Risk factors for candidemia mortality in hospitalized children

Invasive candidiasis in a pediatric tertiary hospital: Epidemiology, antifungal susceptibility, and mortality rates

Invasive infections caused by non-albicans Candida are increasing worldwide. However, there is still a lack of information on invasive candidiasis (IC) in the pediatric setting, including susceptibility profiles and clonal studies. We investigated the clinical, epidemiologic, and laboratory characteristics of IC, possible changes in antifungal susceptibility profiles over time, and the occurrence of clonality in our tertiary children's hospital. We analyzed 123 non-duplicate Candida isolates from sterile sites of pediatric patients in a tertiary hospital in southern Brazil, between 2016 and 2021. Data on demographics, comorbidities, and clinical outcomes were collected. Candida species distribution, antifungal susceptibility profiles, biofilm production, and molecular epidemiology of isolates were assessed using reference methods. The range of IC incidence was 0.88-1.55 cases/1000 hospitalized patients/year, and the IC-related mortality rate was 20.3%. Of the total IC cases, 42.3% were in patients aged < 13 months. Mechanical ventilation, parenteral nutrition, and intensive care unit (ICU) admission were common in this group. In addition, ICU admission was identified as a risk factor for IC-related mortality. The main site of Candida spp. isolation was blood, and non-albicans Candida species were predominant (70.8%). No significant clonal spread was observed among isolates of the three most commonly isolated species, and 99.1% of all isolates were biofilm producers. Non-albicans Candida species were predominant in this study. Notably, clonal expansion and emergence of antifungal drug resistance were not observed in our pediatric setting.

Risk factors and mortality of candidemia in a children's public hospital in Sao Paulo, Brazil

Candida bloodstream infections in children are of special concern in neonatal and pediatric intensive care and patients with comorbidities. This study aimed to estimate the incidence and risk factors associated with mortality in candidemia cases occurring in a public children's hospital in Ribeirao Preto, Brazil. It is a retrospective transversal study. Every patient under the age of 18 admitted to the study facility from January 1, 2013, to December 31, 2019, was considered potentially eligible to be included if they had candidemia. We collected clinical data from medical records. We included 113 blood cultures yielding positive results for Candida. The incidence rate was 2.12 per 1000 admissions. The most common Candida species was Candida parapsilosis. Septic shock during the candidemia episode was the only clinical outcome associated with a relative risk-adjusted (RRa) of 2.77 with an interval >1 (1.12-6.85). Our findings show that the incidence rate and mortality rates of candidemia are in line with those in other children's services in Brazil. We found a global mortality rate of 28.31% (32/113) from candidemia episodes. We highlight the predominance of non-albicans Candida species including C. parapsilosis. Septic shock was the most important factor showing a significant risk of mortality.

Systematic Review of Candidemia in Brazil: Unlocking Historical Trends and Challenges in Conducting Surveys in Middle-Income Countries

INTRODUCTION

Candidemia, a bloodstream infection predominantly affecting critically ill patients, poses a significant global health threat especially with the emergence of non-albicans Candida species, including drug-resistant strains. In Brazil, limited access to advanced diagnostic tools and trained microbiologists hampers accurate identification of Candida species and susceptibility to antifungals testing hindering surveillance efforts.

METHODS

We conducted a systematic review spanning publications from 2017 to 2023 addressing Candida species distribution and antifungal susceptibility among Brazilian patients with candidemia.

RESULTS

Despite initially identifying 7075 records, only 16 met inclusion criteria providing accurate information of 2305 episodes of candidemia. The predominant species were C. albicans, C. parapsilosis, and C. tropicalis, followed by notable proportions of Nakaseomyces glabratus. Limited access to diagnostic tests was evident as only 5 out of 16 studies on candidemia were able to report antifungal susceptibility testing results. In vitro resistance to echinocandins was rare (only 6/396 isolates, 1,5%). In counterpart, fluconazole exhibited resistance rates ranging from 0 to 43%, with great heterogeneity among different studies and species of Candida considered.

CONCLUSION

Our review underscores the critical need for enhanced surveillance and research efforts to address the evolving landscape of candidemia and antifungal resistance in Brazil. Despite some limitations, available data suggest that while resistance to echinocandins and amphotericin B remains rare, there is a growing concern regarding resistance to fluconazole among Candida species.

Glucocorticoid use and parenteral nutrition are risk factors for catheter-related Candida bloodstream infection: a retrospective study

Background

Catheter-related candidemia (CRC) is a serious catheter-related bloodstream infection (CRBSI) caused by Candida spp., with higher mortality than CRBSIs caused by other organisms.

Objective

To identify the risk factors for Candida CRBSI. The clinical characteristics of 297 patients with CRBSI in a local hospital from January 2007 to June 2015 were collected, including 33 Candida CRBSI and 264 non-Candida CRBSI.

Method

The associations of Candida CRBSI with the clinical variables were examined using univariate and multivariate analyses.

Results

Multivariate analysis showed that glucocorticoid use (odds ratio [OR] = 10.313, 95% confidence interval [CI] = 2.032-52.330, P = 0.005) and parenteral nutrition (OR = 5.400, 95% CI = 0.472-61.752, P = 0.0175) were independent risk factors for Candida CRBSI. The most prevalent species were Candida tropicalis (42.4%) and Candida albicans (36.36%). Of the 33 Candida CRBSI cases, 31 (93.93%) had indwelling central venous catheters (CVC) for ≥14 d. The mortality of Candida CRBSI was remarkably higher than that of bacteria CRBSI. Patients with timely catheter removal and appropriate antifungal treatment had dramatically increased 28-d survival compared with those with untimely catheter removal + inappropriate antifungal treatment (88.89% vs. 0, P = 0.006).

Conclusion

The study identified glucocorticoid use and parenteral nutrition as independent risk factors for Candida CRBSI. The outcome of candidemia was associated with the duration of CVC indwelling and antifungal treatment.

Interactions of Candida tropicalis pH-related antigen 1 with complement proteins C3, C3b, factor-H, C4BP and complement evasion

Candida, as a part of the human microbiota, can cause opportunistic infections that are either localised or systemic candidiasis. Emerging resistance to the standard antifungal drugs is associated with increased mortality rate due to invasive Candida infections, particularly in immunocompromised patients. While there are several species of Candida, an increasing number of Candida tropicalis isolates have been recently reported from patients with invasive candidiasis or inflammatory bowel diseases. In order to establish infections, C. tropicalis has to adopt several strategies to escape the host immune attack. Understanding the immune evasion strategies is of great importance as these can be exploited as novel therapeutic targets. C. albicans pH-related antigen 1 (CaPra1), a surface bound and secretory protein, has been found to interact strongly with the immune system and help in complement evasion. However, the role of C. tropicalis Pra1 (CtPra1) and its interaction with the complement is not studied yet. Thus, we characterised how pH-related antigen 1 of C. tropicalis (CtPra1) interacts with some of the key complement proteins of the innate immune system. CtPra1 was recombinantly produced using a Kluyveromyces lactis yeast expression system. Recombinant CtPra1, was found to bind human C3 and C3b, central molecules of the complement pathways that are important components of the innate immune system. It was also found to bind human complement regulatory proteins factor-H and C4b-binding protein (C4BP). CtPra1-factor-H and CtPra1-C4BP interactions were found to be ionic in nature as the binding intensity affected by high sodium chloride concentrations. CtPra1 inhibited functional complement activation with different effects on classical (∼20 %), lectin (∼25 %) and alternative (∼30 %) pathways. qPCR experiments using C. tropicalis clinical isolates (oral, blood and peritoneal fluid) revealed relatively higher levels of expression of CtPra1 gene when compared to the reference strain. Native CtPra1 was found to be expressed both as membrane-bound and secretory forms in the clinical isolates. Thus, C. tropicalis appears to be a master of immune evasion by using Pra1 protein. Further investigation using in-vivo models will help ascertain if these proteins can be novel therapeutic targets.

Invasive Fungal Infections in Under-Five Diarrheal Children: Experience from an Urban Diarrheal Disease Hospital

Invasive fungal infections (IFIs) are opportunistic, especially in immunocompromised and hospitalized patients. Children with IFIs are more vulnerable to a fatal outcome. For early diagnosis and treatment, knowledge of the spectrum and frequency of IFIs among children is prerequisite. In this prospective observational study, we enrolled 168 children of 2–59 months old of either sex from March 2018 to December 2019 admitted to the Dhaka hospital, icddr,b. Study participants with suspected IFIs were with or without severe acute malnutrition (SAM) along with sepsis/pneumonia and fulfilled any of the following criteria: (i) failure to respond to injectable antibiotics, (ii) development of a late-onset hospital-acquired infection, (iii) needed ICU care for >7 days, (iv) took steroids/antibiotics for >2 weeks before hospitalization, and (v) developed thrush after taking injectable antibiotics. The comparison group included non-SAM (weight-for-length Z score ≥ −2) children with diarrhea and fever <3 days in the absence of co-morbidity. We performed real-time PCR, ELISA, and blood culture for the detection of fungal pathogen. Study group children with SAM, positive ELISA and PCR considered to have a IFIs. In the study group, 15/138 (10.87%) children had IFIs. Among IFIs, invasive candidiasis, aspergillosis, histoplasmosis detected in 6 (4.53%), 11 (7.97%), and 1 (0.72%) children, respectively, and (3/15 [2.17%]) children had both candidiasis and aspergillosis. Children with IFIs more often encountered septic shock (26.7% vs. 4.9%; p = 0.013) and had a higher death rate (46.7% vs. 8.9%; p < 0.001) than those without IFIs. IFIs were independently associated with female sex (OR = 3.48; 95% CI = 1.05, 11.55; p = 0.042) after adjusting for potential confounders. Our findings thus implicate that, malnourished children with septic shock require targeted screening for the early diagnosis and prompt management of IFIs that may help to reduce IFIs related deaths.

Characteristics of candidemia in COVID-19 patients; increased incidence, earlier occurrence and higher mortality rates compared to non-COVID-19 patients

Severe COVID‐19 patients in ICU are at high risk for candidemia due to exposure to multiple risk factors for candidemia. We aimed to compare the incidence of candidemia in ICU patients with and without COVID‐19, and to investigate epidemiologic and clinical characteristics of candidemia patients and risk factors for mortality in candidemia patients. This retrospective study was conducted in patients followed in the ICUs of Ankara City Hospital for 2 years, divided into pre‐pandemic and pandemic periods. The incidence (event per 1000 patient‐days) and epidemiology of candidemia, clinical and laboratory characteristics of patients were compared in COVID‐19 and non‐COVID‐19 groups. Candidemia incidence was higher in the COVID‐19 group (2.16, 95% CI 1.77–2.60) than the non‐COVID‐19 group (1.06, 95% CI 0.89–0.125) (p < .001). A total of 236 candidemia episodes (105 in COVID‐19 patients and 131 in non‐COVID‐19 patients) were detected during the study periods. COVID‐19 cases had a higher rate of corticosteroid use (63.8% vs. 9.9%, p < .001). Epidemiology of candidemia and antifungal susceptibility were similar. Candidemia developed 2 weeks earlier in COVID‐19 groups and resulted in higher mortality (92.5% vs. 79.4%, p .005). One‐third of candidemia patients died before receiving any antifungal treatment, and this rate was higher in the COVID‐19 group. In multivariate logistic regression analysis, corticosteroid use, presence of sepsis and age older than 65 years were independent risk factors for mortality in candidemia patients. Candidemia with high mortality is a more serious problem for COVID‐19 patients due to its increased incidence, earlier occurrence and a higher rate of mortality.

Species distribution and antifungal susceptibility profile of Candida isolates from blood and other normally sterile foci from pediatric ICU patients in Tehran, Iran

As data on pediatric invasive candidiasis (IC) and the antifungal susceptibility pattern of associated isolates are scarce in Iran, this study aimed to determine species distribution and antifungal susceptibility profile of Candida species isolated from pediatric patients with suspected or documented IC. A total of 235 yeast strains recovered from normally sterile body fluids of patients admitted at the intensive care units of Children's Medical Centre, Tehran, Iran, were identified using CHROMagar Candida, molecular methods (ITS PCR-RFLP and sequencing), and MALDI-TOF. Susceptibility to amphotericin B, fluconazole, voriconazole, micafungin, and anidulafungin was determined according to the European on Antimicrobial Susceptibility testing reference microdilution method (EUCAST E.Def 7.3.1). Candida albicans (53.6%), C. parapsilosis (24.7%), and C. tropicalis (8.5%) were the most common species, followed by C. lusitaniae (4.3%), C. glabrata (3.0%), C. guilliermondii and C. orthopsilosis (each 1.7%), C. kefyr (1.3%), C. dubliniensis (0.8%), and C. intermedia (0.4%). Amphotericin B MICs were ≤1 mg/l for all Candida isolates. C. albicans isolates were susceptible to all five antifungal agents. All C. parapsilosis isolates categorised as intermediate to micafungin and anidulafungin, except two isolates that had the MICs >2 mg/l for micafungin. MIC50, MIC90, and MIC range for fluconazole were 0.25 mg/l, 1 mg/l, and 0.125 - ≥32 mg/l, respectively. Fluconazole and voriconazole showed 100% activity against the most prevalent Candida species. The low resistance rate, favorable safety profile and low cost of fluconazole make it a reasonable choice for treatment of candidemia/invasive candidemia in Iran.

Risk factors associated with mortality among patients who had candidemia in a university hospital

INTRODUCTION:

Bloodstream infection due to Candida spp. is a primary cause of morbidity and mortality in tertiary hospitals.

METHODS:

In this retrospective study, we included patients with a positive blood culture for Candida spp. after 48 h of hospitalization.

RESULTS

A total of 335 patients who had candidemia were included in this study. Risk factors associated with mortality were hospitalization in internal medicine units and surgical clinics, age >60 years, mechanical ventilation, orotracheal intubation, hemodialysis, corticosteroids use, and C. parapsilosis infection.

CONCLUSIONS:

This study highlights the importance of health care related to invasive procedures and actions to improve patient immunity.

Candida spp bloodstream infections in a Latin American Pediatric Oncology Reference Center: Epidemiology and associated factors

BACKGROUND

Invasive fungal disease is a significant cause of morbidity and mortality in immunosuppressed children. The recognition of patients at risk for candidaemia is paramount to a better prognosis.

OBJECTIVES

To characterize Candida spp bloodstream infections (BSI) in a reference centre for paediatric oncology and to describe the most prevalent risk factors associated with candida infections.

PATIENTS/METHODS

This is a retrospective cohort study carried out with paediatric patients followed up with at the Institute of Pediatric Oncology, Brazil, who presented positive blood culture for Candida spp from January 2004 to December 2016.

RESULTS

Ninety episodes of candidaemia were analysed; patients had a median age of 4.5 years, and 57.8% were males, with a diagnosis of solid tumours in 54.5% of cases. The most common Candida species were C albicans (35.6%), C parapsilosis (30.0%) and C tropicalis (16.7%). C tropicalis BSI was associated with neutropenia and skin lesions. Therapy was successful in 67.1% of the episodes. Older age and thrombocytopenia were associated with therapeutic failure. Death within 30 days occurred in 24.4% of patients; predictive factors were older age and admission to an ICU C parapsilosis candidaemia was a protective factor for death when compared to C albicans.

CONCLUSION

The main species isolated were C albicans, C parapsilosis and C tropicalis. C tropicalis BSI was associated with neutropenia and skin lesions. The death rate was significant, and a worse prognosis was associated with older age, thrombocytopenia and admission to an ICU C parapsilosis infection proved to be a protective factor against mortality.

Candidaemia Mortality Has not Changed Over the Last 2 Decades in Brazil

Despite advances in fungal diagnostics and antifungal therapy, mortality associated with candidaemia remains very high, particularly in developing countries. In this study, we reviewed the Brazilian literature on candidaemia over the last 20 years (1999-2019), with the aim to document if mortality rates changed over the years in Brazil. Variables studied included number of patients with candidaemia per study, age, most prevalent Candida species and use of antifungals. Selected manuscripts evaluated a median of 114 patients, the majority being men (54.4%). Median age was 45 year-old. The most prevalent species in all studies was C. albicans (37.3%), followed by C. parapsilosis (23.0%). An increase in use of echinocandins occurred in recent years, with a proportional decrease in the use of fluconazole and amphotericin B. Surprisingly, mortality of candidaemia has remained unchanged over the years in the largest Latin American country, regardless of treatment with echinocandins. Potential explanations for these findings are discussed.

Invasive candidiasis: Risk factor for mortality in a pediatric tertiary care hospital in south of Brazil

BACKGROUND

Invasive candidiasis (IC) is a major cause of morbimortality in children. Previous studies described the clinical characteristics and risk factors for this infection; however, limited data are available on the predictors of mortality in these patients. In this context, we evaluated the risk factors associated with death due to IC in a pediatric tertiary care hospital in South of Brazil.

METHODS

This is a retrospective, cross-sectional, observational, and analytical study of a series of pediatric patients with clinical and laboratory diagnosis of IC from March 2014 to September 2017. Univariate and multivariate analysis were performed to estimate the association between the characteristics of the patients and death.

RESULTS

A total of 94 cases of IC were included. The incidence was 1.13 cases per 1000 patients/d, with a mortality rate of 14%. There was a predominance of non-albicans Candida (71.3%) in IC cases and, although there is no species difference in mortality rates, biofilm formation was associated with increased mortality. Clinical characteristics such as male sex, stay in the intensive care unit, and thrombocytopenia; comorbidities such as cardiological disease and renal insufficiency; and risks such as mechanical ventilation and dialysis were associated with increased mortality.

CONCLUSION

Data from this study suggest that biofilm formation by Candida sp. is associated with increased mortality, and this is the first study to correlate the male sex and cardiological disease as risk factors for death in pediatric IC patients.