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349
Neonatal candidiasis: Results of an 8 year study
Solmaz Celebi,
1
Mustafa Hacimustafaoglu,
1
Nilgun Koksal,
2
Hilal Ozkan,
2
Merih Cetinkaya
2
and Beyza Ener
3
1
Department of Pediatrics, Division of Pediatric Infectious Diseases,
2
Department of Pediatrics, Division of Neonatology and
3
Department of Microbiology, Uludag University Medical Faculty, Gorukle, Bursa, Turkey
Abstract Background: The aim of the present study was to evaluate the risk factors, demographic features, treatment and clinical
outcome associated with candidemia in a neonatal intensive care unit (NICU) within an 8 year period.
Methods: The data of infants who were diagnosed as having candidemia, were evaluated.
Results: Between January 2000 and December 2007, a total of 28 candidemia episodes were identied in 28 infants. A
1.1% candidemia incidence was documented in the neonatal intensive care unit (NICU). The species most frequently
causing candidemia were Candida parapsilosis (57.1%), followed by C. albicans (42.9%). The main predisposing
factors for candidemia with C. parapsilosis included presence of maternal pre-eclampsia, prematurity, prolonged
mechanical ventilation, prolonged total parenteral nutrition and presence of jaundice. Retinopathy of prematurity and
bronchopulmonary dysplasia were the most frequently seen underlying illnesses in infants with C. parapsilosis. In the
present study, 13 infants (46.4%) had evidence of organ dissemination. The mortality rate was 42.8% in infants with
candidemia. Mean leukocyte counts and mean C-reactive protein were signicantly higher in neonates who died
compared with those who survived.
Conclusion: Candida parapsilosis (57.1%) was the leading causative organism, followed by C. albicans (42.9%) in
infants. The rate of organ dissemination in the present cases was high. The mortality rate was 42.8% in infants with
candidemia.
Key words candidemia, infants, neonatal intensive care unit, risk factors for candidemia.
Candida species are recognized as leading pathogens in the neo-
natal intensive care unit (NICU) for infections occurring after the
third day of life. The incidence has been observed to range from
2.2% to 12.9% among very low-birthweight infants (VLBW;
birthweight <1500 g) and from 5.5% to 16.5% among extremely
low-birthweight infants (ELBW; birthweight <1000 g).
16
It was
reported that Candida was responsible for 9% of all episodes of
late-onset (>3 days of life) bloodstream infections among VLBW
infants.
1
Candida infections are a signicant cause of mortality
(1054%) and morbidity (25%) in the NICU.
7,8
Acquired late-
onset systemic fungal infections occur in neonates who have risk
factors such as prematurity, use of broad spectrum antibiotics,
prolonged endotracheal intubation, total parenteral nutrition
(TPN), presence of central venous catheters, prior colonization
with Candida species, and concomitant drug use such as H2
blockers and steroids.
813
Candida albicans is the most common pathogen associated
with neonatal infections, and C. parapsilosis is the second
common yeast species isolated from bloodstream infections in
several surveys.
14,15
In some NICUs, C. parapsilosis is the most
commonly identied species of Candida.
1618
Preterm and low-
birthweight infants are more vulnerable to acute fungal sepsis,
because of an immature immune system and invasive interven-
tions; and, in addition, prolonged use of antimicrobials that serve
as risk factors for fungal colonization.
19,20
Candida species can
spread through vertical transmission from maternal ora or via
horizontal transmission from the hands of health-care workers or
contaminated sources.
The aim of the present study was to evaluate the incidence,
risk factors, demographic features, causative pathogens, treat-
ment and clinical outcome associated with candidemia in neo-
nates, and to dene parameters associated with candidemia due
to C. albicans and non-albicans species.
Methods
Subjects and denitions
The Pediatric Clinic at Uludag University Hospital in Bursa,
Turkey is a tertiary care pediatric referral unit in the South
Marmara region that includes a 15-bed neonatal NICU. Atotal of
28 infants who were diagnosed with candidemia according to
clinical ndings and positive blood cultures between January
2000 and December 2007 were included in this study. Detailed
demographic, microbiological and clinical data were prospec-
tively collected for each patient. Gestational age, birthweight,
gender, mode of delivery, Apgar scores at 1 and 5 min, prenatal
Correspondence: Solmaz Celebi, MD, Department of Pediatrics and
Pediatric Infectious Diseases, Uludag University Medical Faculty,
16059, Gorukle, Bursa, Turkey. Email: solmaz@uludag.edu.tr
Received 12 September 2011; revised 9 January 2012; accepted 10
January 2012.
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Pediatrics International (2012) 54, 341349 doi: 10.1111/j.1442-200X.2012.03574.x
2012 The Authors
Pediatrics International 2012 Japan Pediatric Society
demographics, premature rupture of membrane (PROM) and
history of chorioamnionitis, TPN, umbilical catheterization,
presence of urinary catheter and/or nasogastric tube, mechanical
ventilation, previous hospitalization were all recorded. Patients
were monitored for nosocomial infections at all body sites and
data were collected prospectively according to standard surveil-
lance protocols, and Centers for Disease Control and Prevention
criteria were used as standard denitions for nosocomial infec-
tions.
21
We dened nosocomial candidemia as the occurrence of
at least one positive blood culture yielding Candida spp. plus
signs and symptoms of infection after at least 72 h of hospital-
ization.
21
The study protocol was approved by the Ethics Com-
mittee of Uludag University, Faculty of Medicine. Informed
consent was obtained from the legal guardians of all infants.
This study included two casecontrol studies. The rst study
was performed to assess the risk factors for candidiasis (compar-
ing C. albicans and C. parapsilosis) in infants with candidemia.
The second study was an assessment of the parameters associated
with mortality in patients with candidemia. Cases were dened as
patients who died from candidemia, controls were dened as
patients who survived candidemia.
Temperature instability (fever or hypothermia), apnea, need
for supplemental oxygen, need for ventilation, tachycardia/
bradycardia, hypotension, feeding intolerance, abdominal disten-
sion, and necrotizing enterocolitis were considered to be clinical
signs of sepsis. Prematurity was dened as gestational age 237
weeks. Prolonged hospitalization was dened as >14 days. Pro-
longed antibiotics use was dened as >14 days.
The changes in the hematologic parameters were analyzed
using the Manroe and Rodwell scoring systems.
22,23
Leukopenia
was dened as leukocyte counts 25000/mm
3
; leukocytosis was
dened as leukocyte counts 325 000/mm
3
at birth, 330 000/mm
3
at 1224 h and 321 000/mm
3
after the second day of life. Throm-
bocytopenia was dened as platelet counts 2150 000/mm
3
.
Before initiating antimicrobial therapy, blood samples for whole
blood count, C-reactive protein (CRP), culture were obtained.
Meningitis was diagnosed according to the cell count, glucose
and protein levels of cerebrospinal uid (CSF) and the CSF
culture. Whole blood count was performed using an automatic
counter, Cell Dyn 3700 (Abbott Diagnostics Division, Abbott
Park, IL, USA). CRP was determined on immunonephelometry
using a BN II device (Dade Behring Marburg, Marburg,
Germany). Detection limits were 0.5 mg/dL for CRP.
Patients were considered to have organ dissemination if, in
addition to a positive blood culture to candidemia, one or more of
the following were present: (i) chorioretinitis or endophthalmitis
on ophthalmologic examination; (ii) endocarditis, with echocar-
diographic evidence of a valvular vegetation; or (iii) solid organ
involvement with focal, discrete or nodular lesions on computed
tomography, magnetic resonance imaging or ultrasound.
The empiric antibiotic therapy protocols in the NICU were
ampicillin plus gentamicin for early onset sepsis. Ceftazidime (or
cefotaxime) plus amikacin with or without vancomycin were
used for late-onset sepsis. Amphotericin B deoxycholate
(D-AmB) or uconazole was initiated for fungal sepsis at NICU.
Liposomal amphotericin B (L-AmB) was used as second-line
therapy if the patient had failed to respond to previous antifungal
therapy and/or there was toxicity due to antifungal therapy.
Patients who had pre-existing renal or hepatic dysfunction
received L-AmB as rst-line therapy. Flucytosine was used only
in combination with other agents. Doses of the antifungal drugs
were as follows: uconazole, 12 mg/kg i.v. (infused in 2 h) as an
initial dose, then 12 mg/kg once daily i.v. (infused in 1 h) in term
neonates; and 12 mg/kg per day once every 72 h during the rst
week of life in preterm neonates <1500 g; D-AmB, 0.5 mg/kg per
day i.v. dissolved in 5% dextrose water (at a concentration of
0.1 mg/mL) infused in 46 h and protected from light as an initial
dose, then 1 mg/kg once daily i.v.; L-AmB, 3 mg/kg per day i.v.
infused in 1 h; ucytosine, 100 mg/kg per day orally in four
divided doses. In the NICU at Uludag University Medical
Faculty, none of the infants received antifungal prophylaxis.
Microbiology
Blood cultures were obtained from peripheral veins by sterile
technique. Other cultures such as urine, CSF and peritoneal uid
were obtained from other sterile sites when clinically indicated.
Blood, CSF, and peritoneal uid specimens were inoculated into
BACTEC Peds Plus/F (Becton-Dickinson, Sparks, MD, USA)
culture bottles. Urine specimens were inoculated into a 5% de-
brinated sheep blood agar and an eosin-methylene blue (EMB)
agar plate. Urinary tract infection was dened as growth of a
single organism at 310
4
c.f.u./mL in urine collected by catheter-
ization. All cultures were monitored using an automated culture
system. Passages to blood agar and Sabouraud dextrose agar
were performed. The isolated yeasts (C. albicans and non-
albicans species) were presumptively identied as C. albicans
using morphological criteria (germ tube and chlamydospore for-
mation) and denitive identication was made using the API ID
32 C system (BioMerieux Diagnostic System, Grenoble, France).
Because C. parapsilosis was isolated from 10 neonates in
NICU between October 2005 and December 2005, we investi-
gated the source of the infection. During investigation into the
possible source of the infection, samples for cultures were taken
from: the TPN solutions, segments of intravascular lines used for
TPN, surfaces of vacuum pump devices, other surfaces exposed
to hand contact and hands of health-care workers in the NICU.
Also, surveillance cultures (oropharyngeal and skin swabs) were
taken from patients with candidemia.
Statistical analysis
Statistical analysis was performed using SPSS (version 13.0;
SPSS, Chicago, IL, USA). Descriptive statistics are given as a
mean 1 SD, and a percentage. The ShapiroWilk test was used to
test the normal distribution of data. The categorical data were
analyzed using a chi-square test and Pearson test. Continuous
variables (birthweight, gestational age and total hospitalization
duration) were compared between groups with MannWhitney
test. P < 0.05 was considered statistically signicant.
Results
A total of 2420 infants were admitted to NICU between January
2000 and December 2007. In the study period, we identied 28
342 S Celebi et al.
2012 The Authors
Pediatrics International 2012 Japan Pediatric Society
infants with candidemia, the overall incidence of candidemia was
11.5 per 1000 NICU admissions. Annual rates of nosocomial
candidemia cases per 1000 admissions are given in Figure 1. In
Turkey no data are collected on vaginal fungal colonization in
pregnancy. The mean number of positive blood cultures per
patient was 4 (range, 122). All of the Candida species were
classied as nosocomial isolates, Forty-six percent of patients
had more than one positive culture. Eighty-six percent of infants
were premature newborns. Mean gestational age and mean birth-
weight of infants with candidemia were 31.4 1 4 weeks (range,
2640 weeks) and 1417.1 1 252.6 g (range, 5902400 g), respec-
tively. C. parapsilosis and C. albicans accounted for 16 (57.1%)
and 12 (42.9%) of the isolates respectively. Demographic and
clinical characteristics and outcome of the patients with candi-
demia are listed in Table 1. Although all of the infants required
nasogastric catheterization, only 24 infants required mechanical
ventilation. Also, 23 infants required both TPN and umbilical
vein catheterization. There were no statistically signicant dif-
ferences between the candidemia caused by C. albicans and
C. parapsilosis with regard to gender, gestational age, birth-
weight, cesarean delivery, maternal age, frequency of organ dis-
semination or mortality rate. Apgar scores at 1 and 5 min were
lower in patients with C. parapsilosis compared with that in
those with C. albicans (P = 0.017). Maternal pre-eclampsia was
more frequent in patients with C. parapsilosis than in those with
C. albicans (P < 0.001). When we compared the candidemia with
regard to most commonly seen underlying illness, prematurity
(P = 0.024), retinopathy of prematurity (P = 0.007) and bron-
chopulmonary dysplasia (P = 0.0003) were more common in
patients with C. parapsilosis than in those with C. albicans.
Patients with C. parapsilosis were more likely to receive ucy-
tosine and L-AmB treatment (P = 0.024). Patients with C. albi-
cans were more likely to receive uconazole treatment (P =
0.024). Fifteen infants (53.7%) had candidemia alone, whereas
13 infants (46.4%) had evidence of organ dissemination. Organ
involvement was most commonly identied in the brain (25%),
followed by kidney (10.7%), and peritoneal cavity (10.7%). Six
patients with meningitis (85.7%) had positive CSF cultures.
None had ndings of endophthalmitis on eye examination. All
Fig. 1 Annual rates of candidemia cases per 1000 admissions.
Table 1 Subject characteristics and candidemia outcome vs species
C. albicans C. parapsilosis P
(n = 12) (n = 16)
Mean 1 SD (range) Mean 1 SD (range)
Male, n (%) 9 (75) 8 (50) 0.253
Gestational age (weeks) 33.5 1 5 (2640) 29.9 1 2.2 (2734) 0.059
Birthweight (g) 1673 1 592 (8702400) 1224 1 384 (5902050) 0.082
Cesarean delivery, n (%) 7 (58.3) 12 (75) 0.432
Apgar at 1 min 6.6 1 2.4 (49) 4.5 1 2.3 (19) 0.017
Apgar at 5 min 8.3 1 1.6 (610) 7 1 1.6 (510) 0.017
Maternal pre-eclampsia, n (%) 0 (0) 9 (56.2) <0.001
Underlying illness, n (%)
RDS
At birth;
during the complete hospitalization. BPD, bronchopulmonary dysplasia; D-AmB, amphotericin B deoxycholate; IVH, intraventricular
hemorrhage; L-AmB, liposomal amphotericin B; NEC, necrotizing enterocolitis; PDA, patent ductus arteriosus; PROM, premature rupture of
membranes; RDS, respiratory distress syndrome; ROP, retinopathy of prematurity.
Neonatal candidiasis 343
2012 The Authors
Pediatrics International 2012 Japan Pediatric Society
of the patients received previous antibiotic treatment in different
combinations of ampicillin, gentamicin, cefotaxime, amikacin,
ceftazidime, vancomycin and carbapenem. Prior to candidemia,
all of the infants received systemic antibiotic treatment, 10 of
whom had documented bacteremia (methicillin-resistant Staphy-
lococcus epidermidis in six, Pseudomonas aeruginosa in two,
Klebsiella pneumoniae in two). Ampicillin plus gentamicin or
cefotaxime plus amikacin were the empiric antibiotics used in the
NICU while awaiting cultures, to which all 28 infants had been
exposed for at least 48 h.
Empiric antifungal therapy was initiated in 16 patients
(57.1%) before a positive blood culture was reported, because of
clinical suspicion of fungal sepsis. The mean length of antifungal
therapy was 28.5 1 18.8 days (range, 585 days). Ten patients
(35.7%) were initially treated with uconazole. No uconazole-
related toxicity was observed. D-AmB was used in 14 patients
(64.2%) as initial therapy. In eight patients (66.6%), however,
D-AmB was changed to L-AmB, because hypokalemia
(<3 meq/dL) attributed to D-AmB was seen in three patients, and
persistently positive cultures and/or persistence of the clinical
signs and symptoms of the candidal infection occurred in ve
patients. L-AmB was given to four patients (14.2%) as initial
therapy. Flucytosine was added to L-AmB in four patients
(14.2%), because of persistence of the clinical signs and symp-
toms of the candidal meningitis. No ucytosine-related toxicity
was observed. Death occurred in one of the patients (25%)
treated with uconazole. Among the patients treated with
D-AmB, L-AmB and L-AmB plus ucytosine, ve, four, and two
patients died, respectively.
Predisposing factors associated with C. albicans and
C. parapsilosis are listed in Table 2. There were signicant dif-
ferences in the mean duration of mechanical ventilation (5.5 1 6.6
days vs 35 1 38.2 days), and TPN (8 1 6.5 days vs 31.5 1 30 days)
before a diagnosis of systemic infection with C. albicans and C.
Parapsilosis, respectively. Also, the duration of total hospitaliza-
tion of patients with C. parapsilosis (93.5 days) was signicantly
longer than in those with C. albicans (43 days; P = 0.037).
Clinical characteristics of the patients with candidemia by
species are given in Table 3. Presence of jaundice was associated
with candidemia caused by C. parapsilosis. The most common
manifestations were jaundice (75%); tachypnea (71.4%); worsen-
ing in general condition (67.9%); low activity (46.4%); and
fever (32.1%). Laboratory ndings of the candidemia patients by
species are presented in Table 4. No statistically signicant dif-
ferences were found in laboratory ndings in candidemia caused
by C. albicans and C. parapsilosis. Demographic and clinical
characteristics associated with mortality are presented in Table 5.
There were also no statistically signicant differences in gender,
gestational age, birthweight, cesarean delivery, apgar scores at
1 and 5 min, or frequency of organ dissemination between
the patients who died from candidemia and those who survived
candidemia.
Predisposing factors associated with mortality are presented
in Table 6. No statistically signicant differences were found in
predisposing factors between the patients who died from candi-
demia and those who survived candidemia.
Clinical ndings associated with mortality are given in
Table 7. There were no signicant differences in clinical ndings
between the patients who died from candidemia and those who
survived. Laboratory ndings associated with mortality are listed
in Table 8. Mean leukocyte count and CRP were higher in
patients who died from candidemia than in those who survived
candidemia (P = 0.01 vs P = 0.03, respectively).
Of the samples taken from the environment, hands of health-
care workers, and the oropharyngeal and skin swabs, none was
positive. Of the 30 segments of intravascular lines used for TPN
cultures, two were positive for C. parapsilosis. Active surveil-
lance for hospital-associated bloodstream infection is conducted
by the infection prevention and control team for all patients
hospitalized at Uludag University Medical Faculty. In the present
Table 2 Predisposing factors
C. albicans (cases) C. parapsilosis (controls) P
(n = 12) (n = 16)
Mean 1 SD (range) Mean 1 SD (range)
Prematurity (<37 week), n (%) 8 (66.6) 16 (100) 0.024
Duration of hospitalization (days)
11 (91.6) 14 (87.5) 1
ROP
5 (41.6) 6 (37.5) 1
BPD
2 (16.6) 2 (12.5) 1
Organ dissemination, n (%) 7 (58.3) 6 (37.5) 0.274
Treatment, n (%)
Fluconazole therapy 1 (8.3) 3 (18.7) 0.281
D-AmB therapy 5 (41.6) 7 (43.7) 1
L-AmB therapy 4 (33.3) 4 (25) 1
Flucytosine and L-AmB therapy 2 (16.6) 2 (12.6) 1
At birth;
during the complete hospitalization. BPD, bronchopulmonary dysplasia; D-AmB, amphotericin B deoxycholate; IVH, intraventricular
hemorrhage; L-AmB, liposomal amphotericin B; NEC, necrotizing enterocolitis; PDA, patent ductus arteriosus; RDS, respiratory distress
syndrome; ROP, retinopathy of prematurity.
Table 6 Predisposing factors associated with mortality
Died Survived P
(n = 12) (n = 16)
Mean 1 SD (range) Mean 1 SD (range)
Prematurity (<37 weeks), n (%) 11 (91.6) 13 (81.2) 0.613
Duration of hospitalization (days)