Original Articleped_3574 341..349

Neonatal candidiasis: Results of an 8 year study

Solmaz Celebi,1 Mustafa Hacimustafaoglu,1 Nilgun Koksal,2 Hilal Ozkan,2 Merih Cetinkaya2 and Beyza Ener31Department of Pediatrics, Division of Pediatric Infectious Diseases, 2Department of Pediatrics, Division of Neonatology and3Department of Microbiology, Uludag University Medical Faculty, Gorukle, Bursa, Turkey

Abstract Background: The aim of the present study was to evaluate the risk factors, demographic features, treatment and clinicaloutcome associated with candidemia in a neonatal intensive care unit (NICU) within an 8 year period.Methods: The data of infants who were diagnosed as having candidemia, were evaluated.Results: Between January 2000 and December 2007, a total of 28 candidemia episodes were identified in 28 infants. A1.1% candidemia incidence was documented in the neonatal intensive care unit (NICU). The species most frequentlycausing candidemia were Candida parapsilosis (57.1%), followed by C. albicans (42.9%). The main predisposingfactors for candidemia with C. parapsilosis included presence of maternal pre-eclampsia, prematurity, prolongedmechanical ventilation, prolonged total parenteral nutrition and presence of jaundice. Retinopathy of prematurity andbronchopulmonary dysplasia were the most frequently seen underlying illnesses in infants with C. parapsilosis. In thepresent study, 13 infants (46.4%) had evidence of organ dissemination. The mortality rate was 42.8% in infants withcandidemia. Mean leukocyte counts and mean C-reactive protein were significantly higher in neonates who diedcompared with those who survived.Conclusion: Candida parapsilosis (57.1%) was the leading causative organism, followed by C. albicans (42.9%) ininfants. The rate of organ dissemination in the present cases was high. The mortality rate was 42.8% in infants withcandidemia.

Key words candidemia, infants, neonatal intensive care unit, risk factors for candidemia.

Candida species are recognized as leading pathogens in the neo-natal intensive care unit (NICU) for infections occurring after thethird day of life. The incidence has been observed to range from2.2% to 12.9% among very low-birthweight infants (VLBW;birthweight

demographics, premature rupture of membrane (PROM) andhistory of chorioamnionitis, TPN, umbilical catheterization,presence of urinary catheter and/or nasogastric tube, mechanicalventilation, previous hospitalization were all recorded. Patientswere monitored for nosocomial infections at all body sites anddata were collected prospectively according to standard surveil-lance protocols, and Centers for Disease Control and Preventioncriteria were used as standard definitions for nosocomial infec-tions.21 We defined nosocomial candidemia as the occurrence ofat least one positive blood culture yielding Candida spp. plussigns and symptoms of infection after at least 72 h of hospital-ization.21 The study protocol was approved by the Ethics Com-mittee of Uludag University, Faculty of Medicine. Informedconsent was obtained from the legal guardians of all infants.

This study included two casecontrol studies. The first studywas performed to assess the risk factors for candidiasis (compar-ing C. albicans and C. parapsilosis) in infants with candidemia.The second study was an assessment of the parameters associatedwith mortality in patients with candidemia. Cases were defined aspatients who died from candidemia, controls were defined aspatients who survived candidemia.

Temperature instability (fever or hypothermia), apnea, needfor supplemental oxygen, need for ventilation, tachycardia/bradycardia, hypotension, feeding intolerance, abdominal disten-sion, and necrotizing enterocolitis were considered to be clinicalsigns of sepsis. Prematurity was defined as gestational age 237weeks. Prolonged hospitalization was defined as >14 days. Pro-longed antibiotics use was defined as >14 days.

The changes in the hematologic parameters were analyzedusing the Manroe and Rodwell scoring systems.22,23 Leukopeniawas defined as leukocyte counts 25000/mm3; leukocytosis wasdefined as leukocyte counts 325 000/mm3 at birth, 330 000/mm3at 1224 h and 321 000/mm3 after the second day of life. Throm-bocytopenia was defined as platelet counts 2150 000/mm3.Before initiating antimicrobial therapy, blood samples for wholeblood count, C-reactive protein (CRP), culture were obtained.Meningitis was diagnosed according to the cell count, glucoseand protein levels of cerebrospinal fluid (CSF) and the CSFculture. Whole blood count was performed using an automaticcounter, Cell Dyn 3700 (Abbott Diagnostics Division, AbbottPark, IL, USA). CRP was determined on immunonephelometryusing a BN II device (Dade Behring Marburg, Marburg,Germany). Detection limits were 0.5 mg/dL for CRP.

Patients were considered to have organ dissemination if, inaddition to a positive blood culture to candidemia, one or more ofthe following were present: (i) chorioretinitis or endophthalmitison ophthalmologic examination; (ii) endocarditis, with echocar-diographic evidence of a valvular vegetation; or (iii) solid organinvolvement with focal, discrete or nodular lesions on computedtomography, magnetic resonance imaging or ultrasound.

The empiric antibiotic therapy protocols in the NICU wereampicillin plus gentamicin for early onset sepsis. Ceftazidime (orcefotaxime) plus amikacin with or without vancomycin wereused for late-onset sepsis. Amphotericin B deoxycholate(D-AmB) or fluconazole was initiated for fungal sepsis at NICU.Liposomal amphotericin B (L-AmB) was used as second-line

therapy if the patient had failed to respond to previous antifungaltherapy and/or there was toxicity due to antifungal therapy.Patients who had pre-existing renal or hepatic dysfunctionreceived L-AmB as first-line therapy. Flucytosine was used onlyin combination with other agents. Doses of the antifungal drugswere as follows: fluconazole, 12 mg/kg i.v. (infused in 2 h) as aninitial dose, then 12 mg/kg once daily i.v. (infused in 1 h) in termneonates; and 12 mg/kg per day once every 72 h during the firstweek of life in preterm neonates

infants with candidemia, the overall incidence of candidemia was11.5 per 1000 NICU admissions. Annual rates of nosocomialcandidemia cases per 1000 admissions are given in Figure 1. InTurkey no data are collected on vaginal fungal colonization inpregnancy. The mean number of positive blood cultures perpatient was 4 (range, 122). All of the Candida species wereclassified as nosocomial isolates, Forty-six percent of patientshad more than one positive culture. Eighty-six percent of infantswere premature newborns. Mean gestational age and mean birth-weight of infants with candidemia were 31.4 1 4 weeks (range,

2640 weeks) and 1417.1 1 252.6 g (range, 5902400 g), respec-tively. C. parapsilosis and C. albicans accounted for 16 (57.1%)and 12 (42.9%) of the isolates respectively. Demographic andclinical characteristics and outcome of the patients with candi-demia are listed in Table 1. Although all of the infants requirednasogastric catheterization, only 24 infants required mechanicalventilation. Also, 23 infants required both TPN and umbilicalvein catheterization. There were no statistically significant dif-ferences between the candidemia caused by C. albicans andC. parapsilosis with regard to gender, gestational age, birth-weight, cesarean delivery, maternal age, frequency of organ dis-semination or mortality rate. Apgar scores at 1 and 5 min werelower in patients with C. parapsilosis compared with that inthose with C. albicans (P = 0.017). Maternal pre-eclampsia wasmore frequent in patients with C. parapsilosis than in those withC. albicans (P < 0.001). When we compared the candidemia withregard to most commonly seen underlying illness, prematurity(P = 0.024), retinopathy of prematurity (P = 0.007) and bron-chopulmonary dysplasia (P = 0.0003) were more common inpatients with C. parapsilosis than in those with C. albicans.Patients with C. parapsilosis were more likely to receive flucy-tosine and L-AmB treatment (P = 0.024). Patients with C. albi-cans were more likely to receive fluconazole treatment (P =0.024). Fifteen infants (53.7%) had candidemia alone, whereas13 infants (46.4%) had evidence of organ dissemination. Organinvolvement was most commonly identified in the brain (25%),followed by kidney (10.7%), and peritoneal cavity (10.7%). Sixpatients with meningitis (85.7%) had positive CSF cultures.None had findings of endophthalmitis on eye examination. All

Fig. 1 Annual rates of candidemia cases per 1000 admissions.

Table 1 Subject characteristics and candidemia outcome vs speciesC. albicans C. parapsilosis P

(n = 12) (n = 16)Mean 1 SD (range) Mean 1 SD (range)

Male, n (%) 9 (75) 8 (50) 0.253Gestational age (weeks) 33.5 1 5 (2640) 29.9 1 2.2 (2734) 0.059Birthweight (g) 1673 1 592 (8702400) 1224 1 384 (5902050) 0.082Cesarean delivery, n (%) 7 (58.3) 12 (75) 0.432Apgar at 1 min 6.6 1 2.4 (49) 4.5 1 2.3 (19) 0.017Apgar at 5 min 8.3 1 1.6 (610) 7 1 1.6 (510) 0.017Maternal pre-eclampsia, n (%) 0 (0) 9 (56.2)

of the patients received previous antibiotic treatment in differentcombinations of ampicillin, gentamicin, cefotaxime, amikacin,ceftazidime, vancomycin and carbapenem. Prior to candidemia,all of the infants received systemic antibiotic treatment, 10 ofwhom had documented bacteremia (methicillin-resistant Staphy-lococcus epidermidis in six, Pseudomonas aeruginosa in two,Klebsiella pneumoniae in two). Ampicillin plus gentamicin orcefotaxime plus amikacin were the empiric antibiotics used in theNICU while awaiting cultures, to which all 28 infants had beenexposed for at least 48 h.

Empiric antifungal therapy was initiated in 16 patients(57.1%) before a positive blood culture was reported, because ofclinical suspicion of fungal sepsis. The mean length of antifungaltherapy was 28.5 1 18.8 days (range, 585 days). Ten patients(35.7%) were initially treated with fluconazole. No fluconazole-related toxicity was observed. D-AmB was used in 14 patients(64.2%) as initial therapy. In eight patients (66.6%), however,D-AmB was changed to L-AmB, because hypokalemia(

Table 4 Laboratory findings of candidemia patients vs species

Laboratory findings C. albicans C. parapsilosis P(n = 12) (n = 16)

Mean 1 SD (range) Mean 1 SD (range)WBC (mm3) 12 424 1 4 800 (4 35015 300) 10 467 1 6 236 (3 21025 400) 0.280Leukocytosis (>20 000/mm3), n (%) 0 (0) 2 (12.5) 0.492Leukopenia (

study, the possible cause of the outbreak of C. parapsilosis can-didemia in NICU was contamination of intravascular catheters.Infection control measures such as skin antisepsis at catheterinsertion sites and strict handwashing practice, helped us tocontrol this outbreak.

DiscussionNeonatal candidiasis is an important cause of morbidity andmortality in premature infants.24 In recent years, candidemia hasemerged as a leading cause of late-onset infection in prematureinfants.25,26 Kossoff et al. reported that 1% of all NICU infantsdeveloped candidemia, and the rate of candidemia had increased11-fold during the 15-year study period.3 A recent study involvinga prospective observational cohort of infants with birthweight21000 g by Benjamin et al. found that invasive candidiasisoccurred in 137 of 1515 infants (9%).27 In the present study, wefound that overall incidence of candidemia was 1.1%. This waslower than the incidence reported from the NICUs in other devel-oped countries of 1.65%.4,13,28

The demographic and clinical characteristics of neonates withcandidemia in the present study paralleled previous studies insome respects: prematurity, use of central venous catheterization,use of prolonged antibiotic treatment, prolonged mechanical ven-tilation, prolonged parenteral nutrition, and prolonged hospital-ization.29,30 Eighty-six of the present cases involved prematureinfants, and all of the present patients had received previousantibiotic treatment in different combinations of cefotaxime,amikacin, vancomycin and carbapenem.

Neonatal candidemia presents with manifestations similar tobacterial sepsis. The signs and symptoms are non-specific andinclude temperature instability, refusal of feeds, respiratory

distress, abdominal distension, apnea, lethargy, bradycardia,decreased perfusion or seizures.31 As in that previous report, wefound jaundice (75%), tachypnea (71.4%), worsening in generalcondition (67.9%), low activity (46.4%), and fever (32.1) in thepresent candidemia patients.

Previous studies reported that C. albicans was the most com-monly isolated Candida species, followed by C. parapsilosis inthe cases of candidal bloodstream infections in infants.14,15,28Other Candida species included C. tropicalis, lusitaniae, gla-brata, and krusei at 4%, 2%, 2%, and 20 000/mm3), n(%) 1 (8.3) 1 (6.2) 1Leukopenia (

Candida species invade virtually all tissues, including theretina, brain, heart, lung, liver, spleen, and joints.40 The changingepidemiology of candidemia in many NICUs may explain someof the heterogeneity in the proportion of infants who experiencedend-organ damage. In a recent study of neonatal candidemia, theauthors reported the following median end-organ invasion ratesfor candidemia: meningitis (15%), central nervous abscesses andventriculitis (4%), endophthalmitis (3%), endocarditis (4%),renal abscess (3%), and liver/spleen abscess (1%).41 Makhoulet al. reported that fungal dissemination in infants was rare (2.57.1%).5 In the present study, 13 infants (46.4%) had evidence oforgan dissemination. Meningitis (25%) was most common, fol-lowed by renal involvement (10.7%), and peritonitis (10.7%).The rate of organ dissemination in the present patients was veryhigh compared with previous studies. Although C. parapsilosisprobably causes less mortality than C. albicans,6 there are notsufficient data to support different end-organ damage evaluationson the basis of species in infants. In our previous study, we foundthat C. albicans had a higher rate of organ dissemination com-pared with non-albicans species in children.42 In the presentstudy, no statistically significant difference was found in organdissemination in candidemia caused by C. albicans andC. parapsilosis.

Amphotericin B continues to be the mainstay of therapy forsystemic fungal infections. In a prospective study of 67 infantswith systemic candidiasis, cure rates were 67.6% and 83.3% forD-AmB and L-AmB, respectively.43 In another study, 24 infantswith culture-proven candidiasis were treated with fluconazole,and both clinical and microbiological cure was achieved in 96%of neonates.26 Although a previous study showed that fluconazoleand D-AmB were equally effective in the treatment of dissemi-nated neonatal fungal infections; fluconazole produced fewertoxic manifestations than D-AmB and was more convenient touse.44 In that study, most of the infants (71.4%) were treated withamphotericin B monotherapy. Fluconazole was used as a singleagent in four infants (14.3%). Patients with C. albicans weremore likely to receive fluconazole treatment. Combinations ofamphotericin B, fluconazole and flucytosine have been reportedto be successful in circumstances in which one or two agentswere unsuccessful at controlling infection.45 In the present study,flucytosine was added to L-AmB in four patients (14.3%),because of persistence of the clinical signs and symptoms of thecandidal meningitis. In these patients, flucytosine was added toL-AmB because flucytosine penetrates the CSF well and is syn-ergistic to amphotericin B.45

In the present study, mean leukocyte count and mean CRPwere significantly higher in neonates who died compared withthe infants who survived. These findings suggest that infants whodied were severely ill. Many studies have reported high rates ofmortality among infants with candidemia: there is a wide varia-tion in crude mortality associated with candidemia in infants,ranging from 10% to 54%.7,8 In a recent review article, Chapmanreported that candidemia in infants had a crude mortality of30%.46 In previous studies, the rate of mortality due to C. albi-cans infection was significantly higher than that due to C. parap-silosis infection (36% vs 7%6 and 26% vs 4%3). In the present

study, the mortality rate was 42.8%. Because this mortality ratewas high, we suggest some precautions for treating Candidainfections in preterm infants. As stated in recent reviews, empiricantifungal treatment for suspected invasive Candida infections(ICI) and standardization of treatment regimens including appro-priate dosing with prompt central catheter removal for docu-mented candidal bloodstream infections have been shown todecrease ICI mortality. Also, the infection control practices statedhere were likely to contribute to reduce the rate of ICI. Just asantibiotic prophylaxis has been implemented for prevention ofearly-onset group B streptococcal infections, development oflocal, national, and international guidelines to prevent invasive,life-threatening candidal infections in the highest-risk NICUpatients should also be developed. Antifungal prophylaxis givento infants with birthweight

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