Invasive Сandidiasis in Сhildren with Severe Sepsis
Background. Вloodstream infections associated with medical care and caused by Candida spp. ranked third place among all infections in intensive care units in the United States and Europe. Candida spp. is the most frequent cause of invasive fungal infection, and 70–90 % of infections occurred in hospital. Materials and methods. We have studied the data of the literature on the prevalence and causes of invasive fungal infections in critically ill children and have done an open, prospective, non-randomized, observational study included 18 children with severe sepsis. Inclusion criteria were clinical signs of severe sepsis, mycological criteria of established invasive mycosis, age from 1 month to 3 years; the exclusion criterion was terminal condition of the patient. All patients with severe sepsis received fluconazole 10–12 mg/kg/day to prevent the development of invasive fungal infection. We have analyzed the incidence of invasive candidiasis among patients with severe sepsis; established risk factors for invasive fungal infections in children with severe sepsis and incidence rate of fluconazole-resistant isolates of Candida spp. Results. The incidence of candidemia in this period was 10.5 cases per 1,000 patient admissions/year. Specifically, the incidence of C.parapsilosis fungemia was 2.5 cases per 1,000 patient admissions/year. Patients infected with C.parapsilosis were more likely to be mechanically ventilated 48 hours prior to candidemia. Non-albicans Candida species predominated in pediatric (56 %) and neonatal (52 %) age groups, yet Candida albicans was the most common species in both groups. Successful treatment responses were observed in pediatric (76 %) and neonatal patients (92 %). Infection with Candida parapsilosis led to successful responses in pediatric (92 %) and neonatal (100 %) patients, whereas infection with Candida glabrata was associated with a lower successful outcome in pediatric patients (55 %). Candida spp. colonization occurs in up to 80 % of critically ill patients after 1 week in intensive care. Early empirical treatment of severe candidiasis has improved survival rate. We found that among 18 patients with severe sepsis, 13 individuals (72 %) had Candida spp. in usually sterile body fluids. We analyzed next nine risk factors for invasive mycosis: the presence of central venous catheter, urinary catheter, prolonged use of antibiotics, prolonged stay in the intensive care units, mechanical ventilation through endotracheal tube, nutritional deficiency, parenteral nutrition, blood transfusions, presence of drainage in body cavities, and established that 50 % of patients with severe sepsis had all nine risk factors for invasive mycosis, 22 % — 8 risk factors, and 28 % of patients — five risk factors. Conclusions. Empirical use of fluconazole for prophylaxis was ineffective in 72 % of cases in patients with severe sepsis and the presence of 8 or more risk factors for invasive fungal infection. We have established the presence of fluconazole-resistant strains of Candida spp. in 61.5 % of patients with severe sepsis and invasive fungal infections. It can be caused by uncontrolled massive use of fluconazole for prophylaxis. The use of the colonization index and corrected colonization index will help to establish the need for the prescription of antifungal drugs. Compliance with the rules of aseptic technique in hospitals will reduce the costs for the treatment of invasive fungal infection.
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