Neonatal and Pediatric Candidemia: Results From Population-Based Active Laboratory Surveillance in Four US Locations, 2009-2015

Epidemiological characteristics, antifungal susceptibility, and mortality factors of candidemia in adults at a tertiary teaching hospital in Zunyi, China (2016-2023)

BACKGROUND

Candidemia, a common nosocomial bloodstream infection caused by Candida species, is associated with a high mortality rate. This study aimed to analyze the epidemiological characteristics, distribution of Candida species, antifungal susceptibility, and mortality risk factors of adult patients with candidemia in Zunyi, China. These findings are expected to inform treatment and prevention strategies for candidemia in this region.

METHODS

Clinical data, Candida species, antifungal susceptibility profiles, and prognosis of 92 patients with candidemia at the First People's Hospital of Zunyi (the Third Affiliated Hospital of Zunyi Medical University) from January 2016 to December 2023 were retrospectively analyzed. Univariate and multivariate logistic regression analyses were performed to analyze risk factors for patient death.

RESULTS

Analysis of 92 candidemia cases revealed an average incidence of 0.19% and mortality rate of 35.87%. Candida albicans was responsible for 33.70% of the infections, whereas non-C. albicans accounted for 66.30% of the total. Non-C. albicans was dominated by C. parapsilosis (31.52%), Nakaseomyces glabratus (18.48%), and C. tropicalis (13.04%). The susceptibility of all Candida species to amphotericin B exceeded 96%. C. albicans and C. parapsilosis showed greater than 70% susceptibility to fluconazole, itraconazole, and voriconazole, whereas C. tropicalis showed less than 60% susceptibility to these antifungal agents. Among the 33 dead patients, C. albicans was associated with a higher mortality rate than non-C. albicans (P = 0.007). Logistic multiple regression analysis showed that cardiovascular disease (OR = 8.913, 95% CI: 1.463-54.289, P = 0.018), kidney disease (OR = 13.672, 95% CI: 2.025-92.326, P = 0.007), and antifungal drug treatment duration less than 7 days (OR = 10.694, 95% CI: 1.841-62.112, P = 0.008) were independent risk factors for mortality in adult patients with candidemia.

CONCLUSIONS

The mortality rate among patients with candidemia remains high with C. albicans is the predominant pathogen in Zunyi, China. Cardiovascular disease, kidney disease, and antifungal drug treatment duration less than 7 days were independent risk factors for mortality in adult patients with candidemia. Therefore, greater attention should be paid to adult patients with risk factors for mortality to improve the outcomes of adult candidemia.

Species distribution and antifungal susceptibility patterns of Candida involvement in pediatric solid organ transplant recipients: A cross-sectional study from a single transplant center

The epidemiology and resistance patterns of Candida infections in pediatric kidney/liver recipients has not been well characterized, recently. In this study, all patients ≤ 18 years old who underwent liver/kidney transplant surgery between September 2021 and 2022 were included. Species identification of isolates recovered from clinical specimens was performed by DNA-sequencing method following amplification of the ITS1-5.8S-ITS2 regions. Antifungal susceptibility patterns of isolates were performed using the micro broth dilution method documented by Clinical & Laboratory Standards Institute (CLSI) guidelines. Of the 117 pediatric recipients enrolled, 16 recipients (13.7 %) had at least one positive Candida culture. Candidemia was detected in 5/89 (5.6 %) of liver and 1/28 (3.6 %) of kidney transplant recipients. Invasive candidiasis was observed in 6/89 (6.7 %) of liver and 2/28 (7.1 %) of kidney transplant recipients. The predominant species was Candida (C.) albicans recovered from 12 of 16 recipients (75 %). In addition to the Pichia kudriavzevii species with inherent resistance to fluconazole, one of C. albicans isolates and one C. tropicalis isolate were also identified as fluconazole-resistant (3/29:10.3 %). Moreover, our findings revealed 13.8 % and 6.8 % resistance to itraconazole and voriconazole, respectively. All Candida spp. were susceptible to caspofungin. Collectively, this study provides valuable insights into the epidemiology and resistance patterns of Candida infections in pediatric kidney and liver recipients. The study also highlights the emergence of fluconazole-resistant strains, which has significant implications for antifungal stewardship efforts in pediatric transplant populations.

Invasive Fungal Infections in the Neonatal Intensive Care Unit

Background Due to the great burden of morbidity and mortality, invasive fungal infections (IFIs) are a major concern in neonatal intensive care units (NICUs) worldwide. This study aimed to evaluate the epidemiological and clinical characteristics, type of pathogen, risk factors, laboratory parameters, treatment, and clinical outcome associated with IFIs in a NICU within a three-year period. Methodology This study was conducted at the NICU, Pediatric Clinic, Clinical Centre of the University of Sarajevo from January 2020 to December 2022. A total of 22 infants were diagnosed with IFIs. Clinical data of the infants were collected from medical histories, including gestational age, gender, birth weight, perinatal conditions, major diseases, type and site of fungal isolate, time of onset of infection, clinical and laboratory findings, antifungal prophylaxis, antifungal therapy, broad-spectrum antibiotic therapy, clinical interventions, associated bacterial sepsis, total duration of hospitalization, and clinical outcomes. The study was approved by the Ethics Committee of Sarajevo University, Faculty of Medicine, Clinical Center University of Sarajevo. All cultures were monitored using an automated culture system. Passages to blood agar and Sabouraud dextrose agar were performed. Absolute numbers and percentages were used to describe categorical data, and median and interquartile ranges were used to describe numerical data due to data distribution that deviated from normal. The chi-square test or Fisher's exact test was used to analyze differences in categorical variables. The Mann-Whitney U-test and the Wilcoxon signed-rank test were used to analyze the differences in numerical variables between the observed groups. P-values <0.05 were considered statistically significant. Statistical analyses were performed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Results Between January 2020 and December 2022, a total of 22 infants had IFIs in the NICU, with an overall incidence of 11.5 per 1,000 admissions per year. Candida albicans was the most frequently isolated species (54.5%). The most important risk factors for IFIs in the NICU were long-term use of broad-spectrum antibiotics, parenteral nutrition, central venous catheter (CVC), mechanical ventilation (MV), birth weight <1,500 g, and prematurity. A significant increase in the median C-reactive protein and a decrease in the median platelet count was recorded between admission and the time of pathogen isolation. The overall mortality rate was 27.3% with significantly higher mortality in patients with C. albicans compared to other Candida species. Conclusions In this study, C. albicans was the most frequent causative agent of IFI (54.5%). The most important risk factors for IFIs in the NICU were long-term use of broad-spectrum antibiotics, parenteral nutrition, CVC, MV, birth weight <1,500 g, and prematurity. The mortality rate was significantly higher in patients infected with C. albicans than with non-albicans species.

Candida glabrata: A Tale of Stealth and Endurance

Candida (Nakaseomyces) glabrata, an opportunistic human fungal pathogen, causes mucosal and deep-seated infections in immunocompromised individuals. Recently designated as a high-priority fungal pathogen by the World Health Organization (WHO), C. glabrata exhibits low inherent susceptibility to azole antifungals. In addition, about 10% clinical isolates of C. glabrata display co-resistance to both azole and echinocandin drugs. Molecular mechanisms of antifungal resistance and virulence in C. glabrata are currently being delineated in-depth. This Review provides an overview of the epidemiology, biology, drug resistance, tools and host model systems for C. glabrata. Additionally, we discuss the immune evasion strategies that aid C. glabrata in establishing infections in the host. Overall, this Review aims to contribute to ongoing efforts to raise awareness of human pathogenic fungi, the growing threat of antifungal drug resistance and the unmet need for novel antifungal therapies, with an ultimate goal of improving clinical outcomes of affected individuals.

The Role of Rotational Thromboelastometry in Early Detection of the Hemostatic Derangements in Neonates with Systemic Candida Infection

BACKGROUND

Systemic Candida infection (SCI) is the third most common cause of late-onset sepsis in Neonatal Intensive Care Units (NICU). While platelet involvement in fungal infections has been extensively studied, evaluation of the hemostatic mechanism in Candida infections, especially in neonates, has not been widely investigated. The aim of the current study was to evaluate the hemostatic profile of neonates with SCI through rotational thromboelastometry (ROTEM), a laboratory method that assesses the viscoelastic properties of blood.

METHODS

This is a single-centered prospective cohort study including a group of neonates with SCI (n = 21); the control group consisted of healthy neonates (n = 24). Demographics, clinical parameters, and laboratory data were recorded at the disease onset. Neonatal scores for the assessment of disease severity (Modified NEOMOD, nSOFA, and NeoBAT) were also calculated. ROTEM parameters of neonates with SCI were compared to those of healthy neonates.

RESULTS

ROTEM parameters differed between neonates with SCI and healthy neonates, indicating a hypocoagulable profile of infected neonates. Specifically, neonates with SCI had significantly prolonged clotting time (CT) and clot formation time (CFT), as well as lower clot amplitude at 10 min (A10) and maximum clot firmness (MCF) when compared to healthy neonates (p values < 0.05), findings that remained consistent after adjusting for confounding factors such as gestational age, birth weight, and sex. In addition, a strong correlation was noted between ROTEM parameters and disease severity based on the modified NEOMOD, nSOFA, and NeoBAT scores.

CONCLUSIONS

ROTEM parameters revealed a hypocoagulable profile in neonates during the early stages of SCI, which is also associated with disease severity. The results of this study highlight the need for monitoring of hemostatic status of this vulnerable group of patients and indicate that ROTEM analysis may have a role in the early detection of the hemostatic derangements associated with SCI in neonates, in order to ensure timely diagnosis and targeted therapeutic intervention.

Perspectives on the Use of Echinocandins in the Neonatal Intensive Care Unit

The neonatal intensive care unit (NICU) population, especially low birth weight and critically ill neonates, is at risk of invasive Candida infections, which are associated with high mortality rates and unfavorable long-term outcomes. The timely initiation of an appropriate antifungal treatment has been demonstrated to enhance the prognosis. Factors that should be considered in the choice of an antifungal agent include the causative Candida strain, the presence and location of deep tissue infection, any previous use of antifungal prophylaxis, and the presence of implanted devices. Amphotericin B and fluconazole, the first-line drugs for neonatal candidiasis, are not always suitable due to several limitations in terms of efficacy and adverse effects. Therefore, alternative antifungals have been studied and used in neonates when conventional antifungals are ineffective or contraindicated. This narrative review aims to provide an overview of the current literature regarding the use of echinocandins in the neonatal population. The three echinocandins, micafungin, caspofungin, and anidulafungin, share characteristics that make them useful for the treatment of neonatal candidiasis, including activity against a wide range of Candida strains and Candida biofilms and a favorable safety profile.

Antifungal Drug Usage in European Neonatal Units: A Multicenter Weekly Point Prevalence Study

BACKGROUND

Data on antifungal prescribing in neonatal patients are limited to either single-center or single-country studies or to 1-day recording. Therefore, we assessed antifungal longitudinal usage in neonatal units (NUs) within Europe.

METHODS

CALYPSO, a prospective weekly point prevalence study on antifungal drug usage in NUs in 18 hospitals (8 European countries), was conducted in 2020 during a 12-week period. All patients receiving systemic antifungals were included. Ward demographics were collected at the beginning; ward and patient data including indication, risk factors and antifungal regimen were weekly collected prospectively.

RESULTS

Among 27 participating NUs, 15 (56%) practiced antifungal prophylaxis for neonates with birth weight <1000 g or <1500 g and additional risk factors. In total, 174 patients received antifungals with a median frequency per week of 10.5% ranging from 6.9% to 12.6%. Indication for antifungal prescribing was prophylaxis in 135/174 (78%) courses and treatment in 22% [39 courses (69% empirical, 10% preemptive, 21% targeted)]. Fluconazole was the most frequent systemic agent used both for prophylaxis (133/135) and treatment (15/39, 39%). Among neonates receiving prophylaxis, the most common risk factors were prematurity (119/135, 88%), mechanical ventilation (109/135, 81%) and central vascular catheters (89/135, 66%). However, gestational age <28 weeks was only recorded in 55/135 (41%) courses and birth weight <1000 g in 48/135 (35%). Most common reason for empirical treatment was late-onset sepsis; all 8 targeted courses were prescribed for invasive candidiasis.

CONCLUSION

Antifungal usage in European NUs is driven by prophylaxis and empirical treatment with fluconazole being the most prescribed agent for both indications.

Clinicopathologic Characterization of Invasive Fungal Intestinal Infections in Pediatric Patients

BACKGROUND

Invasive fungal intestinal infections are rare in pediatric patients with limited studies reported to date.

METHODS

Retrospective study of invasive intestinal fungal infections in pediatric patients. For fungal specification, 18S rRNA gene PCR was performed using formalin-fixed paraffin-embedded tissues.

RESULTS

A total of 19 cases from 18 patients were included (13 males, 72%) with a median age of 20 days (8 days-14 years). About 13 patients (72%) presented within 67 days of birth and 11 patients (61%) were premature and 14 patients (78%) had a significant medical history. The most common location was the jejunum/ileum (56%) followed by the right colon and terminal ileum (22%). In 10 patients, the fungal elements were seen in the mucosa with 3 extending into the submucosa, and only 3 patients showed full-thickness involvement. Tissue necrosis and angioinvasion were seen in 13 (72%) and 8 (44%) patients, respectively. Morphologically, organisms consistent with Candida spp. were seen in 17 patients and with a mucoraceous mold in 1 patient. A 18S rRNA gene sequencing performed in 18 cases identified Candida dubliniensis in 16 cases and Candida spp. in 2 cases. During the study follow-up period, 56% of the patients died.

CONCLUSION

In our experience, most cases were due to Candida spp. and predominantly in premature infants and associated with poor outcomes.

Distribution and antifungal susceptibility profiles of Candida species isolated from candidemia patients admitted to Egyptian tertiary hospitals: a cross-sectional study

BACKGROUND

Candidemia is a widespread threat that can lead to significant complications in healthcare settings.

OBJECTIVES

Our study aimed to identify isolates of Candida isolated from blood culture bottles of patients with candidemia and assess their antifungal susceptibility profiles.

METHODS

We conducted a cross-sectional study at Cairo University tertiary care hospitals over 16 months including 90 patients. Candida isolates were collected from blood culture bottles, and identified using MALDI-TOF MS technology of VITEK MS PRIME (bioMérieux) with the corresponding database VITEK IVD Database 3.2. followed by antifungal susceptibility testing using VITEK 2 Compact system.

RESULTS

Candida albicans was the most common species isolated from both pediatric and adult patients with percentages of 47.3% and 36.4% respectively, followed by Candida parapsilosis with percentages of 32.6% and 25.0% respectively. Voriconazole showed the highest antifungal activity at 90.9% of isolates in adults and 95.7% in pediatrics, followed by caspofungin and micafungin. The mean hospital stays for adults ranged from 8 to 30 days and from 10 to 42 days in the pediatric group.

CONCLUSIONS

C. albicans remains the predominant species isolated from both pediatric and adult candidemia patients, despite a notable increase in other species. C. tropicalis and C. parapsilosis are considered the most common non-albicans Candida (NAC) species. The rise in Candida species other than albicans highlights the urgent need for effective antifungal stewardship programs. Voriconazole exhibited the higher antifungal activity followed by caspofungin and micafungin.

Recent Challenges in Diagnosis and Treatment of Invasive Candidiasis in Neonates

Invasive Candida infections represent a significant cause of morbidity and mortality in the neonatal intensive care unit (NICU), particularly among preterm and low birth weight neonates. The nonspecific clinical presentation of invasive candidiasis, resembling that of bacterial sepsis with multiorgan involvement, makes the diagnosis challenging. Given the atypical clinical presentation and the potential detrimental effects of delayed treatment, empirical treatment is often initiated in cases with high clinical suspicion. This underscores the need to develop alternative laboratory methods other than cultures, which are known to have low sensitivity and a prolonged detection time, to optimize therapeutic strategies. Serum biomarkers, including mannan antigen/anti-mannan antibody and 1,3-β-D-glucan (BDG), both components of the yeast cell wall, a nano-diagnostic method utilizing T2 magnetic resonance, and Candida DNA detection by PCR-based techniques have been investigated as adjuncts to body fluid cultures and have shown promising results in improving diagnostic efficacy and shortening detection time in neonatal populations. This review aims to provide an overview of the diagnostic tools and the current management strategies for invasive candidiasis in neonates. Timely and accurate diagnosis followed by targeted antifungal treatment can significantly improve the survival and outcome of neonates affected by Candida species.

Invasive Candida Infections in Neonatal Intensive Care Units: Risk Factors and New Insights in Prevention

Invasive Candida infections represent a significant cause of morbidity and mortality in neonatal intensive care units (NICUs), with a particular impact on preterm and low-birth-weight neonates. In addition to prematurity, several predisposing factors for Candida colonization and dissemination during NICU hospitalization have been identified, including prolonged exposure to broad-spectrum antibiotics, central venous catheters, parenteral nutrition, corticosteroids, H2 antagonist administration, and poor adherence to infection control measures. According to the literature, the implementation of antifungal prophylaxis, mainly fluconazole, in high-risk populations has proven to be an effective strategy in reducing the incidence of fungal infections. This review aims to provide an overview of risk factors for invasive Candida infections and current perspectives regarding antifungal prophylaxis use. Recognizing and reducing people's exposure to these modifiable risk factors, in conjunction with the administration of antifungal prophylaxis, has been demonstrated to be an effective method for preventing invasive candidiasis in susceptible neonatal populations.

Candida lusitaniae Fungemia in Children: A multicenter case series of emerging pathogen

Candida lusitaniae fungemia is a serious infection that is rarely reported in children. The aim of this study is to describe a case series of C. lusitaniae fungemia and review previous publications regarding this rare pathogen. This is a multicenter case series of children diagnosed with C. lusitaniae fungemia. A total of 18 cases that occurred over a 15-year period in five tertiary hospitals were included. Additionally, a review of the literature regarding C. lusitaniae fungemia in children was performed. A total of 18 cases were enrolled; 11/18 (61%) were males, with a mean age of 2.3 years. All patients had severe underlying diseases and risk factors for opportunistic infection, most commonly prematurity and malignancies. More than one-third of cases occurred during the last 2 years of the study period. All isolates were susceptible to all tested antifungals. The survival rate following the acute infection was 94%, whereas the survival rate of 14 previously published cases was 71%, with the most common underlying diseases being CGD and malignancies. Candida lusitaniae fungemia is not a common event in the pediatric population, occurring exclusively in children with severe underlying diseases and significant risk factors. This cohort revealed better clinical outcomes than previously reported. All tested isolates were susceptible to all antifungal agents; variability in susceptibility as previously reported was not found in this study. The allegedly higher rate of infection in recent years is in need of further investigation in larger prospective studies in order to conclude if a real trend is at play.

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.

Candida albicans-A systematic review to inform the World Health Organization Fungal Priority Pathogens List

Candida albicans is a common fungal pathogen and amongst the leading causes of invasive candidiasis globally. This systematic review examines the characteristics and global impact of invasive infections caused by C. albicans. We searched on PubMed and Web of Science for studies reporting on criteria such as mortality, morbidity, drug resistance, preventability, yearly incidence, and distribution/emergence during the period from 2016 to 2021. Our findings indicate that C. albicans is the most common Candida species causing invasive disease and that standard infection control measures are the primary means of prevention. However, we found high rates of mortality associated with infections caused by C. albicans. Furthermore, there is a lack of data on complications and sequelae. Resistance to commonly used antifungals remains rare. Although, whilst generally susceptible to azoles, we found some evidence of increasing resistance, particularly in middle-income settings-notably, data from low-income settings were limited. Candida albicans remains susceptible to echinocandins, amphotericin B, and flucytosine. We observed evidence of a decreasing proportion of infections caused by C. albicans relative to other Candida species, although detailed epidemiological studies are needed to confirm this trend. More robust data on attributable mortality, complications, and sequelae are needed to understand the full extent of the impact of invasive C. albicans infections.

Antifungal susceptibility and virulence determinants profile of candida species isolated from patients with candidemia

Candida is the most prevalent fungal bloodstream infection (BSI) with a high mortality rate among hospitalized patients. Another concern facing physicians is rising global incidence of drug-resistant Candida. This study aimed to characterize the prevalence, antifungal susceptibility, biofilm formation, and virulence genes (HWP1, ALS1, SAP2) of different Candida spp. isolated from patients with candidemia. 52 isolates of Candida spp. were identified from blood cultures by chromogenic Candida agar and confirmed by the VITEK 2 system. Isolates were tested for antifungal susceptibility by disk diffusion and VITEK 2 system. Biofilm formation and investigated genes were detected by the Congo red method and conventional PCR, respectively. Candida spp. caused 2.3% of detected BSIs, of which 32.7% were caused by Candida albicans (C. albicans) and 67.3% by non-albicans Candida (NAC), with the predominance of C. tropicalis (25%), followed by C. parapsilosis (17.3%), and C. krusei (13.5%). The susceptibility rates to fluconazole, voriconazole, caspofungin, micafungin, amphotericin B, and flucytosine were 64.7%, 76.5%, 100.0%, 100%, 100.0%, and 100.0% in C. albicans, while 53.6%, 71.4%, 91.4%, 91.4%, 94.3%, and 94.3% in NAC, respectively. Biofilm production, HWP1, ALS1, and SAP2 were detected in 70.6%, 82.4%, 76.5%, and 52.9% of C. albicans and 74.3%, 85.7%, 80.0%, and 48.6% of NAC, respectively. There is remarkable shift to NAC BSIs and high azole resistance. Antifungal stewardship and analysis of risk factors associated with this shift are needed.

Taxonomy of Candida parapsilosis complex isolated from neonates and the role of Hsp90 inhibitors to enhanced the antifungal activity of micafungin

Species from Candida parapsilosis complex are frequently found in neonatal candidemia. The antifungal agents to treat this infection are limited and the occurrence of low in vitro susceptibility to echinocandins such as micafungin has been observed. In this context, the chaperone Hsp90 could be a target to reduce resistance. Thus, the objective of this research was to identify isolates from the C. parapsilosis complex and verify the action of Hsp90 inhibitors associated with micafungin. The fungal identification was based on genetic sequencing and mass spectrometry. Minimal inhibitory concentrations were determined by broth microdilution method according to Clinical Laboratory and Standards Institute. The evaluation of the interaction between micafungin with Hsp90 inhibitors was realized using the checkerboard methodology. According to the polyphasic taxonomy, C. parapsilosis sensu stricto was the most frequently identified, followed by C. orthopsilosis and C. metapsilosis, and one isolate of Lodderomyces elongisporus was identified by genetic sequencing. The Hsp90 inhibitor geladanamycin associated with micafungin showed a synergic effect in 31.25% of the isolates, a better result was observed with radicicol, which shows synergic effect in 56.25% tested yeasts. The results obtained demonstrate that blocking Hsp90 could be effective to reduce antifungal resistance to echinocandins.

Disseminated Disease After Candidemia in Children and Young Adults: Epidemiology, Diagnostic Evaluation and Risk Factors

BACKGROUND

Treatment of candidemia may be complicated by hematogenous dissemination. Limited data exist to guide decision-making regarding the evaluation for disseminated disease. We sought to describe the epidemiology of invasive disease after candidemia, report the diagnostic evaluations performed and identify risk factors for disseminated disease.

METHODS

We performed a retrospective single-center study of candidemia from January 1, 2012 to December 31, 2022. Disseminated candidiasis was defined as radiologic findings consistent with end-organ disease, abnormal ophthalmologic exam or growth of Candida spp. from a sterile site after an episode of candidemia. A multilevel regression model was used to identify risk factors for dissemination.

RESULTS

The cohort included 124 patients with 144 episodes of candidemia. Twelve patients died before an evaluation for dissemination occurred. Only 107/132 patients underwent evaluation for dissemination. Tests obtained included abdominal imaging (93/132), echocardiography (91/132), neuroimaging (45/132) and chest imaging (38/132). A retinal examination was performed in 90/132 patients. Overall, 27/107 patients (25%) had disseminated disease. Frequently identified sites of dissemination were lungs and abdominal organs. Regression modeling identified prematurity [adjusted odds ratio (aOR): 11.88; 95% confidence interval (CI): 1.72-81.90] and mitochondrial and genetic disease (aOR: 5.66; 95% CI: 1.06-30.17) as risk factors for disseminated candidiasis. Each additional day of candidemia increased the odds of dissemination (aOR: 1.36; 95% CI: 1.12-1.66).

DISCUSSION

In a heterogeneous cohort of patients, disseminated candidiasis was common. Evaluation for disseminated disease was variable. Those with persistent candidemia had significantly increased risk of dissemination and should undergo a standardized evaluation for disseminated disease.

Invasive candidiasis

Invasive candidiasis is an important fungal disease caused by Candida albicans and, increasingly, non-albicans Candida pathogens. Invasive Candida infections originate most frequently from endogenous human reservoirs and are triggered by impaired host defences. Signs and symptoms of invasive candidiasis are non-specific; candidaemia is the most diagnosed manifestation, with disseminated candidiasis affecting single or multiple organs. Diagnosis poses many challenges, and conventional culture techniques are frequently supplemented by non-culture-based assays. The attributable mortality from candidaemia and disseminated infections is ~30%. Fluconazole resistance is a concern for Nakaseomyces glabratus, Candida parapsilosis, and Candida auris and less so in Candida tropicalis infection; acquired echinocandin resistance remains uncommon. The epidemiology of invasive candidiasis varies in different geographical areas and within various patient populations. Risk factors include intensive care unit stay, central venous catheter use, broad-spectrum antibiotics use, abdominal surgery and immune suppression. Early antifungal treatment and central venous catheter removal form the cornerstones to decrease mortality. The landscape of novel therapeutics is growing; however, the application of new drugs requires careful selection of eligible patients as the spectrum of activity is limited to a few fungal species. Unanswered questions and knowledge gaps define future research priorities and a personalized approach to diagnosis and treatment of invasive candidiasis is of paramount importance.

Candida parapsilosis complex in the clinical setting

Representatives of the Candida parapsilosis complex are important yeast species causing human infections, including candidaemia as one of the leading diseases. This complex comprises C. parapsilosis, Candida orthopsilosis and Candida metapsilosis, and causes a wide range of clinical presentations from colonization to superficial and disseminated infections with a high prevalence in preterm-born infants and the potential to cause outbreaks in hospital settings. Compared with other Candida species, the C. parapsilosis complex shows high minimal inhibitory concentrations for echinocandin drugs due to a naturally occurring FKS1 polymorphism. The emergence of clonal outbreaks of strains with resistance to commonly used antifungals, such as fluconazole, is causing concern. In this Review, we present the latest medical data covering epidemiology, diagnosis, resistance and current treatment approaches for the C. parapsilosis complex. We describe its main clinical manifestations in adults and children and highlight new treatment options. We compare the three sister species, examining key elements of microbiology and clinical characteristics, including the population at risk, disease manifestation and colonization status. Finally, we provide a comprehensive resource for clinicians and researchers focusing on Candida species infections and the C. parapsilosis complex, aiming to bridge the emerging translational knowledge and future therapeutic challenges associated with this human pathogen.

A 14-Year Cohort of Candidemia in the Pediatric Population in a Tertiary Center in Jerusalem: Clinical Characteristics, Antifungal Susceptibility, and Risk Factors for Mortality

Candida spp. can cause bloodstream infection and is associated with significant mortality. The proportion of fluconazole-resistant Candida non-albicans has increased over the years, and empirical fluconazole maybe inappropriate. In this retrospective study, we analyzed clinical characteristics, antifungal resistance patterns, and mortality in children with candidemia treated at a tertiary medical center in Jerusalem between 2009 and 2022. A total of 122 children developed 127 candidemia episodes with 132 Candida isolates. Half the episodes occurred in immunocompromised children. Septic shock was present in 27 (21.3%). Candida non-albicans was responsible for 71/132 (56.5%) episodes; 16/132 (12.1%) of isolates were fluconazole-resistant. The rate of Candida non-albicans was significantly higher in fluconazole-resistant episodes (90 vs. 50.5%, p = 0.02). Prolonged severe neutropenia and previous fluconazole exposure were more frequent in fluconazole-resistant episodes. Thirty-day mortality was 25 (19.7%). Greater mortality, as shown by multivariate analysis, was associated with candidemia contracted in the pediatric intensive care unit (PICU), previous use of azoles or carbapenems, and in the presence of shock. In conclusion, mortality rates in our study were higher than those previously reported. In suspected infection associated with factors which we found to increase the probability of mortality-PICU admission, shock, and earlier azole or carbapenems exposure-empirical antifungals should be considered.

Updates in Laboratory Identification of Invasive Fungal Infection in Neonates

Invasive fungal infection (IFI) in immunocompromised neonates is significantly associated with high morbidity and mortality and has become the third most common infection in Neonatal Intensive Care Units. The early diagnosis of IFI for neonatal patients is difficult because of the lack of specific symptoms. The traditional blood culture remains the gold standard in clinical diagnosis for neonatal patients but it requires a long duration, which delays treatment initiation. Detections of fungal cell-wall components are developed for early diagnosis but the diagnostic accuracy in neonates needs to be improved. PCR-based laboratory methods, such as real-time PCR, droplet digital PCR, and the cationic conjugated polymer fluorescence resonance energy transfer (CCP-FRET) system, distinguish the infected fungal species by their specific nucleic acids and show a high sensitivity and specificity. Particularly, the CCP-FRET system, which contains a cationic conjugated polymer (CCP) fluorescent probe and pathogen-specific DNA labeled with fluorescent dyes, could identify multiple infections simultaneously. In the CCP-FRET system, the CCP and fungal DNA fragments can self-assemble into a complex with an electrostatic interaction and the CCP triggers the FRET effect under ultraviolet light to make the infection visible. Here, we summarize the recent laboratory methods for neonatal IFI identification and provide a new perspective for early clinical fungal diagnosis.

Evaluation of candidemia in children at a university hospital: A retrospective cohort

BACKGROUND

Candidemia is a life-threatening infection in hospitalied children. This study aimed to evaluate candidemia's demographic and clinical characteristics and identify the risk factors and outcomes of Candida albicans (CA) and non-albicans Candida (NAC) spp.

METHODS

A retrospective cohort was designed to evaluate paediatric patients with candidemia between January 2008 and December 2020.

RESULTS

A total of 342 episodes in 311 patients were evaluated. The median age of the patients was 2.1 years (1 month-17 years and 6 months), and 59.6% were male. The prevalence of NAC (67.5%) candidemia was higher than that of CA (32.5%). The most commonly isolated Candida species was Candida parapsilosis (43.3%), followed by C. albicans (32.5%), Candida glabrata (6.1%) and Candida tropicalis (5.0%). The length of hospital stay prior to the positive culture and the total length of hospital stay were longer in the NAC group (p = .003 and p = .006). The neutrophil count was lower in the NAC group (p = .007). In the multivariate analysis, total parenteral nutrition, antifungal prophylaxis and a history of coagulase-negative staphylococci (CoNS) culture positivity in the past month were risk factors for developing candidemia due to NAC (p values were .003, .003 and .045). C. albicans and C. parapsilosis fluconazole resistance were 9.5% and 46.6%, respectively. The rates of amphotericin B resistance were 1.1% and 7.6% in C. albicans and C. parapsilosis, respectively. Mortality (14-day and 30-day) rates did not differ between the groups.

CONCLUSIONS

A history of CoNS culture positivity in the past month, total parenteral nutrition, and antifungal prophylaxis increases the risk of NAC candidemia.

[Recent research on pharmacological prevention strategies for invasive fungal infection in preterm infants]

There is a relatively high incidence rate of invasive fungal infection (IFI) in preterm infants admitted to the neonatal intensive care unit (NICU), and early diagnosis of IFI is difficult in clinical practice. The patients developing IFI tend to have severe conditions, a long course of treatment, high hospital costs, high mortality, and poor prognosis, and therefore, the prevention of IFI is of particular importance. At present, fluconazole is often used as the first-line drug for the prevention of IFI in preterm infants, but no consensus has been reached on the specific dose and course of treatment, and there are still controversies over the targeted population and prophylactic effect. This article reviews the recent research on the pharmacological prevention strategies for IFI in preterm infants in the NICU, so as to provide a reference for clinicians.

Prevalence and species distribution of Candida bloodstream infection in children and adults in two teaching university hospitals in Egypt: first report of Candida kefyr

BACKGROUND

Candidemia is a pervasive problem associated with significant morbidity and mortality in health care settings. This study aimed to determine the changing distribution of Candida species and the emergence of uncommon species.

METHODS

This was a cross-sectional study performed in two Cairo University hospitals between 2019 and 2020. All Candida species isolates recovered from blood cultures of adults and pediatrics patients admitted to the hospitals were included. Candida isolates were identified by chromogenic Candida agar and Vitek2 YST identification card. Candida kefyr was confirmed by chip array.

RESULTS

Candida species were responsible for 1.6% of bloodstream infections in adults and 10.8% in pediatric patients. C. albicans was the most prevalent species representing 27.8% in adults and 48.3% in pediatrics. Non-albicans species (NAC) represented the most isolated Candida species among adults and pediatrics (72.2% and 51.6%, respectively) with the predominance of C. tropicalis (27.8% and 22.5%, respectively) followed by C. parapsilosis (16.7% and 10.8%, respectively). The uncommon Candida, which is Candida species other than C. albicans, C. parapsilosis, C. tropicalis, C. glabrata, and C. krusei, represents 16.6% and 14% of all candidemia in adults and pediatrics, respectively. Only one of each of C. lusitaniae, C. utilis, and C. kefyr were detected in adults. C. lusitaniae was the most frequently recovered uncommon Candida among pediatrics resulting in 6.4% of candidemia followed by C. famata (4.3%), C. utilis (2.2%), and C. kefyr (1.1%).

CONCLUSIONS

C. albicans is still the primary species isolated from pediatrics and adults with candidemia despite the considerable shift to the non-albicans species. C. tropicalis and C. parapsilosis are the most prevalent NAC. The increased prevalence of uncommon Candida species is alarming and necessitates a prompt stewardship program.

Fatal Lodderomyces elongisporus Fungemia in a Premature, Extremely Low-Birth-Weight Neonate

Many rare yeasts are emerging as pathogens, causing invasive infections in susceptible hosts that are associated with poor clinical outcome. Here, we describe the first and fatal case of Lodderomyces elongisporus fungemia in a premature, extremely low-birth-weight neonate after spontaneous vaginal delivery. The bloodstream isolate was identified as C. parapsilosis by the VITEK 2 yeast identification system and as L. elongisporus by PCR-sequencing of the internal transcribed spacer (ITS) region of ribosomal DNA. Antifungal susceptibility testing data for the isolate, performed by the broth microdilution-based MICRONAUT-AM assay, showed susceptibility to all nine antifungal drugs tested. Despite the initiation of treatment with liposomal amphotericin B, the patient died on the same day that the blood culture yielded yeast growth. This is the first report of L. elongisporus bloodstream infection in a neonate as the previous nine cases reported in the literature occurred in adult patients. The crude mortality rate for invasive L. elongisporus infection is 50%, as only 5 of 10 patients survived.

Contemporary Trends in Global Mortality of Sepsis Among Young Infants Less Than 90 Days: A Systematic Review and Meta-Analysis

Objective

Current knowledge on the global burden of infant sepsis is limited to population-level data. We aimed to summarize global case fatality rates (CFRs) of young infants with sepsis, stratified by gross national income (GNI) status and patient-level risk factors.

Methods

We performed a systematic review and meta-analysis on CFRs among young infants < 90 days with sepsis. We searched PubMed, Cochrane Central, Embase, and Web of Science for studies published between January 2010 and September 2019. We obtained pooled CFRs estimates using the random effects model. We performed a univariate analysis at patient-level and a meta-regression to study the associations of gestational age, birth weight, onset of sepsis, GNI, age group and culture-proven sepsis with CFRs.

Results

The search yielded 6314 publications, of which 240 studies (N = 437,796 patients) from 77 countries were included. Of 240 studies, 99 were conducted in high-income countries, 44 in upper-middle-income countries, 82 in lower-middle-income countries, 6 in low-income countries and 9 in multiple income-level countries. Overall pooled CFR was 18% (95% CI, 17-19%). The CFR was highest for low-income countries [25% (95% CI, 7-43%)], followed by lower-middle [25% (95% CI, 7-43%)], upper-middle [21% (95% CI, 18-24%)] and lowest for high-income countries [12% (95% CI, 11-13%)]. Factors associated with high CFRs included prematurity, low birth weight, age less than 28 days, early onset sepsis, hospital acquired infections and sepsis in middle- and low-income countries. Study setting in middle-income countries was an independent predictor of high CFRs. We found a widening disparity in CFRs between countries of different GNI over time.

Conclusion

Young infant sepsis remains a major global health challenge. The widening disparity in young infant sepsis CFRs between GNI groups underscore the need to channel greater resources especially to the lower income regions.

Systematic Review Registration

[www.crd.york.ac.uk/prospero], identifier [CRD42020164321].

Clinical and Microbiological Characteristics of Neonates with Candidemia and Impacts of Therapeutic Strategies on the Outcomes

Neonatal candidemia is associated with significant morbidities and a high mortality rate. We aimed to investigate the clinical characteristics of Candida bloodstream infections in neonates and the impact of therapeutic strategies on the outcomes. We identified all the neonates with candidemia from a medical center in Taiwan over an 18-year period (2003−2021) and analyzed them. Clinical isolates were confirmed by DNA sequencing, and antifungal susceptibility testing was performed. The prognostic factors associated with clinical treatment failure (30-day, all-cause mortality and persistent candidemia > 72 h after antifungal agents) and in-hospital mortality were analyzed using logistic regression modeling. A total of 123 neonates with 139 episodes of candidemia were included in the study. The median (IQR) gestational age and birth weight of the neonates with candidemia were 29.0 (26.0−35.0) weeks and 1104.0 (762.0−2055) g, respectively. The most common Candida spp. was Candida albicans (n = 57, 41.0%), followed by C. parapsilosis (n = 44, 31.7%), Candida guilliermondii (n = 12, 8.6%), and C. glabrata (n = 11, 7.9%). The overall susceptibility to fluconazole was 81.3%, and the resistant rates against other antifungal agents were less than 3%. The cumulative mortality rate at 7 and 30 days after the first episode of candidemia was 11.3% and 32.3%, respectively. The overall in-hospital mortality rate was 42.3%. The treatment outcomes did not change over the study period and were not affected by delayed initiation of antifungal agents. Multivariate analysis showed that delayed catheter removal (odds ratio [OR], 5.54; 95% confidence interval [CI]: 1.93−15.86, p = 0.001), septic shock (OR, 7.88; 95% CI: 2.83−21.93, p < 0.001), and multiple chronic comorbidities (OR, 8.71; 95% CI: 1.82−41.81, p = 0.007) were independently associated with the final in-hospital mortality. We concluded that the overall mortality of neonatal candidemia has remained consistently high over the past decade. Prompt early catheter removal and an aggressive treatment strategy for neonatal candidemia with septic shock would be critical to improving patient outcomes.

Invasive fungal infections in neonates: a review

Invasive fungal infections remain the leading causes of morbidity and mortality in neonates, especially preterm and very low birth weight infants. Most invasive fungal infections are due to Candida or Aspergillus species, and other fungi are increasingly reported and described. Appropriate identification and treatment are required to augment activity and reduce the toxicity of antifungal drugs. Successful use of antifungals in the vulnerable neonatal population is important for both prevention and treatment of infection. Strategies for prevention, including prophylactic antifungal therapy as well as reducing exposure to modifiable risk factors, like limiting antibiotic exposure, discontinuation of central catheters, and hand hygiene are key techniques to prevent and decrease rates of invasive fungal infections. In conclusion, this is a review of the most common causes, prevention strategies, prophylaxis, and treatment of invasive fungal infections in neonates.

Comparisons of the clinical and mycological characteristics of pediatric candidemia

BACKGROUND/PURPOSE

Invasive candidiasis is a severe infectious disease that could lead to mortality in critically ill children.

METHODS

We collected data regarding demographics, underlying diseases, predisposing factors, outcomes for pediatric patients with candidemia at a medical centre in Taiwan from 2011 to 2017.

RESULTS

Fifty-eight patients with 60 candidemia episodes were diagnosed. The 3 most common species were Candida albicans (42%), Candida parapsilosis (25%) and Candida tropicalis (23%). C. parapsilosis predominantly infected infants and neonates (median age: 0.8 years, range: 0.1-14.5). Cases with C. tropicalis had significantly higher rates of multidrug resistance (p = 0.011) and disseminated candidiasis (p = 0.025) compared with other cases. The all-cause mortality rate was 43%, and the candidemia-related mortality rate was 29%. Pediatric sequential organ failure assessment score >8 [adjusted odds ratio (aOR) 66.2, 95% CI 4.03-1088.5] and posaconazole resistance (aOR 33.57, 95% CI 1.61-700.3) were the most significant risk factors associated with candidemia-related mortality, whereas treatment with effective antifungal agents within 48 h (aOR 0.07, 95% CI 0.01-0.9) was the only significant protective factor.

CONCLUSIONS

Candidemia-related mortality was related to azole resistance; therefore, empirical therapy with echinocandin or amphotericin B is recommended pending species and susceptibility results.

Risk factors and outcomes of deep tissue Candida invasion in neonates with invasive candidiasis

BACKGROUND

Deep tissue Candida invasion represents a special entity among neonates with invasive candidiasis. We aimed to explore the risk factors and clinical outcomes for deep tissue Candida invasion among neonates with invasive candidiasis.

METHODS

A retrospective data review of neonates admitted to NICU of Madinah maternity and children hospital, KSA from January 2012 to December 2019 was done. Data were analysed between infants with or without deep tissue candidiasis among infants with invasive candidiasis. Invasive candidiasis was defined as positive blood or catheter collected urine culture for Candida. Deep tissue Candida invasion was defined as an infection of the central nervous system, eyes, heart, skeletal system, lungs, liver or kidneys.

RESULT

A total of 14 (11%) out of 130 neonates with invasive candidiasis had deep tissue Candida invasion. Persistent positive blood culture for Candida [OR 15.2, 95% CI (2.0-114), p = .01], prematurity [OR 7.6, 95% CI (1.04-56.4), p = .04] and prolonged antibiotic duration [OR 1.3, 95% CI (1.02-1.6), p = .03] are independent risk factors for deep tissue Candida invasion. Deep tissue Candida invasion was associated with significantly higher rates of cerebral palsy, hydrocephalus, heart failure and longer length of hospital stay compared to infants without deep tissue invasion.

CONCLUSION

Persistent Candida growth in blood cultures, prematurity and long-term antibiotic use are significant risk factors for deep tissue Candida invasion. Deep tissue Candida invasion is associated with prolonged hospital stay and higher neonatal morbidity.

Invasive fungal disease in children with acute myeloid leukaemia: An Australian multicentre 10-year review

BACKGROUND

Invasive fungal disease (IFD) is a common and important complication in children with acute myeloid leukaemia (AML). We describe the epidemiology of IFD in a large multicentre cohort of children with AML.

METHODS

As part of the retrospective multicentre cohort TERIFIC (The Epidemiology and Risk factors for Invasive Fungal Infections in immunocompromised Children) study, proven/probable/possible IFD episodes occurring in children with primary or relapsed/refractory AML from 2003 to 2014 were analysed. Crude IFD prevalence, clinical characteristics, microbiology and treatment were assessed. Kaplan-Meier survival analysis was used to estimate 6-month survival.

RESULTS

There were 66 IFD episodes diagnosed in 63 children with AML. The majority (75.8%) of episodes occurred in the context of primary AML therapy. During primary AML therapy, the overall prevalence was 20.7% (95% CI 15.7%-26.5%) for proven/probable/possible IFD and 10.3% (95% CI 6.7%-15.0%) for proven/probable IFD. Of primary AML patients, 8.2% had IFD diagnosed during the first cycle of chemotherapy. Amongst pathogens implicated in proven/probable IFD episodes, 74.4% were moulds, over a third (37.9%) of which were non-Aspergillus spp. Antifungal prophylaxis preceded 89.4% of IFD episodes, most commonly using fluconazole (50% of IFD episodes). All-cause mortality at 6 months from IFD diagnosis was 16.7% with IFD-related mortality of 7.6% (all in cases of proven IFD).

CONCLUSIONS

IFD is a common and serious complication during paediatric AML therapy. Mould infections, including non-Aspergillus spp. predominated in this cohort. A systematic approach to the identification of patients at risk, and a targeted prevention strategy for IFD is needed.

Neonatal invasive candidiasis: updates on clinical management and prevention

Neonatal invasive candidiasis is an important cause of morbidity and mortality in preterm infants. The incidence of invasive candidiasis in this population has been declining in high-income settings, largely due to preventive measures, although there are still considerable variations in incidence between health-care centres. Surveillance data and large, multicentre studies in lower-income settings are not available, although preventive measures in these settings have been shown to decrease the incidence of neonatal invasive candidiasis. Understanding risk factors and pathogenesis are key to the prevention of invasive candidiasis. The difficulty of a definitive diagnosis of invasive candidiasis and the high risk for death or substantial neurodevelopmental impairment, even with appropriate treatment, further increase the need for effective preventive measures. In this Review, we examine the pathogenesis, clinical presentation, and diagnosis of invasive candidiasis. We highlight commonly used and emerging preventive and prophylactic measures, including standardised central line care, antibiotic stewardship, antifungal prophylaxis, and probiotics. Finally, we provide updates on empirical treatment, clinical management in confirmed cases of invasive candidiasis, and antifungal pharmacotherapy.

A Rapid, Visible, and Highly Sensitive Method for Recognizing and Distinguishing Invasive Fungal Infections via CCP-FRET Technology

Invasive fungal infection (IFI) is one of the leading causes of death in the intensive care unit (ICU) due to its high morbidity and mortality among immunocompromised patients. Early diagnosis of IFI is typically infeasible because of the lack of clinical signs and symptoms. By virtue of the cationic conjugated polymer-based fluorescence resonance energy transfer (CCP-FRET) technology, we develop a rapid, visible, simple, and sensitive method for simultaneous detection and discrimination of three types of pathogens, including Candida albicans (C. albicans), Klebsiella pneumoniae (K. pneumoniae), and Cryptococcus neoformans (C. neoformans). The CCP-FRET system contains a CCP fluorescent probe and pathogen-specific DNA labeled with fluorescent dyes. These two components spontaneously self-assemble into the complex under electrostatic attraction, resulting in an efficient FRET from CCP to fluorescent dyes when irradiated with a 380 nm ultraviolet (UV) light. The CCP-FRET method can specifically identify the DNA molecules that are extracted from culture pathogen strains or blood samples via PCR and single base extension (SBE) reactions, without any cross-reactions on the DNA of nonspecific strains. In particular, the sensitivity of this method is down to 0.03125 ng, which is ten times higher than that of real-time PCR. We further evaluate its detection efficiency by testing 15 blood samples from neonatal patients who suffer from pathogen infections, in which some of them have undergone antipathogen treatments. Using the CCP-FRET method, 33.3% (5/15) of samples tested positive for C. albicans and/or K. pneumoniae infections, whereas no pathogen DNAs are recognized with real-time PCR, despite using the same primers. Interestingly, the CCP-FRET method can output unique fluorescent color as well as RGB patterns to different types of pathogen infections, by which the infection type can be conveniently determined. Collectively, the CCP-FRET method is a sensitive and reliable detection platform for rapid identification of fungal and bacterial multiple infections, holding great promise for uses in clinical testing.

Epidemiology of Culture-confirmed Candidemia Among Hospitalized Children in South Africa, 2012-2017

BACKGROUND

We aimed to describe the epidemiology of candidemia among children in South Africa.

METHODS

We conducted laboratory-based surveillance among neonates (≤28 days), infants (29 days to <1 year), children (1-11 years) and adolescents (12-17 years) with Candida species cultured from blood during 2012-2017. Identification and antifungal susceptibility of viable isolates were performed at a reference laboratory. We used multivariable logistic regression to determine the association between Candida parapsilosis candidemia and 30-day mortality among neonates.

RESULTS

Of 2996 cases, neonates accounted for 49% (n = 1478), infants for 27% (n = 806), children for 20% (n = 589) and adolescents for 4% (n = 123). The incidence risk at tertiary public sector hospitals was 5.3 cases per 1000 pediatric admissions (range 0.39-119.1). Among 2943 cases with single-species infections, C. parapsilosis (42%) and Candida albicans (36%) were most common. Candida auris was among the 5 common species with an overall prevalence of 3% (n = 47). Fluconazole resistance was more common among C. parapsilosis (55% [724/1324]) versus other species (19% [334/1737]) (P < 0.001). Of those with known treatment (n = 1666), 35% received amphotericin B deoxycholate alone, 32% fluconazole alone and 30% amphotericin B deoxycholate with fluconazole. The overall 30-day in-hospital mortality was 38% (n = 586) and was highest among neonates (43% [323/752]) and adolescents (43% [28/65]). Compared with infection with other species, C. parapsilosis infection was associated with a reduced mortality among neonates (adjusted odds ratio 0.41, 95% confidence interval: 0.22-0.75, P = 0.004).

CONCLUSIONS

Candidemia in this setting mainly affected neonates and infants and was characterized by fluconazole-resistant C. parapsilosis with no increased risk of death.

Recent Trends in the Epidemiology of Fungal Infections

The breadth of fungi causing human disease and the spectrum of clinical presentations associated with these infections has widened. Epidemiologic trends display dramatic shifts with expanding geographic ranges, identification of new at-risk groups, increasing prevalence of resistant infections, and emergence of novel multidrug-resistant pathogenic fungi. Certain fungi have been transmitted between patients in clinical settings. Major health events not typically associated with mycoses resulted in larger proportions of the population susceptible to secondary fungal infections. Many health care-related, environmental, and socioeconomic factors have influenced these epidemiologic shifts. This review summarizes updates to clinically significant fungal pathogens in North America.

Fungaemia due to rare yeasts in paediatric intensive care units: A prospective study

BACKGROUND

Considering the emergence of fungaemia due to rare yeasts at our centre, we performed a systematic epidemiologic study on fungaemia due to rare yeasts.

OBJECTIVES

We undertook the present prospective observational study to explore the epidemiological features and clinical characteristics of fungaemia due to rare yeasts in paediatric ICUs at our centre.

METHODS

The successive yeasts isolated from blood at our PICUs during December 2017 through March 2019 were identified by molecular methods. Fungaemia due to yeasts other than C. albicans, C. tropicalis, C. glabrata, C. krusei and C. parapsilosis was categorised as rare yeast fungaemia. Antifungal susceptibility testing of the yeast isolates was performed as per clinical and laboratory standards institute (CLSI) guidelines. We also compared different clinical parameters of fungaemia due to common versus rare yeasts, and rare yeasts in neonates versus non-neonates.

RESULTS

During the study period, 212 yeast isolates were obtained from 159 patients at PICUs of our hospital, and 127 isolates from 98 patients (61.6%) were categorised as rare yeasts. Neonates acquired fungaemia significantly earlier after ICU admission than non-neonates (median: 4 vs 6 days; p = .005). of rare yeast fungaemia, Wickerhamomyces anomalus (43.8%) and Candida utilis (40.8%) were common isolates; surgical intervention and gastrointestinal disease were significantly associated; overall, azole, echinocandin and amphotericin B resistance was at 9.1%, 1.02% and 1.02%, respectively; overall mortality was 65.3%.

CONCLUSIONS

The emergence of rare yeasts especially W. anomalus and C. utilis causing fungaemia in our children demands urgent attention to control the spread.

Bloodstream Infections With Candida auris Among Children in Colombia: Clinical Characteristics and Outcomes of 34 Cases

BACKGROUND

Candida auris is an emerging multidrug-resistant yeast that can cause invasive infections and healthcare-associated outbreaks. Here, we describe 34 cases of pediatric C. auris bloodstream infections (BSIs) identified during July 2014-October 2017 in 2 hospitals in Colombia.

METHODS

We conducted a retrospective review of microbiology records for possible C. auris cases in 2 hospitals in Barranquilla and Cartagena. BSIs that occurred in patients aged <18 years confirmed as C. auris were included in this analysis.

RESULTS

We identified 34 children with C. auris BSIs. Twenty-two (65%) patients were male, 21% were aged <28 days, 47% were aged 29-365 days, and 32% were aged >1 year. Underlying conditions included preterm birth (26%), being malnourished (59%), cancer (12%), solid-organ transplant (3%), and renal disease (3%). Eighty-two percent had a central venous catheter (CVC), 82% were on respiratory support, 56% received total parenteral nutrition (TPN), 15% had a surgical procedure, and 9% received hemodialysis. Preinfection inpatient stay was 22 days (interquartile range, 19-33 days), and in-hospital mortality was 41%.

CONCLUSIONS

Candida auris affects children with a variety of medical conditions including prematurity and malignancy, as well as children with CVCs and those who receive TPN. Mortality was high, with nearly half of patients dying before discharge. However, unlike most other Candida species, C. auris can be transmitted in healthcare settings, as suggested by the close clustering of cases in time at each of the hospitals.Candida auris is an emerging multidrug-resistant yeast that can cause invasive infections and healthcare-associated outbreaks. This report describes 34 cases of pediatric C. auris bloodstream infections, identified in two hospitals in Colombia, South America.

Injection Drug Use-Associated Candidemia: Incidence, Clinical Features, and Outcomes, East Tennessee, 2014-2018

BACKGROUND

Injection drug use (IDU) is an established but uncommon risk factor for candidemia. Surveillance for candidemia is conducted in East Tennessee, an area heavily impacted by the opioid crisis and IDU. We evaluated IDU-associated candidemia to characterize the epidemiology and estimate the burden.

METHODS

We assessed the proportion of candidemia cases related to IDU during January 1, 2014-September 30, 2018, estimated candidemia incidence in the overall population and among persons who inject drugs (PWID), and reviewed medical records to compare clinical features and outcomes among IDU-associated and non-IDU candidemia cases.

RESULTS

The proportion of IDU-associated candidemia cases in East Tennessee increased from 6.1% in 2014 to 14.5% in 2018. Overall candidemia incidence in East Tennessee was 13.5/100 000, and incidence among PWID was 402-1895/100 000. Injection drug use-associated cases were younger (median age, 34.5 vs 60 years) and more frequently had endocarditis (39% vs 3%). All-cause 30-day mortality was 8% among IDU-associated cases versus 25% among non-IDU cases.

CONCLUSIONS

A growing proportion of candidemia in East Tennessee is associated with IDU, posing an additional burden from the opioid crisis. The lower mortality among IDU-associated cases likely reflects in part the younger demographic; however, Candida endocarditis seen among approximately 40% underscores the seriousness of the infection and need for prevention.

Invasive Candida Infections in Neonates after Major Surgery: Current Evidence and New Directions

Infections represent a serious health problem in neonates. Invasive Candida infections (ICIs) are still a leading cause of mortality and morbidity in neonatal intensive care units (NICUs). Infants hospitalized in NICUs are at high risk of ICIs, because of several risk factors: broad spectrum antibiotic treatments, central catheters and other invasive devices, fungal colonization, and impaired immune responses. In this review we summarize 19 published studies which provide the prevalence of previous surgery in neonates with invasive Candida infections. We also provide an overview of risk factors for ICIs after major surgery, fungal colonization, and innate defense mechanisms against fungi, as well as the roles of different Candida spp., the epidemiology and costs of ICIs, diagnosis of ICIs, and antifungal prophylaxis and treatment.

Papiliotrema laurentii fungemia in a premature, very low-birth-weight neonate in Kuwait successfully treated with liposomal amphotericin B

Papiliotrema laurentii (formerly Cryptococcus laurentii) and Papiliotrema albidus (formerly Cryptococcus albidus) are yeast-like environmental fungi which are largely considered as non-pathogenic to humans. However, invasive infections caused by P. laurentii have recently been reported in some patients with an impaired immune system. Here, we describe the first case of P. laurentii fungemia in a premature, very low-birth-weight neonate in Kuwait and the Middle East. Repeated bloodstream isolates were obtained and were tentatively identified as P. laurentii by Vitek 2 yeast identification system. The identification of the yeast isolates as P. laurentii was confirmed by PCR-sequencing of ribosomal DNA (rDNA). Antifungal susceptibility testing data showed that the isolates were susceptible to amphotericin B, fluconazole and voriconazole but appeared resistant to caspofungin. The baby was successfully treated with liposomal amphotericin B.

Recent changes in candidemia trends in a tertiary hospital (2011-2018)

BACKGROUND

The epidemiology of candidemia has changed over the last decades and varies widely among geographic areas.

AIMS

We examined in children (aged 0-14) with candidemia the trends in the incidence rate of this infection, as well as the clinical characteristics of the patients, in order to optimize the prognosis and the control measures of this serious disease.

METHODS

A retrospective cohort study of candidemia in the period 2011-2018 in the neonatal intensive care unit (NICU), pediatric ICU (PICU) and pediatric wards of a tertiary hospital, was conducted. The clinical course, Candida species isolated, antifungal susceptibility, outcome and incidence rates were analyzed and compared.

RESULTS

We diagnosed 68 episodes of candidemia in 62 children, 48% occurred in the NICU, 31% in the PICU and 21% in pediatric wards. Candida albicans was the most frequent species isolated in NICU infants (53%), and Candida parapsilosis predominated among PICU patients (59%) and pediatric wards (50%). One third of NICU infants had invasive candidiasis (IC), most of them having extremely low birth weight (ELBW) (35%). All isolates were susceptible to the antifungal administered. Over time, the incidence of candidemia decreased in the PICU (from 2.2 to 0.3 episodes/1000 patient-days, OR=0.6; 95%CI 0.5-0.8), whereas in the NICU and in the wards remained stable. Mortality occurred mostly in NICU patients (26%), predominated in ELBW infants and did not change over time.

CONCLUSIONS

The higher incidence and mortality of candidemia and IC observed in preterm infants requires a continuous evaluation of practices and diagnostic methods which will allow improving the prognosis of this most vulnerable population.

Epidemiology, antifungal susceptibility, risk factors and mortality of invasive candidiasis in neonates and children in a tertiary teaching hospital in Southwest China

BACKGROUND

Invasive candidiasis (IC) is a major cause of morbidity and mortality in neonates and children; however, little information on the epidemiology of IC in paediatric patients in China is available.

METHODS

A 7-year retrospective study was conducted to analyse the prevalence, species distributions, antifungal susceptibility, risk factors and mortality among paediatric inpatients with IC in a regional tertiary teaching hospital in Southwest China.

RESULTS

A total of 86 paediatric inpatients with IC during the seven-year study period were identified, with a mean annual incidence of 1.04 cases per 1000 admissions and a neonatal incidence of 2.72 cases per 1000 admissions. The species distributions of Candida albicans and non-albicans Candida were 48.8% and 51.2%, respectively. The total resistance rates to fluconazole (FCA), itraconazole (ITR) and voriconazole (VRC) were 8.1%, 26.7% and 14.0%, respectively. Age, length of hospital stay, respiratory dysfunction, hospitalisation duration > 30 days and IC due to C albicans and Candida glabrata were associated with neonatal mortality (P < 0.05) according to univariate analyses. Respiratory dysfunction [odds ratio (OR), 50.03; 95% confidence interval (CI), 3.47-721.44; P = 0.004] was the only independent predictor of neonatal mortality. The overall mortality rate was 8.1%, and only neonatal IC patients died, with a neonatal mortality rate of 13.0%.

CONCLUSIONS

This report shows that the incidence and mortality of IC among neonatal patients warrants increased attention in Southwest China. Clinical interventions should be actively applied to reduce the incidence and mortality of neonatal infection. Fluconazole was a reasonable choice for the treatment of IC prior to species identification.

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.

A Cluster of Candida auris Blood Stream Infections in a Tertiary Care Hospital in Oman from 2016 to 2019

(1) Background: Candida auris has been reported as emerging yeast pathogen that can cause invasive bloodstream infections in healthcare settings. It is associated with high mortality rates and resistance to multiple classes of antifungal drugs and is difficult to identify with standard laboratory methods. (2) Methods: We conducted a retrospective review of epidemiological, clinical, and microbiological records for 23 C. auris fungemia cases at the Royal Hospital, a tertiary care facility in Oman, between 2016 and 2018. Demographic data, risk factors associated with mortality, microbiology investigation and treatment regimens are described. Yeasts were identified by MALDI-TOF. (3) Results: We identified 23 patients with C. auris fungemia. All positive samples from patients were confirmed as C. auris using MALDI-TOF, and ITS-rDNA sequencing. Microsatellite genotyping showed that the Omani isolates belong to the South Asian clade I. The majority of patients had multiple underlying illnesses and other risk factors that have been associated with fungemia. All isolates were non-susceptible to fluconazole. Isolates from all patients were sensitive to echinocandins and these were used as first line therapy. (4) Conclusions: Candida auris affects adults and children with a variety of risk factors including central venous catheters and overuse of antibiotics. Infections occur in both immunocompromised and immunocompetent individuals. Mortality was high in this series, and the organism can be transmitted in healthcare settings. Programs for raising awareness in Oman hospitals are warranted. Caspofungin remains 1st line therapy as MICs are still low despite its wide use.