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Invasive Candida infections in patients of a medical intensive care unit

Attempt of improving diagnosis by quantifying the colonization

Invasive Candida-Infektionen bei Intensivpatienten einer internistischen Intensivstation

Versuch einer besseren Diagnostik durch Quantifizierung der Kolonisation

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Summary

Background

During the past decades, a steady increase in the incidence of invasive Candida infections in patients requiring intensive care has been reported. Nevertheless, the diagnosis of invasive Candida infections in the intensive care unit setting remains still difficult and is often made late in the course of disease. Additionally, prognosis worsens rapidly with delayed initiation of antifungal therapy. Clinical scoring systems such as the Candida colonization index or the four risk factor-based Candida score could be very useful tools to select patients at high risk of developing invasive Candida infections, who would benefit from the administration of systemic antifungal therapy.

Objectives

The main objective was to determine the incidence of invasive Candida infection among patients of a medical intensive care unit and to investigate its association with the Candida colonization index and the Candida score.

Material and methods

A prospective, observational, single-center study was performed from December 2010 to December 2011. All patients over the age of 18 years who were admitted for at least 7 days in a medical intensive care unit were included. Demographic characteristics, underlying diseases, reasons for intensive care unit admission and presence and duration of risk factors for Candida species colonization and infection were collected for each patient. The Candida colonization index and the Candida score were calculated weekly until discharge or death.

Results

A total of 65 patients were included. Proven invasive Candida infections were diagnosed in five patients (7.7 %), i.e. two developed candidemia, two peritonitis, and one pneumonia. All of these patients were characterized by a Candida colonization index ≥ 0.5 (incidence rate: 16.7 % [5/30]) and a Candida score ≥ 2.5 (incidence rate: 29.4 % [5/17]). Mechanical ventilation (p = 0.013) and both Candida scoring systems (p = 0.013 versus p < 0.001) were statistically and significantly associated with invasive Candida infections. The mortality rate was high (80 %). Interestingly, treatment with antifungal drugs was not statistically and significantly associated with invasive candidiasis (p = 0.077) and patients outcome (p = 0.057).

Conclusion

Both the Candida colonization index and the Candida score with cut-off values ≥ 0.5 and ≥ 2.5 are very useful tools to select patients at high risk of developing invasive Candida infections in the medical intensive care unit setting, who would benefit from early antifungal treatment.

Zusammenfassung

Grundlagen

In den vergangenen Jahrzehnten konnte eine stetige Zunahme der Inzidenz invasiver Candida Infektionen bei schwerkranken Patienten, die an Intensivstationen aufgenommen wurden, beobachtet werden. Die Diagnose invasiver Candida Infektionen ist aber nach wie vor schwierig und wird oft erst im späteren Verlauf der Erkrankung gestellt. Bei verspätetem Beginn einer antimykotischen Therapie verschlechtert sich die Prognose dramatisch. Klinische Scoring-Systeme wie der Candida Colonization Index und der auf vier Risikofaktoren-basierte Candida Score könnten wirksame Hilfsmittel darstellen, um Patienten mit hohem Risiko für die Entwicklung invasiver Candida Infektionen zu erkennen, die von der Gabe systemischer Antimykotika profitieren könnten.

Material und Methoden

Eine prospektive, monozentrische Beobachtungsstudie wurde von Dezember 2010 bis Dezember 2011 durchgeführt. Es wurden alle Patienten über 18 Jahre eingeschlossen, die länger als 7 Tage auf einer internistischen Intensivstation aufgenommen waren. Demographische Daten, zugrundeliegende Erkrankungen, Gründe für die Aufnahme auf die Intensivstation, sowie das Vorhandensein und die Dauer von Risikofaktoren für die Kolonisierung und Infektion mit Candida Arten wurden für jeden Patienten erhoben. Die Berechnung des Candida Colonization Index und des Candida Scores erfolgte wöchentlich, bis zur Entlassung oder bis zum Tod des Patienten.

Ziele

Das Hauptziel dieser Studie war die Feststellung der Inzidenz invasiver Candida Infektionen einer internistischen Intensivstation und die Bestimmung der Korrelation invasiver Candida Infektionen mit dem Candida Colonization Index und dem Candida Score.

Ergebnisse

Insgesamt wurden 65 Patienten in die Studie eingeschlossen. Invasive Candida Infektionen wurden in 5 Patienten nachgewiesen (7,7 %): 2x Candidämie, 2x Peritonitis und 1x Pneumonie. Alle Patienten wiesen einen Candida Colonization Index ≥ 0,5 (Inzidenzrate 16,7 % [5/30]) und einen Candida score ≥ 2,5 (Inzidenzrate 29,4 % [5/17]) auf. Künstliche Beatmung (p = 0,013) sowie beide Candida Scoring-Systeme (p = 0,013 vs. p < 0,001) waren statistisch signifikant mit invasiven Candida Infektionen assoziiert. Die Mortalitätsrate war hoch (80 %). Interessanterweise konnte keine statistisch signifikante Korrelation zwischen einer Behandlung mit systemischen Antimykotika und dem Vorhandensein einer invasiven Candida Infektion (p = 0,077) sowie dem Outcome der Patienten (p = 0,057) gefunden werden.

Schlussfolgerung

Sowohl der Candida Colonization Index als auch der Candida Score mit Grenzwerten von ≥ 0,5 und ≥ 2,5 stellen sehr nützliche Hilfsmittel zur Identifizierung von Patienten mit hohem Risiko für die Entwicklung invasiver Candida Infektionen dar, die von einem frühen Beginn antimykotischer Therapie profitieren könnten.

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The authors declare that there is no conflict of interest.

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Correspondence to Elisabeth Presterl MD.

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Kautzky, S., Staudinger, T. & Presterl, E. Invasive Candida infections in patients of a medical intensive care unit. Wien Klin Wochenschr 127, 132–142 (2015). https://doi.org/10.1007/s00508-014-0644-z

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