Blood Culture For Candida Species Research Articles

Epidemiology and associated risk factors for candidemia in a Canadian tertiary paediatric hospital: An 11-year review.

Candidemia represents a significant cause of morbidity and mortality in children. We examined the epidemiology and associated risk factors of candidemia at a Canadian tertiary care paediatric hospital over an 11-year period. A retrospective chart review was conducted on children with positive blood culture for Candida species between January 1, 2007 and December 31, 2018. Patient demographics, previously described candidemia risk factors, Candida species, follow-up investigations, interventions, and outcome data were included in the analysis. Sixty-one candidemia episodes were reported with an overall incidence rate of 5.1 cases per 10,000 patient admissions. Of the 66 species identified, the most common was Candida albicans (53%, 35), followed by Candida parapsilosis (18%, 12), and Candida glabrata (8%, 5). Mixed candidemia was noted in 8% (5/61) of episodes. The most common risk factors included presence of central venous catheter (95%, 58/61) and receipt of antibiotics in the last 30 days (92%, 56/61). Majority of patients received abdominal imaging (89%, 54/61), ophthalmology consult (84%, 51/61), and echocardiogram (70%, 43/61), regardless of age. Line removal was performed in 81% (47/58) of cases. Evidence of disseminated fungal disease on abdominal imaging was observed in 11% (6/54) of patients, all in non-neonates but with risk factors including immunosuppression and gastrointestinal abnormalities. The overall 30-day case fatality rate was 8% (5/61). C. albicans was the most commonly isolated species. Disseminated candidiasis was demonstrated mainly on abdominal imaging in patients with relevant risk factors, including immunosuppression and gastrointestinal abnormalities.

Κey Role of Early Source Control in Candidemic Patients With Sepsis or Septic Shock.

BackgroundDespite advances in diagnostic and therapeutic approaches, candidemia remains associated with high mortality rates. This study aimed at identifying predictors of mortality among patients with candidemia, with a focus on early interventions that can improve prognosis.MethodsThis was a single-center retrospective study including all adult patients with at least 1 positive blood culture for Candida species from 2014 to 2021.ResultsA total of 222 episodes of candidemia were included. Most candidemias were of unknown origin (36%) or vascular catheter related (29%). Septic shock developed in 29% episodes. Overall, 14-day mortality rate was 23%. In univariate analyses, septic shock was associated with higher 14-day mortality, whereas catheter-related candidemia and early (<72 hours) interventions, such as appropriate antifungal therapy, source control, and infectious diseases consultation, were associated with improved survival. In a Cox multivariate regression model, septic shock (odds ratio [OR], 3.62 [95% confidence interval {CI}, 2.05–6.38]) was associated with higher mortality. While the impact of early antifungal therapy did not reach statistical significance, early (<72 hours) infectious diseases consultation (OR, 0.46 [95% CI, .23–.91]) and early source control (OR, 0.15 [95% CI, .08–.31]) were associated with better survival. Subanalyses showed that the benefits of early source control, specifically catheter removal, were significant among patients with sepsis or septic shock, but not among those without sepsis. These associations remained significant after exclusion of patients who died prematurely or were in palliative care.ConclusionsEarly source control, in particular catheter removal, was a key determinant of outcome among candidemic patients with sepsis or septic shock.

Factors associated with the development of ocular candidiasis and ocular prognosis with echinocandin therapy for candidemia

PurposeTo evaluate the factors associated with the development of ocular candidiasis (OC) and ocular prognosis with echinocandin therapy for candidemia.MethodsThe medical records of 56 consecutive patients with a positive blood culture for Candida species between November 2016 and October 2019 were retrospectively reviewed. Information on patient characteristics, isolated Candida species, treatment details for candidemia, and ocular findings were extracted to identify factors associated with OC development.ResultsThe leading pathogen of candidemia was Candida albicans (C.albicans) (41.1%). Of 56 patients, 18 (32.1%) were diagnosed with chorioretinitis, categorized as either probable (8 patients) or possible OC (10 patients). There was no case of endophthalmitis with vitritis. The incidence of probable OC was not significantly different between the groups treated with echinocandins and other antifungal drugs (15.2% vs. 11.1%, p = 1.00). In all probable OC cases, systemic antifungal therapy was switched from echinocandins to azoles, and no case progressed to endophthalmitis. A multivariate logistic analysis revealed that female sex (adjusted odds ratio [aOR], 8.93; 95% confidence interval [CI], 1.09–72.9) and C. albicans (aOR, 23.6; 95% CI, 1.8–281) were independent factors associated with the development of probable OC.ConclusionOne-seventh of patients with candidemia developed probable OC. Given the evidence of female and C. albicans as the factors associated with OC development, careful ophthalmologic management is required with these factors, especially in candidemia. Although echinocandins had no correlation with OC development and did not lead to the deterioration of ocular prognosis, further investigation is required.

Retrospective evaluation of candidemic patients among general surgery department in a tertiary care university hospital

Candida species are among the most important causes of hospital acquired blood borne infections, and with high rates of mortality and morbidity, these infections are still a major problem today. History of gastrointestinal surgery, administration of total parenteral nutrition and/or wide spectrum antibiotics and immune suppression following organ transplantations are considered serious risk factors for these infections. This study aimed to evaluate the patients from our general surgery department with diagnosed candidemia; by means of strain, treatment and prognosis. Patients with positive blood cultures for Candida species who were treated in the wards and Ege University Faculty of Medicine general surgery department of surgical intensive care units of our between 2012 and 2017 were retrospectively analyzed by means of strain, treatment and prognosis. A total of 50 patients were enrolled in the study. Mean age was 58.96 years and 54% of the patients were female. There were nine patients with organ transplantation (four liver and five kidney transplantations), six with intestinal perforation and three with anastomotic leakage. Isolated strains were Candida albicans (36%; 18/50), Candida tropicalis (14%; 7/50), Candida glabrata (12%; 6/50), Candida parapsilosis (8%; 4/50), Candida kefyr (6%; 3/50), Candida krusei (4%; 2/50), Candida pulcherrima (2%; 1/50), Cryptococcus neoformans (2%, 1/50), Geotrichum capitatum (2%, 1/50), Candida spp. (unidentified, 14%; 7/50) with decreasing frequency. The highest antifungal sensitivity rates (> 90%) were measured for amphotericin B, voriconazole and echinocandins among all isolates. One-month mortality rate was 43.4% (20/46). Documented eradication was achieved among 24 of the 33 patients who had control blood culture samples (72.7%), and mean eradication time was 7.6 days. Echocardiography was performed in 14% (7/50) and ophthalmic examination in 8% (4/50). Although C. albicans appears to be the dominant strain in patients with candidemia, frequencies of other strains are increasing. Early diagnosis and treatment of patients with candidemia is of vital importance due to high mortality and morbidity rates.

Chronic disseminated candidiasis manifesting as hepatosplenic abscesses among patients with hematological malignancies

BackgroundThe outcomes of deep-seated abscesses attributed to chronic disseminated candidiasis (CDC) in patients with hematological malignancies have rarely been reported in recent years.MethodsWe retrospectively reviewed and analyzed the data of patients with hematological malignancies who received a diagnosis of CDC at a medical center in Taiwan between 2008 and 2013.ResultsSixty-one patients (32 men and 29 women) were diagnosed with CDC. The median age was 51 years (range: 18–83). The overall incidence of CDC was 1.53 per 100 patient-years in patients with hematological malignancies between 2008 and 2013. The highest incidence of CDC was 4.3 per 100 patient-years for acute lymphoblastic leukemia, followed by 3.6 for acute myeloid leukemia. We detected 3 (4.9%) proven, 13 (21.3%) probable, and 45 (73.8%) possible cases of CDC. A total of 13 patients had positive blood cultures for Candida species: C. tropicalis (8), C. albicans (2), C. glabrata (2), and C. famata (1).The median duration of antifungal treatment was 96 days (range: 7–796 days). Serial imaging studies revealed that the resolution rate of CDC was 30.0% at 3 months and 54.3% at 6 months. Five patients (8.2%) had residual lesions that persisted beyond one year. A multivariate analysis of the 90-day outcome revealed that shock was the only independent prognostic factor of 90-day survival in patients with CDC.ConclusionThe incidence of CDC did not decrease between 2008 and 2013. Patients with acute leukemia had a higher risk of CDC than those with other hematological malignancies. Imaging studies conducted at 6 months after diagnosis revealed that only half of the patients showed complete resolution. CDC requires prolonged treatment, and serial imaging at 6 months interval is suggested. Shock is the only independent prognostic factor of 90-day survival in patients with CDC.

2092. How Long Should You Delay Insertion of a Long-Term Central Venous Catheter (LTCVC) in Patients with Candida Bloodstream Infection (CBSI)?

BackgroundGuidelines suggest that among patients with candidemia, placement of an LTCVC, often needed for treatment, can proceed when “additional blood cultures show no growth” but the timeframe is not well defined. There is theoretical risk of relapsed CBSI after therapy if yeast are still circulating in the blood and adhere to the LTCVC. We sought to determine the blood culture time to detection (TTD) for candida to identify a timeframe for LTCVC insertion that would mitigate risk for relapsed CBSI.MethodsWe conducted a retrospective cohort study of all positive (+) blood cultures for Candida species (albicans, glabrata, tropicalis, parapsilosis, dubliniensis, krusei, and lusitaniae) isolated from August 1, 2013–December 31, 2017. Data were retrieved from the microbiology laboratory and the BD BACTEC™ blood culture system was used. TTD was recorded for each (+) blood culture in hours and the mean TTD was calculated by species.ResultsOne hundred and twenty-eight blood cultures were (+) for Candida species. C. glabrata was the most common species isolated, followed by C. albicans and C. parapsilosis. Overall, the mean TTD was 43 hours (range 7.1–117.7 hours); 19.5% were positive within 24 hours, 67.2% within 48 hours, and 86.7% within 72 hours, and none required more than 120 hours (table).ConclusionAmong patients with candidemia, the majority of blood cultures were positive within 72 hours after inoculation and all were positive within 120 hours; however, among the three most common species, 16.3% required more than 72 hours. Waiting 120 hours before insertion of a LTVC should mitigate risk for relapsed CBSITable.TTD for Candida Species Isolated from Blood Culture# (%)TTD (Hours)# (+) Within 24 Hours (%)# (+) Within 48 Hours (%)# (+) Within 72 Hours (%)# (+) Between>72–120 Hours (%)MeanMedian C. glabrata 52 (40.6)44338 (15.4)27 (51.9)8 (15.4)9 (17.3) C. albicans 27 (21.1)48493 (11.1)10 (37)10 (37)4 (14.8) C. parapsilosis 25 (19.5)45385 (20)12 (48)4 (16)4 (16) C. tropicalis 14 (10.9)34345 (35.7)6 (42.8)3 (21.4)0 C. krusei 6 (4.7)31292 (33.3)4 (66.7)00 C. dubliniensis 3 (2.3)23192 (66.7)1 (33.3)00 C. lusitaniae 1 (0.8)303001(100)00 Total 128433725 (19.5)61 (47.7)25 (19.5)17 (13.3)Disclosures All authors: No reported disclosures.

Candidemia in Cancer Patients

Introduction While the global epidemiology of candidemia has been studied in great detail, there are relatively few data available examining the effects of recent changes in antifungal treatment patterns on the susceptibility and species distribution patterns of Candida species. Likewise, there are relatively few data documenting improved outcomes in patients with candidemia. Materials and Methods We reviewed the charts of all patients at our institution with one or more positive blood cultures for Candida species between January 1, 2001, and June 18, 2014. We first looked at the remaining set of 247 patients who met these criteria, followed by an isolated subset of 115 patients with hematologic malignancies (HMs). All patients were selected from the H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, based on positive Candida culture reports obtained from Moffitt's microbiology laboratories. From these reports, we obtained the patient name and medical record number, positive sample collection dates, number of positive culture days, species of Candida, and patient location in the hospital. We included positive samples taken from peripheral and central lines but excluded samples taken from catheter tips. Blood cultures were initially analyzed using either the Bactec or the BacT/Alert system. Cultures that were positive for yeasts were Gram-stained, and yeasts were cultured on Sabouraud dextrose agar and chocolate agar. Yeast species were tentatively classified by visual examination and conclusively identified using either the RapID YeastOne system or the Vitek 2 system. Drug susceptibilities were determined via serial dilutions using the TREK Sensititre YeastOne system. After data collection from the laboratory reports, we examined the patient's medical records and collected additional data points. Susceptibility data on fluconazole, amphotericin B, voriconazole, micafungin, 5-flucytosine, posaconazole, caspofungin, itraconazole, and anidulafungin were collected if available. We compared frequency of each Candida species overall as well as over different time intervals for all patients, those with only non-HMs, and those with only HMs. Results The most prevalent infecting species overall was Candida albicans followed closely by Candida glabrata. The frequency of infection with other species, beginning with Candida krusei, was much lower. The most prevalent infecting species was C. albicans, which by itself represented a little less than half of all non-HM patients. Candida glabrata was once again the next most frequent species. The most prevalent infecting species for patients with HMs was C. glabrata followed by C. krusei, which together combined for more than half of infections. Candida albicans was not nearly as frequent in this group, and in fact was the least prevalent of the major species. When comparing the first 5 years with the last 5 years, the most prevalent species during both periods was C. glabrata, C. albicans, and Candida tropicalis with incidences falling substantially, whereas Candida parapsilosis incidences rose substantially. The prevalence of C. krusei also showed a moderate increase. There were no other Candida species between 2001 and 2006, further illustrating the shift that has occurred. Eleven deaths were deemed attributable to candidemia in comparison to 40 deaths deemed attributable to the underlying disease (malignancy, other infections, organ failure due to graft-versus-host disease, etc). Conclusions Our data regarding breakthrough infections while on prophylactic antifungal treatment illustrate how most candidemias that breakthrough while on micafungin are C. parapsilosis and C. krusei. Further information is needed to determine how these trends might impact treatment recommendations for candidemia and to ensure optimal effectiveness in preventing and treating candidemia in patients with cancer.

Central venous catheter (CVC) removal for patients of all ages with candidaemia.

Candida bloodstream infections most often affect those already suffering serious, potentially life-threatening conditions and often cause significant morbidity and mortality. Most affected persons have a central venous catheter (CVC) in place. The best CVC management in these cases has been widely debated in recent years, while the incidence of candidaemia has markedly increased. The main purpose of this review is to examine the impact of removing versus retaining a CVC on mortality in adults and children with candidaemia who have a CVC in place. We searched the following databases from inception to 3 December 2015: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid SP), EMBASE (Ovid SP), the Commonwealth Agricultural Bureau (CAB), Web of Science and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We searched for missed, unreported and ongoing trials in trial registries and in reference lists of excluded articles. We searched for randomized controlled trials (RCTs) and quasi-RCTs involving adults and children with candidaemia and in which participants were randomized for removal of a CVC (the intervention under study), irrespective of publication status, date of publication, blinding status, outcomes published or language.However, two major factors make the conduct of RCTs in this population a difficult task: the large sample size required to document the impact of catheter removal in terms of overall mortality; and lack of economic interest from the industry in conducting such a trial. Our primary outcome measure was mortality. Several secondary outcome measures such as required time for clearance of blood cultures for Candida species, frequency of persistent candidaemia, complications, duration of mechanical ventilation and length of stay in the intensive care unit (ICU) and in the hospital were planned, as were various subgroup and sensitivity analyses, according to our protocol. We assessed papers and abstracts for eligibility and resolved disagreements by discussion. However, we were not able to include any RCTs or quasi-RCTS in this review and, as a result, have carried out no meta-analyses. However, we have chosen to provide a brief overview of excluded observational studies. We found no RCT and thus no available data for evaluation of the primary outcome (mortality) nor secondary outcomes or adverse effects. Therefore, we conducted no statistical analysis.A total of 73 observational studies reported on various clinically relevant outcomes following catheter removal or catheter retention. Most of these excluded, observational studies reported a beneficial effect of catheter removal in patients with candidaemia. None of the observational studies reported results in favour of retaining a catheter. However, the observational studies were very heterogeneous with regards to population, pathogens and interventions. Furthermore, they suffered from confounding by indication and an overall high risk of bias. As a consequence, we are not able to provide recommendations or to draw firm conclusions because of the difficulties involved in interpreting the results of these observational studies (very low quality of evidence, GRADE - Grades of Recommendation, Assessment, Development and Evaluation Working Group). Despite indications from observational studies in favour of early catheter removal, we found no eligible RCTs or quasi-RCTs to support these practices and therefore could draw no firm conclusions. At this stage, RCTs have provided no evidence to support the benefit of early or late catheter removal for survival or other important outcomes among patients with candidaemia; no evidence with regards to assessment of harm or benefit with prompt central venous catheter removal and subsequent re-insertion of new catheters to continue treatment; and no evidence on optimal timing of insertion of a new central venous catheter.

The ever-evolving landscape of candidaemia in patients with acute leukaemia: non-susceptibility to caspofungin and multidrug resistance are associated with increased mortality.

The epidemiology and clinical course of candidaemia in patients with acute leukaemia, a population frequently exposed to antifungals, have not been extensively studied. In the present contemporary series of acute leukaemia patients, we describe patient characteristics, Candida species and MIC distributions and investigate the association between antifungal resistance and all-cause mortality. We performed a retrospective review of medical records and microbiological data of adult patients with acute leukaemia or high-risk myelodysplastic syndrome with at least one positive blood culture for Candida species at the MD Anderson Cancer Center between January 2008 and October 2012. Susceptibility was defined according to the 2012 epidemiological cut-off values and clinical breakpoints. We identified 67 episodes of candidaemia in 65 patients. Almost all episodes (94%) occurred in patients who were receiving antifungal agents, 71% in patients receiving an echinocandin. Almost all isolates (99%) were of non-albicans Candida species [most frequently Candida parapsilosis (32%), Candida tropicalis (23%) and Candida glabrata (20%)]. Caspofungin non-susceptibility was significantly associated with fluconazole resistance (P < 0.001). Non-susceptibility to caspofungin and multidrug resistance were associated with excess 14 day [adjusted HR (aHR) 3.02 (95% CI 1.28-7.09), P = 0.011 and aHR 3.02 (95% CI 1.27-7.14), P = 0.012, respectively] and 30 day [aHR 2.96 (95% CI 1.38-6.37), P = 0.005 and aHR 2.86 (95% CI 1.31-6.21), P = 0.008, respectively] all-cause mortality. In patients with acute leukaemia, a shift in candidaemia epidemiology was noted with a 99% predominance of non-albicans species. Non-susceptibility of Candida strains to caspofungin or multidrug resistance were independent markers of poor outcome in this patient population.

The Epidemiology of Neonatal and Pediatric Candidemia in England and Wales, 2000–2009

There are few population-based studies on the epidemiology of neonatal and pediatric invasive Candida infections, despite their significant clinical impact on patients. This study aimed to describe the epidemiology of pediatric candidemia in England and Wales during a 10-year period as a means of quantifying the changing burden of infection and identifying emerging trends. National Health Service hospital microbiology laboratories in England and Wales routinely report clinically significant invasive infections electronically to the Health Protection Agency. Records of all positive blood cultures for Candida species in children aged <15 years between 2000 and 2009 inclusive were extracted for analysis. During 2000 to 2009, 1473 childhood candidemia cases were reported in England and Wales (annual incidence, 1.52/100,000 person-years), with the highest rate in <1 year olds (n = 706; 11.0/100,000), followed by 1-4 year olds (n = 440; 1.77/100,000), 5-9 year olds (n = 168; 0.53/100,000) and 10-14 year olds (n = 159; 0.47/100,000). Incidence increased from 1.04 per 100,000 in 2000 to 2.09 per 100,000 in 2007 (P < 0.001) before falling to 1.53 per 100,000 in 2009 (P < 0.001). Candida species was reported in 89.6% (1320/1473) cases, with Candida albicans and Candida parapsilosis accounting for most infections in all age groups. There were no significant differences in species distribution by season or year of study and the proportion of non-albicans cases did not increase with time. Pediatric candidemia rates are beginning to fall in England and Wales. C. albicans continues to account for most Candida bloodstream infections in all age groups with no evidence of increases in non-albicans species.

Persistent candidemia in neonatal care units: risk factors and clinical significance

The prevalence and clinical significance of persistent candidemia among neonates are poorly understood. This study aimed to describe the rate and the clinical relevance of persistent candidemia over a 4-year period in Kuwait. A retrospective chart review of infants admitted to the Neonatal Care Unit of the Maternity Hospital in Kuwait between January 2007 and December 2010, who had a positive blood culture for Candida species, was conducted. Persistent candidemia was defined as the isolation of the same Candida species more than 6 days after the initiation of antifungal therapy, or death due to candidemia within 6 days of antifungal treatment. Stepwise logistic regression was used to investigate factors associated with persistent candidemia. Of 89 neonates with a Candida infection, 54 (60.7%, 95% confidence interval 49.7-70.9%) had persistent candidemia. The case-fatality rate was 54% among those with persistent candidemia and 3% among those with non-persistent candidemia (p<0.001). Neonates with persistent candidemia were more likely to be female, have a central vascular catheter at diagnosis, and have a low platelet count. All isolated Candida species were susceptible to antifungal agents. Persistent candidemia is common among neonates with a Candida infection and is associated with an increased risk of mortality. Drug resistance is unlikely to explain the persistent candidemia; host-related factors seem to be more important and hence could be used to identify those at risk in order to institute appropriate preventive and treatment measures.

Septic Shock Attributed to Candida Infection: Importance of Empiric Therapy and Source Control

Delayed treatment of candidemia has previously been shown to be an important determinant of patient outcome. However, septic shock attributed to Candida infection and its determinants of outcome have not been previously evaluated in a large patient population. A retrospective cohort study of hospitalized patients with septic shock and blood cultures positive for Candida species was conducted at Barnes-Jewish Hospital, a 1250-bed urban teaching hospital (January 2002-December 2010). Two hundred twenty-four consecutive patients with septic shock and a positive blood culture for Candida species were identified. Death during hospitalization occurred among 155 (63.5%) patients. The hospital mortality rate for patients having adequate source control and antifungal therapy administered within 24 hours of the onset of shock was 52.8% (n = 142), compared to a mortality rate of 97.6% (n = 82) in patients who did not have these goals attained (P < .001). Multivariate logistic regression analysis demonstrated that delayed antifungal treatment (adjusted odds ratio [AOR], 33.75; 95% confidence interval [CI], 9.65-118.04; P = .005) and failure to achieve timely source control (AOR, 77.40; 95% CI, 21.52-278.38; P = .001) were independently associated with a greater risk of hospital mortality. The risk of death is exceptionally high among patients with septic shock attributed to Candida infection. Efforts aimed at timely source control and antifungal treatment are likely to be associated with improved clinical outcomes.

Septic Shock Due to Candidemia: Outcomes and Predictors of Shock Development

BackgroundThe present report describes the outcomes of a cohort of patients with Candida induced septic shock.MethodsRetrospective analysis of individuals who had at least one positive blood culture for Candida species ≥ 48 h after ICU admission. Data from patients that developed septic shock within 48 hr of the positive blood culture were compared to non-shock candidemic patients. Patients with a concomitant bacteremia and/or endocarditis were excluded.ResultsFifteen patients with Candida induced septic shock were studied and compared to 35 candidemic patients without shock. Overall mortality was 76% (87 % among those who had shock). A high proportion of non-albicans Candida species causing fungemia (74%) was observed. All patients with shock were receiving antibiotics but not antifungal treatment at the time of shock development, eight were on parenteral nutrition, six on steroids and nine had a cancer history. High dose fluconazole was the most common initial treatment provided. Four patients died before receiving any antifungal treatment. Time in ICU before the development of candidemia was identified as a predictor of shock development (higher chance if fungemia developed < 7 days after ICU admission).ConclusionsSeptic shock due to invasive candidiasis is a near fatal condition. No conventional risk factors were identified to predict shock development other than time (shorter) spent in ICU before the development of candidemia. We encourage clinicians to consider the initiation of appropriate empiric antifungal treatment in high-risk patients who develop septic shock while on antimicrobial treatment.KeywordsSeptic shock; Candidemia; Outcome; Predictor

Étude rétrospective de la prise en charge des candidémies en 2004 dans un centre hospitalier universitaire français

This study aimed to retrospectively evaluate the adequate use of antifungal drugs in the treatment of the candidaemia. A collection of clinical, biological and therapeutic data was carried out for the patients who had a positive blood culture for Candida species during the year 2004. The antifungal therapy was compared to the guidelines of the French Conference of consensus named « Prise en charge des candidoses et aspergilloses invasives de l'adulte ». The degree of conformity was classified as follows: complying, partly complying (molecule in conformity but delay of treatment or unsuited dosing) and not complying with the guidelines. The analysis was performed, according to the guidelines, before and after knowledge of Candida species growing from the blood culture. On 29 candidaemia, the found species were: Candida albicans 55%, Candida glabrata 14%, Candida krusei 10%, Candida parapsilosis and Candida lusitaniae 7%, Candida pelliculosa and Candida tropicalis 3.5%. Only 19 candidaemia were included in this study because blood cultures were known positive for Candida on the day of death ( N = 7) or medical charts were not available ( N = 3). For treatment before identification of Candida species, 37% were complying, 37% in partly complying and 26% not complying with the guidelines. For the treatment after identification of the species, 26% were complying, 63% partly complying and 11% not complying with the guidelines. As a whole, antifungal therapy was totally or partly complying in 74 to 89% of candidaemia in adult patients. Lower dosages of fluconazole explained most of the treatments that partly complied with guidelines.

Evaluation of blood stream infections by Candida in three tertiary hospitals in Salvador, Brazil: a case-control study

Invasive infections caused by Candida spp. are an important problem in immunocompromised patients. There is scarce data on the epidemiology of blood stream candidiasis in Salvador, Brazil. This study evaluates the risk factors associated with candidemia, among patients admitted to three tertiary, private hospitals, in Salvador, Brazil. We conducted a case-control, retrospective study to compare patients with diagnosis of candidemia in three different tertiary hospitals in Salvador, Brazil. Patients were matched for nosocomial, acquired infections, according to the causal agent: cases were defined by positive blood cultures for Candida species. Controls were those patients who had a diagnosis of systemic bacterial infection, with a positive blood culture to any bacteria, within the same time period (+/- 30 days) of case identification. The groups were compared for the main known risk factors for candidemia and for mortality rates. A hundred thirty-eight patients were identified. Among the 69 cases, only 14 were diagnosed as infected by Candida albicans. Candida species were defined in only eight cultures: C. tropicalis (4 cases), C. glabrata, C. parapsilosis, C. guillermondi, C. formata (1 case each). The main risk factors, identified in a univariate analysis, were: presence of a central venous catheter (CVC), use of parenteral nutrition support (PNS), previous exposure to antibiotics, and chronic renal failure (CRF). No association was detected with surgical procedures, diabetes mellitus, neutropenia or malignancies. Patients were more likely to die during the hospitalization period, but the rates of death caused by the infections were similar for cases and controls. The length of hospitalization was similar for both groups, as well as the time for a positive blood culture. Blood stream infection by Candida spp. is associated with CVC, PNS, previous use of antibiotics, and CRF. The higher mortality rate for cases probably better reflects the severity of the underlying diseases, than as a direct consequence of Candidemia.

RISK FACTORS FOR MORTALITY IN CHILDREN WITH CANDIDEMIA

We performed a retrospective cohort study of hospitalized children with positive blood cultures for Candida species. Independent risk factors for mortality by multivariable analysis were location in the pediatric intensive care unit at the time of infection (hazard ratio, 6.3; 95% confidence interval, 1.6-24.3) and the presence of an arterial catheter (hazard ratio, 2.4; 95% confidence interval, 1.1-5.8). Our findings help identify a group of pediatric patients that should be targeted for future interventions to prevent and treat candidemia.

Risk factors for disseminated candidiasis in children with candidemia.

To determine the risk factors for disseminated infection in hospitalized children with candidemia. We performed a nested case-control study within a cohort of hospitalized children with candidemia. The cohort was defined by all patients with positive blood cultures for Candida species in a large, urban, academic, tertiary care children's hospital from 1998 to 2001. Cases were patients with clinical, microbiologic or radiographic evidence of disseminated candidiasis. Controls were patients with no evidence of disseminated candidiasis. Among 168 total children with candidemia, the median age was 3.5 years (interquartile range, 0.6-14.3). There were 189 episodes of candidemia. Candida species included:Candida albicans (41%), Candida parapsilosis (24%), Candida glabrata (13%) and Candida tropicalis (9%). The most common underlying diagnoses were oncologic (24%), gastrointestinal (15%) and cardiac (10%) diseases. Eighty-nine patients (53%) were admitted to an intensive care unit, 46 (27%) to a general pediatric or surgical ward and 33 (20%) to the oncology ward. Of the 168 patients with candidemia, 153 were included in the analysis of risk factors for disseminated candidiasis. Of 153 (17%) patients, 26 had evidence of organ dissemination. Organ involvement was most commonly identified in the lung (58%), followed by the liver (23%), kidney (16%), brain (12%), spleen (8%), eye (8%) and heart (8%). Eight of the 26 patients had evidence of dissemination to more than 1 organ. Independent risk factors for disseminated candidiasis were persistently positive blood cultures for Candida (>3 days) with a central venous catheter in place (odds ratio, 3.0; 95% confidence interval, 1.2, 7.8; P = 0.02) and immunosuppression (odds ratio, 2.9; 95% confidence interval, 1.2, 7.0; P = 0.02). Prolonged duration of candidemia with a central venous catheter in place and immunosuppression were independent risk factors for disseminated candidiasis in children with candidemia. Furthermore review of the epidemiology of candidemia at our institution revealed a heterogeneous population of children at risk for candidemia and a predominance of non-albicans species as the cause of these infections. Future studies are needed to determine the extent of evaluation needed for detecting dissemination among children with candidemia and to explore interventions for its prevention.

Candidemia in critically ill patients: difference of outcome between medical and surgical patients.

Candidemia is increasingly encountered in critically ill patients with a high fatality rate. The available data in the critically ill suggest that patients with prior surgery are at a higher risk than others. However, little is known about candidemia in medical settings. The main goal of this study was to compare features of candidemia in critically ill medical and surgical patients. Ten-year retrospective cohort study (1990-2000). Medical and surgical intensive care units (ICUs) of a teaching hospital. Fifty-one patients with at least one positive blood culture for Candida species. Risk factors were retrieved in all of the patients: central venous catheter (92.1%), mechanical ventilation (72.5%), prior bacterial infection (70.6%), high fungal colonization index (45.6%). Candida albicans accounts for 55% of all candidemia. The overall mortality was 60.8% (85% and 45.2% in medical and surgical patients, respectively). Independent factors associated with survival were prior surgery (hazard ratio [HR] =0.25; 0.09-0.67 95% confidence interval [CI], p<0.05), antifungal treatment (HR =0.11; 0.04-0.30 95% CI, p<0.05) and absence of neutropenia (HR =0.10; 0.02-0.45 95% CI, p<0.05). Steroids, neutropenia and high density of fungal colonization were more frequently found among medical patients compared to surgical ones. Candidemia occurrence is associated with a high mortality rate among critically ill patients. Differences in underlying conditions could account for the poorer outcome of the medical patients. Screening for fungal colonization could allow identification of such high-risk patients and, in turn, improve outcome.

Candida sepsis and association with retinopathy of prematurity.

To assess the association of Candida sepsis with retinopathy of prematurity (ROP) in extremely low birth weight infants. We prospectively identified 253 infants admitted to the Critical Care Nursery at Georgetown University Hospital with birth weights </=1000 g born between January 1, 1994, and June 30, 1996. Of these 253 infants, 62 died and 55 were transferred to other institutions before ophthalmologic screening for ROP. Clinical data on 98% (133/136) infants were reviewed. Candida sepsis was defined as a positive blood culture for Candida species. Severity of ROP was staged by the International Classification for ROP. Data were analyzed using the chi2 test for nominal data, unpaired t test for continuous data, Mann-Whitney U test for ordinal data, and logistic regression. The mean birth weight (+/-SD) of the population studied was 777 g (+/-136 g), and the mean gestational age at birth was 26.0 weeks (+/-1.8 weeks). The overall incidence of ROP was 74%, and it correlated significantly with birth weight, gestational age, days on supplemental oxygen, and 5-minute Apgar scores. The incidence of ROP was significantly higher in the infants who had Candida sepsis (21/22 [95%]) compared with those who did not (77/111 [69%]). Using logistic regression to control for the influence of birth weight, gestational age, days on supplemental oxygen, and 5-minute Apgar scores, Candida sepsis was an independent predictor of stage 3 or worse ROP. In addition, 9 (41%) of 22 infants with Candida sepsis required laser surgery compared with 10 (9%) of 111 infants without Candida sepsis. This difference was significant independent of birth weight, gestational age, days on supplemental oxygen, and 5-minute Apgar scores. Candida sepsis is independently associated with increased severity of ROP and the need for laser surgery in extremely low birth weight infants.

The changing face of candidemia: emergence of non- Candida albicans species and antifungal resistance

To assess the changing epidemiology of candidemia in the 1990s, to evaluate the clinical implications for the presence of non-Candida albicans in blood, and to evaluate the presence of antifungal resistance in relation to prior antifungal administration. Multicenter prospective observational study of patients with positive blood cultures for Candida species or Torulopsis glabrata. Four tertiary care medical centers. Four hundred twenty-seven consecutive patients were enrolled. The frequency of candidemia due to non-C. albicans species significantly increased in each hospital throughout the 3.5-year study period (P = 0.01). Thirteen percent of candidemias occurred in patients who were already receiving systemic antifungal agents. Candidemias developing while receiving antifungal therapy were more likely caused by non-C. albicans species than by C. albicans species (P = 0.0005). C. parapsilosis and C. krusei were more commonly seen with prior fluconazole therapy, whereas T. glabrata was more commonly seen with prior amphotericin B therapy. Candida species isolated during episodes of breakthrough candidemia exhibited a significantly higher MIC to the antifungal agent being administered (P < 0.001). In this large scale study, the non-C. albicans species, especially T. glabrata, emerged as important and frequent pathogens causing fungemia. This finding has major clinical implications given the higher complication and mortality rate associated with the non-C. albicans species. The change in the pattern of candidemia might be partly attributed to the increase in number of immunocompromised hosts and the widespread use of prophylactic or empiric antifungal therapy. This is an ominous sign given the in vitro resistance of the non-C. albicans species to currently available antifungal agents.