Citation Information :
Sridharan S, Gopalakrishnan R, Nambi PS, Kumar S, Sethuraman N, Ramasubramanian V. Clinical Profile of Non-neutropenic Patients with Invasive Candidiasis: A Retrospective Study in a Tertiary Care Center. Indian J Crit Care Med 2021; 25 (3):267-272.
Introduction: Invasive candidiasis (IC) is a major cause of morbidity and mortality in critically ill patients in the intensive care unit (ICU). In this study, we aim to analyze the clinical profile, species distribution, and susceptibility pattern of patients with IC. Methods: Case records of non-neutropenic patients ≥18 years of age with IC between January 2016 and June 2019 at a tertiary care referral hospital were analyzed. IC was defined as either candidemia or isolation of Candida species from a sterile site (such as CSF; ascitic, pleural, or pericardial fluid; or pus or tissue from an intraoperative sample) in a patient with clinical signs and symptoms of infection. Results: A total of 114 patients were analyzed, out of which 105 (92.1%) patients had bloodstream infection (BSI) due to Candida and 9 (7.9%) had IC identified from a sterile site. Central line-associated blood stream infection (27 patients, 23.6%) and a gastrointestinal source (30 patients, 26.3%) were the most common presumed sources for candidemia. The commonest species was Candida tropicalis 42 (36.8%), followed by Candida glabrata 20 (17.5%). Serum beta-D-glucan (BDG) was done only in 32 patients of the 114 (35.3%); among those who were tested, 5 (15.6%) had a BDG value of less than 80 pg/mL despite having Candida BSI. Fluconazole sensitivity was 69.5% overall. At 14 days after diagnosis of IC, 49.1% had recovered, with the remainder having an unfavorable outcome (32.4% had died and 18.4% had left against medical advice). Clinical significance: IC is a major concern in Indian ICUs, with a satisfactory outcome in only half of our patients. Serum BDG is a valuable test to diagnose blood culture–negative IC, but more studies are needed to determine its role in the exclusion of IC, as we had a small minority of patients with negative tests despite proven IC. Conclusion: We recommend sending two sets of blood cultures and serum BDG assay for all suspected patients. Initiating empiric antifungal therapy with an echinocandin is advisable, in view of increasing azole resistance and the emergence of Candida auris, with de-escalation to fluconazole for sensitive isolates after clinical stability and blood culture clearance.
Chakrabarti A, Sood P, Rudramurthy SM, Chen S, Kaur H, Capoor M, et al. Incidence, characteristics and outcome of ICU-acquired candidemia in India. Intensive Care Med 2015;41(2):285–295. DOI: 10.1007/s00134-014-3603-2.
Gupta P, Prateek S, Chatterjee B, Kotwal A, Singh AK, Mittal G. Prevalence of Candidemia in ICU in a tertiary care hospital in North India. Int J Curr Microbiol Appl Sci 2015;4(6): 566–575.
Jeffery-Smith A, Taori SK, Schelenz S, Jeffery K, Johnson EM, Borman A, et al. Candida auris: a review of the literature. Clin Microbiol Rev 2017;31(1):e00029-17. DOI: 10.1128/CMR.00029-17.
Oberoi JK, Wattal C, Goel N, Raveendran R, Datta S, Prasad K. Non-albicans Candida species in blood stream infections in a tertiary care hospital at New Delhi, India. Indian J Med Res 2012;136(6):997–1003.
Bassetti M, Merelli M, Ansaldi F, de Florentiis D, Sartor A, Scarparo C, et al. Clinical and therapeutic aspects of candidemia: a five year single centre study. PLoS One 2015;10(5):e0127534. DOI: 10.1371/journal.pone.0127534.
Rajalakshmi A, Shareek PS, Sureshkumar D, Gopalakrishnan R, Yamuna E, Ramasubramanian V. Candidemia species distribution and emergence of Candida haemulonii complex isolates resistant tofluconazole in South India. J Contemp Clin Pract 2018;4(2):47–52. DOI: 10.18683/jccp.2018.1035.
Bhattacharjee P. Epidemiology and antifungal susceptibility of Candida species in a tertiary care hospital, Kolkata, India. Curr Med Mycol. 2016;2(2):20–27. DOI: 10.18869/acadpub.cmm.2.2.5.
Tak V, Mathur P, Varghese P, Gunjiyal J, Xess I, Misra MC. The epidemiological profile of candidemia at an Indian trauma care center. J Lab Physicians 2014;6:96–101. DOI: 10.4103/0974-2727.141506.
Bansal N, Gopalakrishnan R, Sethuraman N, Ramakrishnan N, Nambi PS, Kumar DS, et al. Experience with β-D-glucan assay in the management of critically ill patients with high risk of invasive candidiasis: an observational study. Indian J Crit Care Med 2018;22(5):364–368. DOI: 10.4103/ijccm.IJCCM_4_18.
Del Bono V, Delfino E, Furfaro E, Mikulska M, Nicco E, Bruzzi P, et al. Clinical performance of the (1,3)-β-D-glucan assay in early diagnosis of nosocomial Candida bloodstream infections. Clin Vaccine Immunol 2011;18(12):2113–2117. DOI: 10.1128/CVI.05408-11.
Agnelli C, Bouza E, del Carmen Martínez-Jiménez M, Navarro R, Valerio M, Machado M, et al. Clinical relevance and prognostic value of persistently negative (1,3)-β-D-glucan in adults with candidemia: a 5-year experience in a tertiary hospital. Clin Inf Dis 70(9):1925–1932. DOI: 10.1093/cid/ciz555.
Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, et al. Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Inf Dis 2016;62(4):e1–e50. DOI: 10.1093/cid/civ933.
Martin-Loeches I, Antonelli M, Cuenca-Estrella M, Dimopoulos G, Einav S, De Waele, JJ, et al. ESICM/ESCMID task force on practical management of invasive candidiasis in critically ill patients. Intensive Care Med 2019;45:789–805. DOI: 10.1007/s00134-019-05599-w.
Rodríguez-Adrián LJ, King RT, Tamayo-Derat LG, Miller JW, Garcia CA, Rex JH. Retinal lesions as clues to disseminated bacterial and Candidal infections: frequency, natural history, and etiology. Med (Baltim) 2003;82:187–202. DOI: 10.1097/01.md.0000076008.64510.f1.
Xiao Z, Wang Q, Zhu F, An Y. Epidemiology, species distribution, antifungal susceptibility and mortality risk factors of candidemia among critically ill patients: a retrospective study from 2011 to 2017 in a teaching hospital in China. Antimicrob Resist Infect Control 2019;8:89. DOI: 10.1186/s13756-019-0534-2.
Koehler P, Stecher M, Cornely OA, Koehler D, Vehreschild MJGT, Bohlius J, et al. Morbidity and mortality of candidaemia in Europe: an epidemiologic meta-analysis. Clin Microbiol Infect 2019;25(10):1200–1212. DOI: 10.1016/j.cmi.2019.04.024.