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

Species Distribution and Antifungal Susceptibility Patterns of Candida Isolates: A Cross-Sectional Study From a Tertiary Care Hospital in South India

Background The increasing prevalence of Candida infections and emerging antifungal resistance presents a significant challenge in tertiary healthcare settings. The epidemiological landscape of candidiasis is evolving, with non-albicans Candida species gaining prominence. This cross-sectional study aimed to investigate the distribution patterns of Candida species isolated from various clinical specimens at Srinivasan Medical College and Hospital, Samayapuram, India with particular emphasis on emerging non-albicans species that demonstrate varying virulence and antifungal susceptibility profiles. Methodology The study employed a hospital-based cross-sectional design conducted over six months from October 2023 to March 2024. A sample size of 97 clinical specimens was processed using standardized microbiological procedures, including potassium hydroxide (KOH) mount, Gram staining, and culture on Sabouraud's dextrose agar. Species identification utilized the Germ Tube Test, CHROMagar, and corn-meal agar techniques. Antifungal susceptibility testing was performed via disk diffusion method following Clinical and Laboratory Standards Institute (CLSI) guidelines for fluconazole, voriconazole, itraconazole, and amphotericin B. Statistical analysis employed Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 25.0, Armonk, NY), utilizing descriptive statistics, chi-square tests, and multivariate logistic regression. Results The study population demonstrated a mean age of 47.9 years, comprising 52 female and 45 male patients. Among clinical specimens, urinary samples constituted 51 specimens (52.6%), followed by high vaginal swabs with 23 specimens (23.7%), and sputum with 15 specimens (15.5%). Microbiological analysis revealed 45 isolates of Candida albicans (46.4%), while non-albicans species included 25 isolates of C. tropicalis (25.8%), 20 of C. krusei (20.6%), and 7 of C. glabrata (7.2%). Diabetes mellitus emerged as the predominant risk factor, affecting 38 patients (39.2%). Antifungal susceptibility testing demonstrated complete sensitivity to amphotericin B and voriconazole across all isolates, while 32 isolates showed resistance to itraconazole (33.0%). Fluconazole resistance patterns revealed 19 isolates with acquired resistance (19.6%) and 20 isolates with intrinsic resistance (20.6%). Conclusion The study reveals a significant prevalence of non-albicans Candida species and concerning levels of antifungal resistance, particularly to azoles. These findings emphasize the critical importance of species identification and antifungal susceptibility testing in guiding therapeutic decisions for Candida infections.

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.

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.

Risk of invasive candidiasis with prolonged duration of ICU stay: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the duration of intensive care unit (ICU) stay prior to onset of invasive candidiasis (IC)/candidaemia.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Cochrane, Embase and Web of Science databases were searched through June 2019 to identify relevant studies.

ELIGIBILITY CRITERIA

Adult patients who had been admitted to the ICU and developed an IC infection.

DATA EXTRACTION AND SYNTHESIS

The following data were extracted from each article: length of hospital stay, length of ICU stay, duration of ICU admission prior to candidaemia onset, percentage of patients who received antibiotics and duration of their antibiotic therapy prior to candidaemia onset, and overall mortality. In addition to the traditional meta-analyses, meta-regression was performed to explore possible mediators which might have contributed to the heterogeneity.

RESULTS

The mean age of patients ranged from 28 to 76 years across selected studies. The pooled mean duration of ICU admission before onset of candidaemia was 12.9 days (95% CI 11.7 to 14.2). The pooled mean duration of hospital stay was 36.3±5.3 days (95% CI 25.8 to 46.7), and the pooled mean mortality rate was 49.3%±2.2% (95% CI 45.0% to 53.5%). There was no significant difference in duration of hospital stay (p=0.528) or overall mortality (p=0.111), but a significant difference was observed in the mean length of ICU stay (2.8 days, p<0.001), between patients with and without Candida albicans. Meta-regression analysis found that South American patients had longer duration of ICU admission prior to candidaemia onset than patients elsewhere, while those in Asia had the shortest duration.

CONCLUSIONS

Patients with IC are associated with longer ICU stay, with the shortest duration of ICU admission prior to the candidaemia onset in Asia. This shows a more proactive strategy in the diagnosis of IC should be considered in caring for ICU patients.

Pediatric Blood Cultures and Antibiotic Resistance: An Overview

Bloodstream infections (BSI) due to multidrug-resistant organisms, especially from pediatric intensive care units (PICU), are being increasingly reported across the world. Since BSI is associated with high mortality, it is essential to treat these infections early with appropriate antibiotics. Surveillance of etiology and emerging antimicrobial resistance (AMR) is considered an important step in the formulation of antibiotic policy for early treatment and judicious use of antibiotics. In this review on etiology and its antibiogram in community acquired BSI, S. typhi followed by S. paratyphi A were the major bacterial isolates. Quinolone resistance of more than 90% in Salmonella is now reported from all over India. Ceftriaxone remains the drug of choice for enteric fever due to its 100% susceptibility. In PICU there is an emergence of candidemia due to non-albicans candida which are now predominant isolates at few centers. BSI due to gram-negative bacteria, mostly by Klebseilla pneumoniae and gram-positive cocci (S. aureus) are the other major pathogens commonly observed in BSI from PICU. There is a high prevalence of antimicrobial resistance to commonly used antibiotics like ampicillin (94.9%-90.7%), cefotaxime (92.4%-71.4%), piperacillin-tazobactum (31.2%-27.5%) and levofloxacin (42.4%-39.8%). Resistance to carbapenems, primarily due to bla_NDM is seen in all the centers and the rate varies between 1%- 79% with K. pneumoniae and A. baumannii showing the maximum resistance. This review highlights the magnitude of the AMR in the pediatric population and calls for the urgent implementation of antimicrobial stewardship programs to save the remaining antimicrobials.

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.

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.