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Monitoring candidemia epidemiology essential for management strategies
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Researchers from several U.S. sites suggested that shifts in antibiotic use patterns as well as changes in the prevalence of several Candida species may have important implications for candidemia management.
The researchers conducted a retrospective case series involving 154 patients and 203 episodes of candidemia at Morgan Stanley Children’s Hospital in New York City. Although the average candidemia rate remained stable at 5.52 cases per 1,000 patient-discharges from 2002 to 2006, antifungal use increased from 79 days to 150 days per 1,000 hospital stays during the same period. Use rates for specific antifungals were:
- Fluconazole (Diflucan, Pfizer), 57% — increased from 41.7 days to 91.1 days per 1,000 hospital-days.
- Amphotericin B, 25% — remained stable around 30 days per 1,000 hospital-days.
- Caspofungin (Cancidas, Merck), 7% — increased from 4.9 days to 16.7 days per 1,000 hospital-days.
- Voriconazole (Vfend, Pfizer), 6% — varied from 1.6 days to 12.8 days to 10.4 days per 1,000 hospital-days.
The researchers were particularly concerned about changes in antifungal susceptibility among Candida isolates as fluconazole is increasingly used as prophylaxis to prevent infection among extremely low birth weight infants. Antifungal susceptibility testing revealed that more than 98% of the two most common isolates — C. albicans (26%) and C. parapsilosis (43%) — were susceptible to fluconazole with no changes in minimum inhibitory concentrations observed.
However, the proportion of cases caused by non-albicans Candida species such as C. glabrata (5.3%-23%) and C. krusei (0%-8.5%) increased. Other isolates identified in the study included C. tropicalis (6.4%), C. guilliermondii, C. rugosa, C. lusitaniae, C. stellatoidea, C. dublinensis and C. intermedia (7.4% combined.)
"If one evaluates all isolates during the study, only 82% were fully susceptible to fluconazole, which has implications for [its use] as the empiric choice for treating candidemia," the researchers wrote.
A "large proportion" of patients with gastrointestinal disorders as a comorbid condition (33%) may have influenced species distribution, according to the researchers, as complicated medical history, multiple hospitalizations and exposure to multiple antibacterial and antifungal agents put them at increased risk for infection. Additional studies in larger populations are necessary to confirm these trends.
"Local epidemiology should be monitored in pediatric populations for potential impact on management strategies," the researchers wrote.
Neu N. Pediatr Infect Dis J. 2009;28:806-809.