Trends in Pediatric Candidemia: Epidemiology, Anti-Fungal Susceptibility, and Patient Characteristics in a Children’s Hospital

Anabel Piqueras,Kelly B Flett,Lakshmi Ganapathi,Julia R Köhler,Thomas J Sandora,Thomas Rubio,Jane F Carpenter

doi:10.3390/jof7020078

Abstract

Candida bloodstream infections (CBSIs) have decreased among pediatric populations in the United States, but remain an important cause of morbidity and mortality. Species distributions and susceptibility patterns of CBSI isolates diverge widely between children and adults. The awareness of these patterns can inform clinical decision-making for empiric or pre-emptive therapy of children at risk for candidemia. CBSIs occurring from 2006–2016 among patients in a large children’s hospital were analyzed for age specific trends in incidence rate, risk factors for breakthrough-CBSI, and death, as well as underlying conditions. Candida species distributions and susceptibility patterns were evaluated in addition to the anti-fungal agent use. The overall incidence rate of CBSI among this complex patient population was 1.97/1000 patient-days. About half of CBSI episodes occurred in immunocompetent children and 14% in neonatal intensive care unit (NICU) patients. Anti-fungal resistance was minimal: 96.7% of isolates were fluconazole, 99% were micafungin, and all were amphotericin susceptible. Liposomal amphotericin was the most commonly prescribed anti-fungal agent included for NICU patients. Overall, CBSI-associated mortality was 13.7%; there were no deaths associated with CBSI among NICU patients after 2011. Pediatric CBSI characteristics differ substantially from those in adults. The improved management of underlying diseases and antimicrobial stewardship may further decrease morbidity and mortality from CBSI, while continuing to maintain low resistance rates among Candida isolates.

Highlights

Candida bloodstream infections (CBSIs) are a leading cause of invasive fungal infections in hospitalized children, and one of the most common causes of healthcare-associated infections worldwide
CBSI, varies according to the geographical region and patient population, globally nonalbicans Candida species together cause the majority of CBSI, and resistant Candida species and strains are emerging among adult patient populations
Half of the CBSI episodes occurred in immunocompetent patients, while about a third occurred in immunocompromised patients, with the remainder occurring in neonates in the neonatal intensive care unit (NICU) (Table 1)

Summary

Introduction

Candida bloodstream infections (CBSIs) are a leading cause of invasive fungal infections in hospitalized children, and one of the most common causes of healthcare-associated infections worldwide. While the CBSI incidence in children has been decreasing in the United States over recent decades [1], as infection control and antimicrobial stewardship practices have continued to become more rigorous and universally implemented, CBSI still remain associated with high pathogen-related morbidity and mortality, increased length of hospitalization, 4.0/). Diagnosis is especially challenging in children given the nonspecific symptoms of candidemia and the low sensitivity of blood cultures [6]. In some populations, such as premature neonates and neutropenic oncologic patients, empiric or pre-emptive anti-fungal therapy can decrease delays to the initiation of the appropriate therapy inevitably caused by the reliance on blood culture results

Methods

Results

Conclusion