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Candidaemia in Critically Ill
Patients 2005-2010
Dr Bunny Saberwal, Mrs Rakhee Patel,
Dr Seng Zhi Quan and Dr A. Gonzalez
ICE 2
Background
• Invasive candida infections – insidious course with nonspecific signs and symptoms
• Candidaemia is frequent cause of invasive fungal
Bloodstream Infections (BSI) in hospitalised patients
• High candidaemia attributable mortality
• Early recognition can aid efforts to ensure appropriate
empirical therapy is initiated → improve clinical outcome
• Emergence of non-albicans candida species influences
choice of empirical therapy
• Increased mortality with delayed treatment
The management of fungal infections, George H Karem MD Louisiana State University School of Medicine in New Orleans
Aim
• To provide a picture of local epidemiology
• To assess whether antifungal therapy is
administered in a timely fashion
• Appropriate duration of therapy
• To evaluate risk factors, outcome and the
associated costs
Standards as per IDSA guidelines
• Antifungal treatment within 24hrs of
positive cultures
• Fundoscopic Examination on ALL patients
with proven Candida BSI
• Confirmatory negative cultures
IDSA Guidelines: Clinical Practice Guidelines for the management of Candidiasis: 2009 Update by the Infectious Disease Society
of America, Peter G Pappas et al CID 2009:48
Methods
• Retrospective analysis
• Over period 1st January 2005 – 31st
December 2010
• Medical notes and electronic records from
microbiology blood culture database
cross-referenced to identify patients with
candidaemia
Results
• 60 patients 2005-2010 with Candida BSI (CBSI)
• Prevalence 0.24 per 1000 patient admissions
• 55/60 case-notes obtained
• 38.3% Female
• Average age 65.2
Evaluation of Candidaemia
2005-2010
Evaluation of Candidaemia 2005-2010
Number of Cases
16
14
15
14
12
10
9
8
8
6
4
2
13
12
8
7
3
5
4
4
3
4
3
1
1
5
1
0
2005
2006
2007
2008
2009
Year
Albicans
Non-albicans
Unknown
Number of Cases
2010
Candida Species Breakdown
Candida albicans
43 (73%)
Candida dubliniensis
2 (3%)
Candida glabrata
6 (10%)
Candida krusei
1 (1%)
Candida parapsilosis
5 (9%)
Candida species (unknown)
1 (1%)
Candida tropicalis
2 (3%)
Reasons for admission
45 Emergency (82%)
10 Elective (18%) – involved complex intraabdominal surgery
Co-Morbidities
Ischaemic Heart
Disease
27 (49%)
Diabetes Mellitus
COPD/Asthma
Liver
8 (14.5%)
10 (18%)
2 (4%)
Chronic Kidney
Disease stage
22 (40%) Stage 1
7 (14%) Stage 2
16 (29.1%) Stage 3
3 (5.5%) Stage 4
1 (2%) Stage 5
6 (10.9%) Unknown including 4
with ARF
21 (43%)
Malignancy
Risk Factors
CVP line
37 (67%)
Malignancy
TPN
Hospitalisation within last
30 days
21 (43%)
20 (36%)
Surgery in last 3 months
Total days with CVP Line
Immunosuppression/Type
IV drug use
Past Antifungal exposure
19 (35%)
12 (24%)
Recorded for 11 (22%),
Average of 29 days
6 (11%)
1 (2%)
1 (2%)
Time to candidaemia after
admission
Time to onset of postive candida blood culture after hospital
admission
25
Number of Cases
21
20
15
10
10
8
5
5
7
4
0
0
0
1-2 days
3-7 days
8-14 days 15-21 days 22-28 days > 28 days
Days of hospitalisation
• 46 cases (84%) occurred
after 8 days of admission
• 21 cases (38%) occurred
after greater than 28 days
of admission
• Percentage Diagnosed in
ITU: 56%
• ITU prevalence of 9.4 per
1000 patient admissions
• Non ITU prevalence 0.10
per 1000 patient
admissions
• Difference ~ 100 fold
Timeliness of Therapy
Time from positive blood culture to antifungal treatment
18
17
Number of Cases
16
14
14
12
9
10
8
6
4
9
8
5
4
2
3
2
1
0
PRIOR TO BC BC +ve (Day 0)
+ve
Day 1
Day 2
1
0
Day 3
UNKNOWN
N/A
Duration from +ve BC to treatment (days)
Crude Mortality
45 patients (89%) received antifungal treatment within 24 hours of positive culture
However mortality was ~ 50% regardless of antifungal administration times
Average number of days for a culture to become positive = 2.02 (range 1-4 days)
Treatment Duration
• No patients had any documented evidence
that fundoscopy looking for ocular
candidiasis was done
• Even though this was recommended in
writing by the microbiology consultant
• Only 4 cases had surveillance negative
blood cultures after initiation of therapy
• VITAL to guide treatment duration!
Mortality
C. albicans
Non-Albicans candida
Discharged
Deceased
Discharged
Deceased
26
15
7
6
Crude Mortality = 37%
Crude Mortality = 46%
Difference – 9% (not significant p=0.75, Fisher’s
exact test)
Overall Crude Mortality – 39%
Length of Stay & Cost
• ITU bed day cost = approximately £2000 and
non ITU bed day cost = approximately £300
• Total bed days and antifungal costs were
– 2180 bed days (£48,698/pt) C. albicans group
– 969 bed days (£67,809/pt) non-albicans candida
group
• Difference in costs between the groups is
£19,111/pt
• Therefore the C. albicans group on average is
£19,111/pt cheaper
Limitations
• Documentation – Some notes missing
• Transfers
• Small sample size
Conclusions
• 89% of patients received appropriate antifungal
treatment within 24hours of positive blood culture
• In very few instances were confirmatory negative blood
cultures obtained or fundoscopy performed
• There is a high mortality rate in patients with Candida
BSI
• Timely antifungal therapy did not influence mortality in
our cohort
• Management cost of C. albicans ~ £19,111/pt cheaper
Recommendations
• Prevention is key
• Patients with risk factors for Candida BSI should be
placed on empirical antifungal treatment early
• Fundoscopy should be performed and documented, and
confirmatory negative blood cultures obtained from
patients on treatment to guide duration
• Documentation in notes must be CLEAR (this includes
ITU notes, for line changes etc)
• Trust outcome to devise, validate and implement a
candidaemia score card to improve outcomes and costs
Action plan
• Increase awareness of Candida BSI locally
(Presented at Trust meetings Summer and Autumn 2011)
• Incorporate Candida BSI into junior doctor education
(Consultant Microbiologist to take forward)
• Update Trust CVP Policy - including education, training and
improving documentation (ICC to take forward)
• Introduce silver coated CVP lines in ITU (Initiated April 12)
• Share data with peers and external colleagues (Presented
at SEC SHA Antimicrobial Pharmacists Network [Sept 11],
UK Federation of Infection Societies Conference [Nov 11]
and European Congress of Clinical Microbiology and
Infectious Diseases [March 12])
• Devise, validate and implement a candidaemia risk score
card (Research proposal to be written June 2012)
Questions?