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ORIGINAL ARTICLE  
Year : 2011  |  Volume : 54  |  Issue : 3  |  Page : 552-555
Candiduria in catheterized intensive care unit patients : Emerging microbiological trends


Department of Microbiology, GB Pant Hospital, New Delhi, India

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Date of Web Publication20-Sep-2011
 

   Abstract 

Objectives: Urinary tract infection (UTI) as a result of Candida spp. is becoming increasingly common in hospitalized setting. Clinicians face dilemma in differentiating colonization from true infection and whether to treat candiduria or not. The objective of the present study was to look into the significance of candiduria in catheterized patients admitted in the ICUs and perform microbiological characterization of yeasts to guide treatment protocols. Materials and Methods: One hundred consecutive isolates of Candida spp. from the urine sample of 70 catheterized patients admitted in the ICU were collected and stocked for further characterization. A proforma was maintained containing demographic and clinical details. Blood cultures were obtained from all these 70 patients and processed. Species identification of yeasts was done on VITEK. Results: Candiduria was more common at extremes of age. The mean duration of catheter days was 11.1 ± 6 days. Other associated risk factors such as diabetes mellitus and antibiotic usage were seen in 38% and 100% of our study group. Concomitant candidemia was seen in 4.3% of cases. Non-albicans Candida spp. (71.4%) emerged as the predominant pathogen causing nosocomial UTI. Conclusion: The present study reiterates the presence of candiduria in catheterized patients, especially in the presence of diabetes and antibiotic usage. Non-albicans Candida spp. are replacing Candida albicans as the predominant pathogen for nosocomial UTI. Hence, we believe that surveillance for nosocomial candiduria should be carried out in hospitalized patients.

Keywords: Candiduria, catheterized, diabetics, ICU patients

How to cite this article:
Jain M, Dogra V, Mishra B, Thakur A, Loomba PS, Bhargava A. Candiduria in catheterized intensive care unit patients : Emerging microbiological trends. Indian J Pathol Microbiol 2011;54:552-5

How to cite this URL:
Jain M, Dogra V, Mishra B, Thakur A, Loomba PS, Bhargava A. Candiduria in catheterized intensive care unit patients : Emerging microbiological trends. Indian J Pathol Microbiol [serial online] 2011 [cited 2014 Jul 29];54:552-5. Available from: http://www.ijpmonline.org/text.asp?2011/54/3/552/85091



   Introduction Top


Candiduria or presence of Candida spp. in the urine is rarely encountered in otherwise healthy people with structurally normal urinary tract. [1],[2],[3] It is, however, of common occurrence in hospitalized patients. Candida spp. account for almost 10-15% of nosocomial urinary tract infections (UTIs). [2],[4],[5] The clinicians always face a diagnostic dilemma as to whether the presence of candiduria in a patient represents contamination, colonization or true infection. [1],[2],[4],[6] Though contamination of urine sample is very common, it can often be ruled out by obtaining a second sterile urine sample. But till date, there are no reliable methods of differentiating colonization of urinary tract from true UTI with Candida spp. [2],[4],[6],[7] Furthermore, the prevalence of true infection has increased significantly over the past few years due to the presence of various predisposing factors in hospitalized patients.

The predisposing factors frequently associated with candiduria are urinary tract instrumentation, prior antibiotic use, prolonged hospital stay, extremes of age, diabetes mellitus, female sex and use of immunosuppressive therapy. [5],[6],[8] In spite of the increasing prevalence and increased risk of candidemia in patients with associated risk factors, there is no consensus regarding the management of such cases. [9],[10] It has been observed by various researchers that since candiduria in the presence of risk factors predisposes the patient to disseminated candidiasis, more aggressive approach is warranted. [10],[11],[12]

It is important to know the Candida spp. causing the UTI before initiating the treatment as many non-albicans Candida spp. are inherently resistant to treatment with fluconazole. [13],[14],[15] Though Candida albicans is the most frequently isolated species, few observers have emphasized the changing microbiological characteristics of yeasts as a causative agent of nosocomial UTI. [16],[17]

The present study was thus envisaged with the objective of analyzing the various risk factors associated with candiduria in hospitalized patients and the prevalence of candidemia in these patients. Microbiological characterization of yeast was also done to determine the common Candida spp. associated with nosocomial UTI to help the clinicians in the better management of such cases.


   Materials and Methods Top


The study was carried out during May 2009 to November 2009 in a 550-bedded tertiary care hospital at New Delhi, India. One hundred yeast isolates from 70 admitted patients presenting with nosocomial UTI were included in the present study.

Inclusion Criteria

The yeast isolates were included in the study if they were isolated as a pure growth in a significant colony count which was >10 4 colony forming units/ml of urine sample. These isolates were from catheterized patients admitted in the intensive care unit for more than 72 hours. These isolates were from the samples where direct microscopic examination showed concomitant pyuria to rule out contamination of urine samples.

Exclusion Criteria

The urine samples where Candida spp. was isolated in the absence of pyuria or as a mixed growth were excluded from analysis. The isolates were also excluded if they were obtained from non-catheterized patients or from patients whose duration of admission was less than 72 hours in the hospital.

Thus, for final analysis, 100 yeast isolates from 70 catheterized patients admitted in the ICU for more than 72 hours were included in the study. A single urine sample showing the presence of yeast was available for 51 patients, whereas more than one repeat sample showing the presence of yeast was available for 19 patients. All the repeat samples which were included in the study showed the presence of yeast as a pure growth in a significant colony count. All these yeast isolates were stocked at -20°C for further microbiological characterization.

Patient's demographic details such as age, sex, duration of hospital stay, duration of catheterization and other clinical details were maintained in a proforma. Presence of other associated risk factors like diabetes mellitus, history of antibiotic use, any urinary tract instrumentation, any invasive procedure carried out on the patient or use of immunosuppressive drugs were also recorded. Follow-up of these patients was done to know the outcome in such patients.

Urine Sample Processing and Identification

The urine samples obtained were immediately processed in the microbiology laboratory by semi-quantitative method as per the standard protocols. All the yeast isolates were stocked for further microbiological characterization.

Direct microscopic examination of urine sample was also done to look for the presence of pus cells, red blood cells, casts, crystals or any bacterial or fungal element.

Identification

Species identification for yeast was done on VITEK 2 Compact system (Bio Merieux, Mumbai, India) as per the manufacturers' instruction.

Blood Culture and Identification

Five to ten milliliters of blood sample was collected by venipuncture aseptically from all these patients and processed as per the standard protocols.

Statistical Analysis

The data were obtained and entered using SPSS software 12.0 version for statistical analysis. Descriptive statistics was used to characterize the study group. Fischer's exact test was applied for comparing the difference between two groups. P value was calculated for determining whether the results obtained were statistically significant. P value of <0.05 was considered as statistically significant.


   Results Top


A total of 100 yeast isolates from 70 catheterized patients were included in the present study for final analysis. The age distribution of the study group is as shown in [Table 1].
Table 1: Age distribution of the study group

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More than 80% of the study group belonged to extremes of age, i.e. was either below 15 years of age or above 46 years of age.

Other associated risk factors and demographic profile of the study group are as shown in [Table 2].
Table 2: Demographic profi le and various risk factors in patients with candiduria

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The risk of developing candiduria was high in patients who were admitted in the ICU for 13 days and after 11 days of urinary catheterization. History of antibiotic was a universal risk factor seen in all the patients. The risk was highest after administering Imipenam group of drugs and lowest after administration of Vancomycin. The mean total leukocyte count (TLC) did not help in differentiating colonization from infection.

Three of these 70 patients (4.3%) also had concomitant candidemia, i.e. presence of Candida in the blood culture drawn 3-5 days after candiduria. Mortality is very high in the presence of concomitant candidemia as seen in the present study also. Antifungal therapy was not instituted in majority of the patients. Only in three patients where concomitant candidemia was present, the patients were started on antifungal therapy, and even in presence of the treatment, all the three patients succumbed to their illness.

Microbiological characterization of yeast was done and the distribution of various Candida spp. in these patients is shown in [Table 3].
Table 3: Distribution of Candida spp. in the study group

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In our study group, non-albicans Candida spp. emerged as the predominant pathogen and was responsible for 71.4% of nosocomial fungal UTI. Candida tropicalis accounted for 52.9% of the cases, whereas C. albicans accounted in 28.6% of the cases.

There was no statistically significant difference on the outcome of patients whether C. albicans or non-albicans Candida spp. were isolated from the urine sample (P >0 0.05 using Fisher's exact test).

There were 19 patients whose repeat samples also showed candiduria. These strains were identified to species level, and in 17 out of 19 patients (89.5%), the same species of Candida was present. Thus, strain persistence was quite common. The most common species identified in these patients included C. tropicalis (9/17, 52.9%) followed by C. albicans (4/17, 23.5%). Other non-albicans Candida spp. which were isolated included Candida haemulonii (2/17, 11.7%), Candida famata (1/17, 5.8%) and Candida parasilosis (1/17, 5.8%).


   Discussion Top


Nosocomial UTI is the most common healthcare associated infections. Candida spp. are increasingly becoming an important causative agent of nosocomial UTI. In the present study, we observed that nosocomial UTI due to Candida spp. was more common during extremes of age (80%). This could be due to lowered host defenses at extremes of age. This finding is supported by many other researchers also. [6],[7],[8] Since colonization of vulvo vestibular area with Candida spp. is frequent in females, they are more at risk of developing candiduria due to ascending infection. [1],[4] But in our study, we found that candiduria was more common in males (61.4%) as compared to the females (38.6%). There have been few other observers who did not find significant difference in terms of female sex having more chances of candiduria. [18] This could be due to the predominance of other associated risk factors in our study group.

Other risk factors that were present included diabetes mellitus which was seen in 38.6% of our patients. Diabetes is a well-known risk factor for developing nosocomial UTI due to Candida spp. [1],[2],[4],[19] This is because diabetes lowers host resistance to invasion by fungi and also promotes stasis of urine in neurogenic bladder, thus further increasing the chances of colonization of Candida spp.[19]

Previous history of antibiotic use was a universal risk factor in our patients. The risk was highest after treatment with Imipenam/Meropenam group of drugs (75%), followed by cephalosporin (57%). Antibiotics increase the risk of colonization of Candida spp. by suppressing endogenous flora and the risk of candiduria increases with prolonged antibiotic use. [20]

Blood culture was obtained from all 70 patients to determine the risk of developing candidemia in patients presenting with candiduria. The risk of developing candidemia varies and has been observed to be between 2 and 50% by various authors. [2],[4],[5],[10],[21] In the present study, the risk was 4.3%, which is in agreement with various other researchers who observed lowered risk of candidemia following candiduria. [2],[4],[5],[21] There is definite risk of developing invasive candidiasis in the presence of associated risk factors, and the mortality in these patients is very high. Hence, in critically ill patients having other associated risk factors and admitted in the ICUs, candiduria should not be ignored.

Our study also highlights the ascending infection to be the most common route for UTI due to Candida spp. rather than the hematogenous spread, as blood cultures were negative in most of the patients. Urinary catheters serve as a portal of entry and most catheters become colonized if left for longer duration. [22] In our study also, the mean duration of catheterization was 11.6 ± 6 days. There is direct relationship between the duration of catheterization, candidal colonization and of nosocomial candiduria. Thus, as the duration of catheterization increases, the risk of developing candiduria also increases. This point strongly favors the removal of urinary catheters as soon as possible in ICU patients.

The specific identification of yeast helps in guiding the clinicians for proper management of candiduria. C. albicans has been the most frequent species isolated from nosocomial UTI. [8],[12],[13],[18] Of concern is the finding in our study that the Candida spp. causing UTI might be shifting to non-albicans Candida spp. (71.4%). This change in etiology toward non-albicans Candida spp. has been seen by other authors also. [16],[17],[23],[24],[25] Amongst these non-albicans Candida spp., C. tropicalis was the most frequent isolate (52.9%) followed by C. haemulonii, C. famata, Candida rugosa, Candida parasilosis and Candida glabrata.

Mortality was very high in the study group (61.4%), but there was no statistically significant difference in the outcome of study group in relation to the Candida spp. isolated from UTI cases. The mortality in our study group could also be high due to various other comorbid conditions present in the study group. Routinely, candiduria is often ignored and antifungal therapy is not started in most of the hospitals as is the case in our study also. The limitation of our study is that we could not study whether early appropriate institution of antifungal therapy in our study group could decrease the mortality. This aspect needs to be further discussed using detailed experimental studies.

Strain persistence as determined in the follow-up samples was very high (17/19, 89.5%). The persistence of same strain in cases of recurrent or persistent candiduria is seen by other authors also. [26] The chances that the primary strain causing candiduria would be persistent were significantly higher with non-albicans Candida spp. as compared to C. albicans.

Catheterized patients admitted in the ICU with other associated risk factors like diabetes mellitus, previous surgery and previous history of antibiotic use are at risk of developing nosocomial UTI due to Candida spp. In the presence of associated risk factors, there is a definite risk of invasive candidiasis following candiduria; hence, aggressive approach is warranted by the clinicians. Moreover, there is a change in trend with shift toward non-albicans Candida spp. as the predominant pathogen causing nosocomial UTI. The non-albicans Candida spp. are more difficult to treat and chances that these strains would remain persistent are higher. Thus, species identification should also be performed for appropriate management of such patients.


   Acknowledgment Top


We acknowledge Mr. Gyanender and Mrs. Abhilasha for their technical assistance.

 
   References Top

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Correspondence Address:
Manisha Jain
Department of Microbiology, GB Pant Hospital, New Delhi
India
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DOI: 10.4103/0377-4929.85091

PMID: 21934219

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    Tables

  [Table 1], [Table 2], [Table 3]

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