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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 5  |  Page : 229-230

Candidemia in pediatric intensive care unit: A new common and complicated comorbidity

1 Department of Pediatric Intensive Care, Rainbow Children's Hospital, Bengaluru, Karnataka, India
2 Department of Pediatric Intensive Care, St. Philomena's Hospital, Bengaluru, Karnataka, India

Date of Submission02-Aug-2020
Date of Acceptance11-Aug-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. Rakshay Shetty
Department of Pediatric Intensive Care, Rainbow Children's Hospital, Marathalli, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JPCC.JPCC_122_20

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How to cite this article:
Shetty R, Mishra S. Candidemia in pediatric intensive care unit: A new common and complicated comorbidity. J Pediatr Crit Care 2020;7:229-30

How to cite this URL:
Shetty R, Mishra S. Candidemia in pediatric intensive care unit: A new common and complicated comorbidity. J Pediatr Crit Care [serial online] 2020 [cited 2021 Mar 4];7:229-30. Available from: http://www.jpcc.org.in/text.asp?2020/7/5/229/295015

Last decade has seen a rise in the use of advanced invasive and indwelling devices in pediatric intensive care units (PICUs) with the emergence of newer therapies for sick children. Unfortunately, it has led to the rising incidence of hospital-acquired infections and candidemia is one such condition. Candidemia has been demonstrated in PICU to be an individual risk factor contributing to higher mortality rate. This is possibly owing to the delayed diagnosis, increased incidence of nonalbicans candidemia (NAC), and rising resistance against the antifungals. Therefore, it is crucial to identify the risk factors, epidemiology, and adequate preventive and control measures.

It is estimated that 10%–20% of all nosocomial bloodstream infections in intensive care units (ICUs) are due to Candida species.[1],[2]Candida is a part of normal flora, which in the presence of breached protective barriers due to invasive catheters and endotracheal tubes turns into a pathogen, particularly in vulnerable and immunocompromised hosts. Apart from this, cross contamination through the hands of health-care workers in PICU also plays a significant role in transmission.

Zaoutis et al. conducted a population-based case–control study in Children's Hospital of Philadelphia and identified an incidence of candidemia as 3.5/1000 PICU admissions. The presence of a central venous catheter (CVC), malignancy, and use of broad-spectrum antibiotics including antimicrobials with activity against anaerobic organisms were identified as risk factors. Vancomycin and hyperalimentation were identified as individual risk factors.[3],[4] Singhi et al. in their retrospective cohort study found that the NAC accounted for 70% of Candidiasis in PICU. Candida tropicalis was identified as the most common and was associated with higher mortality and resistance to fluconazole. Although candiduria was identified commonly, they emphasized that it does not necessarily lead to Candidemia and hence need not be treated if not associated with clinical findings or suspicion of coexisting invasive disease. However, there is a need for high-risk surveillance and early antifungal therapy if the blood cultures are suggestive of fungal growth or there is presence of risk factor.[5] Mantadakis et al. reported few other risk factors such as prematurity, parenteral nutrition, neutropenia, steroid therapy, neurological disease, transplant recipients, and mechanical ventilation. The risk with the utilization of various invasive devices were different e.g., silastic percutaneous CVCs were related with a higher hazard than port-a-catheters.[6]

A shift from Candida albicans group to NAC group (Candida parapsilosis, Candida glabrata, C. tropicalis, and Candida krusei) has been noted since almost past two decades probably due to the increased use of azoles for both treatment and prophylaxis. C. tropicalis is associated with candidemia in neutropenic patients with hematologic malignancies[7] and is the most common NAC in Indian PICUs compared to the rest of the world.[8],[9]

The prolonged turnover time for fungal culture and the critical nature of the diseases in ICU has led to the increased use of prophylactic and empiric fungal therapy. A systematic review was done in critically ill children and adults to see the effects of untargeted antifungal treatment. There was moderate grade evidence among the 22 studies reviewed of insignificant effect on the mortality (risk ratio = 0.93, 95% confidence interval = 0.79–1.09, P = 0.36), although the risk of invasive fungal infections was significantly reduced.[10] Hence, the role of untargeted antifungal administration before positive culture remains debatable and warrants further studies.

The emerging resistance to common antifungal drugs such as azoles and the rising incidence of NAC is a major concern in PICU. Many studies including Kaur et al.[11] done in adults have found similar results of higher incidence of NAC species with C. tropicalis being more followed by C. glabrata, C. parapsilosis, C. krusei, and Candida kefyr. Candida colonization is a common finding in ICU in almost 73% of patients;[12] however, most patients suffer no ill effects in the absence of immunosuppressed states or other risk factors.[13] Antifungal susceptibility indicated that 37.8% and 7.8% of the Candida isolates were resistant to fluconazole and amphotericin B, respectively.[11] Further studies are required in PICU to substantiate the same.

In this issue, Behera C et al.[14] in their retrospective observational study have tried to study the incidence, risk factors of candidemia in PICU, associated mortality, and the sensitivity pattern over a period of 2 years in a tertiary care hospital. Out of 1034 cases, 36 cases were identified with candidemia. The study showed a male predilection with age groups between 6 and 14 years being most affected, though mortality was high in the younger age group (1–5 years). The risk factors were consistent with previous studies such as CVCs, immunosuppression, use of broad-spectrum antibiotics with anti-anaerobic activity, multiorgan dysfunction syndrome, and concurrent sepsis. Incidence of NAC group was higher with higher resistance and mortality. Most common among them was C. tropicalis, followed by C. glabrata, C. parapsilosis, and C. krusei (5.6%). Most of the isolates were sensitive to amphotericin B, followed by clotrimazole, voriconazole, and itraconazole and least to fluconazole and nystatin.

The results are consistent with many other studies highlighting the need for high-risk stratification and precautions to prevent the growing incidence of fungal infections and resistance to common antifungal drugs. This study has also identified Candiduria as an associated factor in 58.3% cases of Candidemia. Prophylactic antifungal in the presence of Candiduria with other risk factors and signs of fungal sepsis warrant early start of antifungals. However, whether it requires routine start of antifungal even in the absence of other factors remains debatable and needs further evidence.

This study emphasizes the burden of growing candidemia in the PICU units and the need to have stringent guidelines on invasive procedures to maintain asepsis, risk stratification to identify and initiate early treatment, and cautious use of antifungal therapy to curb the surge in resistant species. Overall, it is an important addition to the available evidence on fungal sepsis in order to have a more aware and cautious PICU care. However, further studies are required across the country for formulation of uniform policies based on Indian pediatric subpopulation and distribution of the species along with their resistance pattern.

  References Top

Jarvis WR. Epidemiology of nosocomial fungal infections, with emphasis on Candida species. Clin Infect Dis 1995;20:1526-30.  Back to cited text no. 1
Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Crit Care Med 1999;27:887-92.  Back to cited text no. 2
Zaoutis TE, Prasad PA, Localio AR, Coffin SE, Bell LM, Walsh TJ, et al. Risk factors and predictors for candidemia in pediatric intensive care unit patients: Implications for prevention. Clin Infect Dis 2010;51:e38-45.  Back to cited text no. 3
MacDonald L, Baker C, Chenoweth C. Risk factors for candidemia in a children's hospital. Clin Infect Dis 1998;26:642-5.  Back to cited text no. 4
Singhi SC, Reddy TC, Chakrabarti A. Candidemia in a pediatric intensive care unit. Pediatr Crit Care Med 2004;5:369-74.  Back to cited text no. 5
Mantadakis E, Pana ZD, Zaoutis T. Candidemia in children: Epidemiology, prevention and management. Mycoses 2018; 61: 614-22.  Back to cited text no. 6
Tadec L, Talarmin JP, Gastinne T, Bretonnière C, Miegeville M, Le Pape P, et al. Epidemiology, risk factor, species distribution, antifungal resistance and outcome of Candidemia at a single French hospital: A 7-year study. Mycoses 2016;59:296-303.  Back to cited text no. 7
Pappas PG, Rex JH, Lee J, Hamill RJ, Larsen RA, Powderly W, et al. A prospective observational study of candidemia: Epidemiology, therapy, and influences on mortality in hospitalized adult and pediatric patients. Clin Infect Dis 2003;37:634-43.  Back to cited text no. 8
Awasthi AK, Jain A, Awasthi S, Ambast A, Singh K, Mishra V. Epidemiology and microbiology of nosocomial pediatric candidemia at a northern Indian tertiary care hospital. Mycopathologia 2011;172:269-77.  Back to cited text no. 9
Cortegiani A, Russotto V, Maggiore A, Attanasio M, Naro AR, Raineri SM, et al. Antifungal agents for preventing fungal infections in non-neutropenic critically ill patients. Cochrane Database Syst Rev 2016;2016:CD004920.  Back to cited text no. 10
Kaur R, Dhakad MS, Goyal R, Kumar R. Emergence of non-albicans Candida species and antifungal resistance in intensive care unit patients: Asian Pac J Trop Biomed 2016;6:455-60.  Back to cited text no. 11
Hedderwick SA, Lyons MJ, Liu M, Vazquez JA, Kauffman CA. Epidemiology of yeast colonization in the intensive care unit. Eur J Clin Microbiol Infect Dis 2000;19:663-70.  Back to cited text no. 12
Arslankoylu AE, Kuyucu N, Yilmaz BS, Erdogan S. Symptomatic and asymptomatic candidiasis in a pediatric intensive care unit. Ital J Pediatr 2011;37:56.  Back to cited text no. 13
Behera C, Mishra R, Jena PK, Mishra S, Sahoo B, Patnaik SB, et al. Candidemia in the pediatric intensive care unit in Eastern India. J Ped Crit care 2020;7:237-42.  Back to cited text no. 14


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