candida infections in surgical patients

8/11/2019 Candida Infections in surgical patients

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Tsikrikonis Giorgos

Department of Microbiology, Hippokration

General Hospital of Thessaloniki, Greece


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Candida infections remain an important cause ofmorbidity and mortality in surgical settings.

Surgical patients are at particular risk for fungalinfection: more than 50% of all fungal infectionsoccur in this patient population.

Data from the NNIS indicated that in the periodfrom 1989 to 1998 C. albicans was the seventh mostcommon cause of nosocomial infection in the ICUsetting, accounting for 4.9% of bloodstream

infections and 4.8% of surgical site infections.

Candida species(spp) have emerged as the fourthmost common bloodstream pathogen in thecritically ill with an associated mortality rate of 19-

50%.


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Nosocomial Blood Stream Infections, NationalNosocomial Infection Surveilance System (NNIS)1985-1988

Rank 1988 Pathogen Percent Rank 1984

1 Coag-neg Staph 25.5 1

2 S. aureus 15.0 2

3 Enterococci 7.9 6

4 Candidaspp. 7.7 8

5 E. coli 6.8 3

6 Enterobacter 5.2 77 P. aeruginosa 5.0 5

8 Klebsiella spp. 4.4 4

Horan T, et al. Antimicrob Newsletter 5:56, 1988


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Underlying Conditions ImmuneDefects

Iatrogenic Factors

Burns, disruption ofcutaneous or mucosal

barriers Cancer Candidacolonization Cytomegalovirus (CMV) Diabetes mellitus

Graft versus host disease Hematological malignancies HIV, DIC, Shock Malnutrition Organ transplantation

(liver, pancreas and small

bowel in particular)

Granulocytopenia

Neutropenia T-cell

defects

Broad-spectrumantibiotics

Central venouscatheters

Chemotherapy High-dose steroids Immunosuppressive

therapy Intra-abdominal (GI)

surgery Total parenteral

nutrition Longer stays in the

ICU

Risk factors for the development ofCandidainfections can be broken

down into three components :


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The most common types of candidainfections in surgical patients are:

candidemia,

secondary peritonitis

surgical wound infection and

urinary tract infection


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Candidemia is the fourth most common

nosocomial bloodstream infection in the UnitedStates. The attributable mortality rate is 33-47%for invasiveCandida infections, which issignificantly higher than the mortality rate for

the other major causes of nosocomialbloodstream infections.

Central venous catheters are well documentedas independent risk factors for the developmentof candidemia. C. albicansandC. parapsilosisare the most commonly associatedCandida spp.with the production of biofilms on invasivedevices, which renders them nearly completely

resistant to antifungal therapy.


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Candida is either the most common or thesecond most common pathogen isolated fromthe urine in surgical ICU patients. The termurinary candidiasis refers to an ill-defined

group of syndromes, many of which probablyrepresent colonization rather than infection.

Candiduria is very common in hospitalizedpatients who have urinary catheters in placefor more than 14 days. In this setting it ismore likely to reflect colonization thaninfection.


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Candidal Endopthalmitis: Usually implieshematogenous spread to multiple organs.Identification of eye involvement early in therapy iscrucial for preserving visual activity.

Suppurative thrombophlebitis: Results frominfection of a vessel traumatized by prolongedcatheterization.

Endocarditis: Candida endocarditis is very difficultto treat. The overall outcome of candidainfectiveendocarditis is grim, carrying a reported mortalityof up to 80%.

Pericarditis: The surgical patients at risk forpurulent pericarditis caused by Candidaare thosewho have undergone a cardiac operation, those whohave a malignancy and whose host defenses areimpaired and those who have a debilitating chronic

disease.


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Arthritis :Candida joint infections tend to occur in

patients with rheumatoid arthritis or prosthetic jointdevices. Osteomyelitis:Except for sternal infections

complicating median sternotomy, most cases ofcandidal osteomyelitis develop through hematogenous

spread. Meningitis:Candidal meningitis may followhematogenous spread, or it may be a complication ofa neurosurgery or the implantation ofventriculoperitoneal shunts. The infection is insidiousand sometimes goes undiagnosed. Most patients withcandidal meningitis have recently receivedantibacterial agents, and half have previously hadbacterial meningitis.

Pneumonia:True candidal pneumonia is rare, but itcan occur through hematogenous dissemination into

the lung as one of many sites of infection.


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Culture: The workup of a surgical patient withsuspected hematogenous candidiasis begins witha complete set of cultures of sputum,oropharynx, stool, urine, all drain sites, and

blood. A rapid and inexpensive test is the germ tube

test(formation of filamentous extensions fromyeast cells in a serum suspension of yeast),which can distinguish C. albicans (positive result)

from other Candidaspecies. Positive cultures from nonsterile sites (sputum,

urine, and wound drainage) must be interpretedwith caution because of the frequent occurrenceof Candida as a normal commensal of humans


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Histologic analysis: Analysis of fungal smears is arelatively insensitive method of diagnosingcandidiasis and other fungal infections inotherwise sterile sites (e.g. joint fluid,peritoneal fluid, vitreous humor, or

cerebrospinal fluid). Centrifugation of these fluids and examination

of the sediment may improve the diagnosticyield.

Conventional fungal stains, such as hematoxylin-

eosin, periodic acid-Sciff (PAS), and Gomorimethenamine-silver (GMS), are useful. The mostsensitive stain is calcofluor white, butunfortunately it requires fluorescent microscopy.Deep tissue biopsy provides a definitive diagnosis

of candidiasis.


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Candida albicansis the most commonly isolatedCandida spp.Most C. albicans isolates aresensitive to all of the currently availableagents, but some low-level resistance has been

reported, especially with previous long-termexposure to azoles at low dosages. However, the increasing emergence of non-

albicans Candida spp. poses a significant threat

to an older and more immunocompromisedpopulation. Candida glabrata, Candida

tropicalis,andCandida parapsilosisare the

most commonly isolatednon-albicansspecies.


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The concern with the increasing number ofCandida non-albicansspecies is that anti-fungal susceptibility patterns vary based onthe specificCandida spp.

For example,C. lusitanie may be resistant toamphotericin B, C. kruseiis intrinsicallyresistant to fluconazole andC. glabrataexhibits dose-dependant susceptibility tofluconazole (i.e., requires higher doses to

effectively treat). Identifying the specific species ofCandida

isolated makes a significant impact onantifungal therapy decisions.


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Species Polyene Azole Echinocandin

Ampho B Flucon Vori Posa Caspo Anid

C. albicans S S S S S SC. glabrata S to I S-DD to R S - S-DD S - S-DD S S

C. krusei S to I R S - S-DD S - S-DD S S

C. lusitaniae R S S S S S

C. parapsilosis S S S S I I

C. tropicalis S S S to I S S S

Ampho B = amphotericin B, Flucon = filuconazole, Vori = voriconazole,Posa = posaconazole, Caspo = caspofungin, Anid = anidulafungin. S =

sensitive, S-DD = sensitive dose-dependent, I = intermediate, R = resistant

The following table reflects the susceptibility profiles of the more commonCandida spp.


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Our objective was to study the frequency and typesof Candida infections that surgical patients developed

in our hospital over the last three years.


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We retrospectively studied allnon-immunosuppressedpatients who underwentsurgery and developed an

infection caused by Candidaspecies over the last 3 yearsin Hippokration GeneralHospital of Thessaloniki.

All the samples wereinoculated for culture inSabouraud dextrose agar(SDA) and incubated at 37Cfor 24-72 hours.


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Germ tube test:A sample of fungalspores are suspended in

serum. Incubate the testat 350C for 2.5-3 hours.Examine by microscopyfor the detection of anygerm tubes.

Candida albicanswas identified by the germtube test.

Non-albicansspecies that were isolated fromblood cultures were identified using the VITEK2

system (bioMrieux).


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:

A total of 4279 patients had some type ofpostoperative infections, 591 (13.8 %) of

whom developed a Candidainfection.

Candida albicanswas isolated from 53.5 % of

the infected with Candida patients. Non-

albicans species were detected in 46.5 % ofthe positive cultures for Candida.


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The site of isolation of Candidaisolates was:

67.5 % from urine,

12.7 % from surgical wounds, 10.2 % from blood and

at proportions of 4.5 %, 3.7 % and 1.4 %

from peritoneal fluid, central venous

catheters and other sources respectively.


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:

As for candidemiasall species isolated wereCandida non-albicans.

Analysis of all positive blood cultures for

Candidayielded detection of:

Candida parapsilosis in51.4 %,

Candida tropicalisin 21.6 %,

Candida famata in21.6 %and

Candida glabrata in 5.4 %.


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Candidainfections represent a significant

proportion of the infections that surgical patientsdeveloped in our hospital (13.8 % of infectionswere due to Candidaspecies).

The frequency of isolation of non-albicans strains

was significant (46.5 % of the positive cultures forCandida).

At ORMC, a review ofCandidaisolates from blood

and urine cultures from July 2006 through June

2007 revealed a nearly 50:50 splitC. albicans to

non-albicans(52%C. albicans,48%Candida non-

albicans) similar to our study.


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Marsch et al, 1983

Few studies have investigated the characterization typesof candidainfections in surgical patients.


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Compared with the 1980s, a larger proportion of

Candida BSI is now caused by Candida glabrata inthe United States and by Candida parapsilosis andCandida tropicalis in European, Canadian, and LatinAmerican hospitals.

This change in the most frequent cause ofcandidemia has been explained in part by the highaffinity of C. parapsilosis for intravascular devicesand parenteral nutrition and their widespread use.

The increasing use of antifungal agents to preventrisk patients might also have favored changes in thespecies causing infections. Nosocomial outbreaks ofC. parapsilosis have also been described previously,and the hands of healthcare workers may be the

predominant environmental source.


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Candida has been the commonest fungal pathogen

described in surgical patients in previous studies. Anincreasing number of serious Candidainfections has

been noted on surgical services in recent years.

This increase may be related to improvements in

surgical technique and perioperative care that allow

high-risk patients to survive, despite serious

underlying diseases. The price for increased survival

is the propensity to develop unusual infections.

The important risk of Candida infections in surgical

patients requires vigilance and probably an early

start of antifungal therapy in patients at high risk.


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