| Abstract|| |
Context: Candida colonization in neonates results in significant morbidity and mortality. The prevalence and clinical significance of neonatal candidemia are poorly understood. Aims: This study aimed to study clinical spectrum and risk factors of neonatal candidemia. Settings and Methods: 108 cases of septicemia were studied. Blood samples were collected into Glucose broth and Bile broth, which are inoculated on Blood agar and MacConkey's agar and incubated at 37° C for 7 days. Candida species were isolated were confirmed by standard techniques. Statistical Analysis Used: The data was collected and analyzed using by using SPSS IBM Company, Chicago, Version 16.0. Results: 62 newborn patients who had a positive Candida blood culture. 47 (79.03%) were low birth weight and 37 (59.67%) were male. 19 (30.65%) were died. Candida species was a contributory factor to mortality in 14 (73.68%) patients. Among Candida isolates, Candida albicans was the commonest (65%) followed by Candida parapsilosis (15%) and Candida glabrata (10%). The risk factors like intrapartum use of antibiotics, vaginal delivery, low birth weight are identified in culture positive neonates. Conclusions: Candida species are assuming an increasing role in nosocomial infections in neonates and is associated with an increased risk of mortality.
Keywords: Birth asphyxia, Candida albicans, glucose broth, low birth weight
|How to cite this article:|
Wadile RG, Bhate VM. Study of clinical spectrum and risk factors of neonatal candidemia. Indian J Pathol Microbiol 2015;58:472-4
| Introduction|| |
Candida species are the leading cause of invasive fungal infection in neonatal intensive care unit (NICU). Systemic candidiasis in neonates is increasing in frequency especially since the survival of babies with low birth weight (LBW) has increased. Colonization of skin and gastrointestinal tract is the first step in the pathogenesis of invasive candidiasis. A number of factors including the use of indwelling devices, broad-spectrum antibiotics, LBW, prematurity, total parenteral nutrition, gastrointestinal surgery, artificial ventilation, and/or history of fungal colonization contribute to the risk. Preterm, very LBW (VLBW): ≤1500 g; extremely LBW: ≤1000 g; and critically ill infants are at highest risk of invasive Candida infections.Candida spp. can also spread through vertical transmission from maternal flora or via horizontal transmission from hands of healthcare workers (HCW)., The gross mortality of fungal infections in NICUs ranges from 25% to 50%., While in an Indian study, Candida attributed deaths occurred in 17% cases. Delay in recognition of Candida infections and in the initiation of appropriate antifungal therapy often leads to significant morbidity and mortality rates among high-risk infants. Therefore, this study was conducted to assess the rate and risk factors associated with neonatal candidemia.
| Materials and Methods|| |
A total of 108 clinically suspected cases of septicemia were studied from January 2014 to December 2014 in our rural teaching hospital. Detailed histories were taken. Blood samples were collected into Glucose and Bile broths, which were incubated at 37°C for 7 days. Subcultures were made on blood and MacConkey's agar. Candida spp. isolated were confirmed by: (a) Germ tube production, (b) growth on cornmeal agar (Hi-Media), (c) pigmentation on Hi-Chrome Candida differential agar (Hi-Media), (d) sugar assimilation tests (Hi-Media) as per standard techniques.Candida isolates were considered clinically significant if isolated more than one site or on two successive blood cultures.
The data was collected and analyzed using by using SPSS for windows IBM Company, Chicago, version 16.0.
| Results|| |
Gram-negative bacilli accounted for (38.70%) followed by Candida spp. (32.26%) and Gram-positive cocci (29.04%) of positive blood cultures [Table 1]. Sixty two newborn patients who had a positive Candida blood culture were identified and studied. Forty seven of these (79.03%) were LBW and 37 (59.67%) were male. Nineteen out of these 62 newborns (30.65%) died, 9 of whom (47.37%) died within 3 days of the diagnosis of candidemia. More importantly, Candida spp. was a contributory factor to mortality in 14 (73.68%) patients.
Among Candida isolates, Candida albicans was the commonest (65%) followed by Candida parapsilosis (15%) and Candida glabrata (10%) [Table 1].
[Table 2] shows that the risk factors identified in culture positive neonates: intrapartum use of antibiotics (95.16%) followed by vaginal delivery (85.48%) and LBW (79.03%). Most common clinical presentation of culture positive neonates were lethargy (79.03%) followed by failure to thrive (74.169%) and birth asphyxia [Table 3].
| Discussion|| |
In the NICUs infection with unusual organisms is an increasing problem. Due to advances in medical and surgical management an increase in nosocomial fungal infection rate has been observed. Newborns admitted to intensive care units are at greater risk of contracting nosocomial infections. These risks are associated with their susceptibility to infections as a result of both prematurity and invasive medical equipment needed for survival. Rates of Candida bloodstream infections have increased dramatically during the past decade, in part related to the improvement in survival rates of infants with VLBWs. Other risk factors associated with candidiasis include immunocompromised hosts, early fungal gastrointestinal tract colonization, predisposition to invasive fungal dermatitis, and use of parenteral antibiotics and corticosteroids.
In the present study C. albicans was responsible for 65% of cases of the of neonatal candidemia whereas nonalbicans Candida (NAC species) accounted for 35%. This corroborates well with the results of other authors.,, In the present study isolation of C. parapsilosis (15%), C. glabrata (10%), and C. tropicalis (5%) as the most common NAC species is in contrast to results of other authors.,
In this study the following were identified as risk factors: intrapartum use of broad-spectrum antibiotics, prematurity, LBW, endotracheal intubation, indwelling catheters, use of central lines, and parenteral nutrition. No differences were identified between those patients who survived and who died.
Most of the clinical characteristics of candidemia in this study were similar to previous publications. However, it was identified here that the finding of birth asphyxia, respiratory distress syndrome, failure to thrive, and lethargy were more common clinical feature in neonates who died. Use of multiple invasive devices, such as catheters and endotracheal tubes may be responsible for the nosocomial spread of pathogens through the hands of HCW. The hands of HCW and environmental surfaces are newly-appreciated potential reservoirs for nosocomial strains of Candida.
Even though candidemia has been associated with prolonged hospitalization, most fatal cases occurred in neonates younger than 3 weeks of age. Given that infants of this age have decreased immunity, their host response to Candida may contribute to mortality. The mortality rate associated with these infections is 20–50% and occurs among all the ages. In this study, the mortality rate was 30.65%.
| Conclusion|| |
Candida spp. are assuming an increasing role in nosocomial infections in neonates and are associated with an increased risk of mortality. A restrictive policy of antibiotic use to decrease Candida colonization/infection rates should be implemented to reduce the morbidity and mortality associated with these infections. Epidemiological data of our study can serve as a template for the development of local guidelines for prevention and appropriate treatment of neonatal candidemia.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Rahul Gopichand Wadile
37, Utkarsh Colony, Near Gurukul Vidyalaya, Sakri Road, Dhule - 424 001, Maharashtra
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]