (2005-2006). Crit Care Med. 2009;37:1612–8.
• 16. Ghrenassia E, Mokart DD, Mayaux J, Demoule A, Rezine I, Kerhuel L, et al. Candidemia in critically ill immunocompromised patients: Report of a retrospective multicenter cohort study. Ann Intensiv Care. 2019;9:62.
• 17. Sbrana F, Sozio E, Bassetti M, Ripoli A, Pieralli F, Azzini AM, et al. Independent risk factors for mortality in critically ill patients with candidemia on Italian Internal Medicine Wards. Intern Emerg Med. 2018;13(2):199–204. doi: 10.1007/s11739-017-1783-9.
• 18. Tümtürk A. Risk factors, clinical characteristics and mortality of candidemia in non-neutropenic, critically ill patients in a tertiary care hospital. J Surg Med. 2020;4(2):157-60.
• 19. Xess I, Jain N, Hasan F, Mandal P, Banarjee U. Epidemiology of candidemia in a tertiary care centre of north India: 5-year study. Infection. 2007;35:256–9.
• 20. Anunnatsiri S, Chetchotisakd P, Mootsikapun P. Fungemia in non-HIV infected patients: a five-year review. Int J Infect Dis. 2009;13:90–6.
• 21. 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 Off Publ Infect Dis Soc Am. 2012;54(12):1739–46.
• 22. Saillard C, Darmon M, Bisbal M, Sannini A, Chow-Chine L, Faucher M, et al. Critically ill allogenic HSCT patients in the intensive care unit: a systematic review and meta-analysis of prognostic factors of mortality. Bone Marrow Transpl. 2018;53:1233–41.
• 23. Bassetti M, Trecarichi EM, Righi E, Sanguinetti M, Bisio F, Posteraro B, et al. Incidence, risk factors, and predictors of outcome of candidemia. Survey in 2 Italian university hospitals. Diagn Microbiol Infect Dis. 2007;58:325–31.
• 24. Chow JK, Golan Y, Ruthazer R, Karchmer AW, Carmeli Y, Lichtenberg D, et al. Factors associated with candidemia caused by nonalbicans Candida species versus Candida albicans in the intensive care unit. Clin Infect Dis. 2008;46:1206–13.
• 25. Pfaller MA, Diekema DJ. Epidemiology of invasive candidiasis: a persistent public health problem. Clin Microbiol Rev. 2007;20:133–63.
• 26. León C, Ruiz-Santana S, Saavedra P, Almirante B, Nolla-Salas J, Alvarez-Lerma F, et al; EPCAN Study Group. 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.
• 27. 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. Critical Care. 2019;23:219. doi: 10.1186/s13054-019-2497–3.
• 28. Ala-Houhala M, Valkonen M, Kolho E, Friberg N, Anttila VJ. Clinical and microbiological factors associated with mortality in candidemia in adult patients 2007–2016. Infectious Diseases. 2019;51(11-12):824–30.