Saudi Journal of Medicine and Medical Sciences

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 10  |  Issue : 2  |  Page : 125--130

Clinical characteristics and outcome of candidemia: Experience from a tertiary referral center in Saudi Arabia


Hind Alhatmi1, Sarah Almansour1, Reem Abanamy1, Abdullah Akbar1, Mohammed Abalkhail1, Ahmad Alharbi2, Abdulrahman Alsaedy2, Ebrahim Mahmoud2, Bassam Alalwan3, Sameera AlJohani3, Omar S Aldibasi4, Mohammad Bosaeed2, Adel Alothman2,  
1 Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
2 Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
3 Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
4 King Abdullah International Medical Research Center, Riyadh, Saudi Arabia

Correspondence Address:
Mohammad Bosaeed
Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh 11426
Saudi Arabia

Abstract

Background: Candida bloodstream infections cause significant excess morbidity and mortality in the health-care setting. There is limited evidence regarding Candida species causing invasive infections in Saudi Arabia. Objective: To identify Candida species causing bloodstream infection and determine the clinical outcome and factors associated with mortality in a tertiary center in Saudi Arabia. Materials and Methods: This retrospective study included all cases of positive blood culture for Candida in patients admitted to King Abdulaziz Medical City, a tertiary care center in Riyadh, Saudi Arabia, between January 1, 2013 and June 30, 2019. Results: A total of 532 patients with candidemia were identified (male: 55.4%; mean age: 54 ± 26.2 years). The most common Candida species isolated was Candida albicans (26.7%), followed by Candida glabrata (22.7%), Candida parapsilosis (22.2%), and Candida tropicalis (18.4%). Non-albicans candidemia was more common in patients with diabetes (76.7%; P = 0.0560), neutropenia (89.8%; P = 0.0062), recent exposure to fluconazole (85.7%; P = 0.0394), and active chemotherapy (83.1%; P = 0.0128). In non-albicans, susceptibility to fluconazole varied from 95.9% with C. tropicalis to 41.5% with C. parapsilosis; nonetheless, all species were highly susceptible to echinocandins. The overall 30- and 90-day mortality rates were 39.9% and 56.4%, respectively. The mortality rate was nonsignificantly higher with non-albicans species at 30 days (41.2% vs. 35.9%; P = 0.2634) and 90 days (58.2% vs. 51.4%; P = 0.1620). Conclusion: This study found a changing pattern in the Candida species causing bloodstream infections and an epidemiological shift toward more non-albicans Candida species in Saudi Arabia.



How to cite this article:
Alhatmi H, Almansour S, Abanamy R, Akbar A, Abalkhail M, Alharbi A, Alsaedy A, Mahmoud E, Alalwan B, AlJohani S, Aldibasi OS, Bosaeed M, Alothman A. Clinical characteristics and outcome of candidemia: Experience from a tertiary referral center in Saudi Arabia.Saudi J Med Med Sci 2022;10:125-130


How to cite this URL:
Alhatmi H, Almansour S, Abanamy R, Akbar A, Abalkhail M, Alharbi A, Alsaedy A, Mahmoud E, Alalwan B, AlJohani S, Aldibasi OS, Bosaeed M, Alothman A. Clinical characteristics and outcome of candidemia: Experience from a tertiary referral center in Saudi Arabia. Saudi J Med Med Sci [serial online] 2022 [cited 2022 Aug 14 ];10:125-130
Available from: https://www.sjmms.net/text.asp?2022/10/2/125/343330


Full Text



 Introduction



Candidemia is a common etiology of nosocomial bloodstream infection: in the United States, it is fourth most common etiology.[1] Advancement in surgical interventions and use of new antifungal agents have not only contributed to prolonged survival of critically ill patients but also increased the incidence of invasive candidiasis and candidemia.[2],[3],[4],[5] The burden of candidemia in health-care settings in terms of excess mortality, morbidity, length of hospital stay and costs is significant. Mortality rates directly associated with candidemia have been reported to range from 19.6% to 61%.[6],[7],[8]

Candida species distribution differs worldwide. Nonetheless, Candida albicans is the historically predominant Candida species, and at least 15 other species are known to contribute to human diseases. However, recent trends have shown an increase in infections being caused by non-albicans Candida species.[4],[7],[9],[10],[11],[12] Chemotherapy, previous surgery, and treatment with antibiotics (such as aminopenicillins, carbapenems, and glycopeptides) have been identified as possible risk factors for this trend.[13] Recent systemic antifungal exposure is also reported as an independent risk associated with non-albicans Candida bloodstream infection. Specifically, chronic liver disease, neutropenia, and male gender were established as independent risk factors for Candida tropicalis candidemia.[14] A very recent study also revealed malnourishment as an independent factor associated with a higher risk of all-cause 28-day mortality in patients with non-albicans candidemia.[15]

Limited available evidence from Saudi Arabia has shown that Candida infections are increasingly being caused by non-albicans Candida species.[12],[16],[17] Of these, one of the more concerning species is Candida auris, which is an aggressive pathogen and is difficult to treat.[18],[19] However, there is scarcity of data regarding the current candidemia trends in Saudi Arabia. This study was conducted with the aim of evaluating the trends of Candida species causing bloodstream infection in a tertiary center in Saudi Arabia and to determine the clinical outcome and factors associated with mortality.

 Materials and Methods



This retrospective study included all cases of positive blood culture for Candida in patients admitted to King Abdulaziz Medical City, a >1900-bed tertiary care center in Riyadh, Saudi Arabia, between January 1, 2013 and June 30, 2019. The study was conducted after receiving ethical approval from the Institutional Review Board (IRB) of King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.

Candidemia was defined as the isolation of any pathogenic species of Candida at least once in a blood culture specimen along with consistent signs and symptoms of bloodstream infection. Only the first episode of candidemia was considered. Eligible patients' clinical and demographic data were obtained from electronic medical records using the local Hospital Information System (BESTCare). The primary parameters evaluated were patient characteristics, risk factors, comorbidities, duration of hospitalization, and clinical outcome in terms of mortality.

Microbiological studies

Microbiological identification of species and susceptibility profiles were performed using the VITEK® 2 system (bioMérieux). Minimum inhibitory concentrations and resistance rates were determined following the Clinical and Laboratory Standards Institute method.

Data analysis

Categorical data are reported as frequencies and percentages, and continuous data as mean ± standard deviation. Univariate analysis was conducted with outcome variables to determine factors associated with 30- and 90-day mortalities. All variables were examined for significance using the Chi-square tests and data were reported using counts and relative frequencies. No imputation method was applied for missing values. A P < 0.05 was considered statistically significant. All statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC, USA).

 Results



Patients

A total of 532 patients with candidemia were identified during the study period, of which 55.5% were male and the mean age was 54 (±26.2) years. The pediatric age group (i.e., aged <18 years) represented 13% of the cohort. More than half of the patients were diabetic and hypertensive (52.6% and 51.5%, respectively). The majority of the patients had recently been exposed to antibiotics (88.5%), had a central venous catheter (79.3%), and were admitted to the intensive care unit (ICU) at the time of diagnosis with candidemia (61.5%). Patients with active malignancy on chemotherapy constituted 19% of the study population, while solid organ transplant and hematopoietic stem cell transplant recipients represented 4% and 1.9%, respectively [Table 1].{Table 1}

Microbiology

The most common Candida species isolated were C. albicans (26.7%), Candida glabrata (22.7%), Candida parapsilosis (22.9%), and C. tropicalis (18.4%). In addition, another 10 non-albicans Candida species were isolated in smaller proportions. However, in the pediatric group, C. albicans (47%) was the most common species isolated followed by C. tropicalis (28%). While the incidence of C. albicans isolates was relatively stable over the study period, C. parapsilosis showed a steady increase in incidence rate in the last 3 years of the study period [Figure 1].{Figure 1}

Non-albicans candidemia was more frequently identified compared to C. albicans among diabetic patients (76.8% vs. 23.2%; P = 0.0560), neutropenic patients (89.8% vs. 10.2%; P = 0.0062), those receiving active chemotherapy for malignancy (83.17% vs. 16.83%; P = 0.0128), and those with recent exposure to fluconazole (85.71% vs. 14.29%; P = 0.0394) [Table 2].{Table 2}

Susceptibility testing was done for all isolates with different antifungal agents. Fluconazole was the most commonly tested agent, and its susceptibility was high among C. albicans isolates (95.1%). Similarly, the susceptibility of fluconazole in non-albicans C. tropicalis and C. glabrata isolates was high (95.9% and 81.8%, respectively); however, it was low in C. parapsilosis (41.5%). The majority of the isolates were susceptible to echinocandins: no resistance was detected among C. parapsilosis, and only five isolates in total were resistant to one of the echinocandins tested. Amphotericin susceptibility also remained high in the isolated species [Table 3].{Table 3}

Outcome

The overall 30- and 90-day mortality were 39.9% (212/512) and 56.4% (300/512), respectively. The mortality rate was non-significantly higher with non-albicans species compared to C. albicans at both 30 days (41.3% vs. 35.9%; P = 0.2634) and 90 days (58.2% vs. 51.4%; P = 0.1620). The 30-day mortality varied among species: it was high with C. lusitaniae (90%), C. kefyr (66.7%), C. utilis (66.7%), and C. dubliniensis (61.5%), and low with C. glabrata (41.3%), C. tropicalis (40.8%), and C. parapsilosis (33.05%). In univariate analysis, 90-day mortality was significantly associated with patients' comorbidities, ICU admission, presence of a central venous catheter, and use of corticosteroid [Table 4].{Table 4}

 Discussion



C. albicans (26.7%) was the most frequently isolated species, which is consistent with the findings of other studies conducted in Saudi Arabia.[12],[20] The study also found candidemia caused by 13 non-albicans Candida species, of which C. glabrata, C. parapsilosis, and C. tropicalis were the most common. Of these, a steady increase in the incidence of C. parapsilosis was noted, which contrasted with the relatively stable incidence of C. albicans throughout the study period. Diabetes, neutropenia, active chemotherapy, and recent exposure to fluconazole were factors associated with increased risk of non-albicans Candida species infection. In line with this finding, increase in non-albicans isolates has previously been attributed to more exposure to antifungals prophylaxis, increased invasive procedures, ICU admissions and a larger population of immunocompromised patients.[21],[22]

Both the 30- and 90-day mortality rates in our cohort was high (about 40% and >50%, respectively), with no statistical difference between C. albicans and non-albicans. The 30-day mortality rates varied across species: it was higher among the less commonly isolated non-albicans than those more commonly isolated. The high mortality rate despite the reasonable susceptibility of Candida species to the commonly used antifungal agents could be explained by the association of mortality with the criticality of the patients' condition and >61% of the patients in the cohort being critically ill and requiring ICU care.

In the univariate analysis, the worse 90-day mortality outcomes were associated with chronic liver disease, ICU admission, receiving total parenteral nutrition, and corticosteroids, which is considered to be usually correlated in other studies.[1],[23] Patients with malignancy on active chemotherapy have significantly higher 30-day mortality (P = 0.0004). Higher mortality was not significantly associated with transplant recipients, which might be related to the level of the immune defect and the overall prognosis compared with patients on active chemotherapy.

There are no precise data about the incidence of candidemia in Saudi Arabia; however, dated studies have estimated the incidence to be 0.2–0.76 cases/1000 hospital discharges and 0.45–1.6/10,000 patient-days/year. Retrospective studies with small sample sizes have also been conducted over the past two decades to describe the evolving epidemiology of candidemia in Saudi Arabia. However, these reports remain scarce and difficult to generalize to the population.[12],[16],[24],[25] It is essential to comprehend the local epidemiology and consider it during the bedside decision-making process. The selection of empirical antifungal agents in populations with a high risk of non-albicans Candida infection should view all aspects, as this might impact the patient's outcome. The increase in infections with non-albicans Candida is considered a significant change in candidemia epidemiology over the past two decades.[22],[26],[27],[28] Similar to our findings, the Surveillance Reports from the United States found C. glabrata accounted for 21% of non-C. albicans isolates in specific US centers and C. parapsilosis in other European and Latin American centers.[23]

Fluconazole susceptibility remained high among C. albicans isolates, reaching 95%; this is consistent with international figures where the susceptibility of isolates of C. albicans to fluconazole ranges from 97 to 100% at ≤8 μg/ml. Initial reports of fluconazole susceptibility among C. albicans in Saudi Arabia were considered low at 74.2%.[28] This discrepancy between our study and older studies from Saudi Arabia can be explained by improved microbiological susceptibility testing and the adoption of newer testing methods such as Etest, microbroth dilution, and the VITEK® 2 system.[29]

Fluconazole susceptibility among C. glabrata was considered low at 81.82%. This is also reported in large surveillance programs, the SENTRY 2006-2010, where 9.7% of C. glabrata isolates were found to be resistant to fluconazole. Fluconazole susceptibility was found to be the lowest among C. parapsilosis (41.5%), which is similar to the findings of international studies, including from the Middle East region.[29],[30] Amphotericin susceptibility also remained high among the isolated species, with the lowest susceptibility reported in C. krusei (94.4%). This is similar to findings previously reported from Saudi Arabia.[21]

Limitations

Although this study reveals long-term data that would be helpful in selecting an appropriate antifungal therapy, it involves a single-center experience. The study's retrospective design is a limitation. Nonetheless, the current electronic medical records at National Guard Health Affairs, which provide digital, searchable, and continuously accessible information about each patient, ensured accuracy and completeness. The time between diagnosis and starting the antifungal therapy was not collected in this study. However, the hospital's policy includes early notification and immediate intervention for any positive blood cultures, and thus a significant delay in the initiation of antifungal therapy is not anticipated in the included patients.

 Conclusion



This study found a changing pattern of the Candida species causing bloodstream infections and an epidemiological shift toward more non-albicans Candida species in Saudi Arabia. ICU admission, total parenteral nutrition, and malignancy were independently associated with candidemia in these species and correlated with worst outcomes. All species were highly susceptible to echinocandins, while C. tropicalis was most susceptible to fluconazole and C. parapsilosis the least.

Ethical considerations

This study was approved by the IRB of King Abdullah International Medical Research Center (Protocol no.: RC18/011) on February 4, 2018. The study adhered to the ethical principles mentioned in the Declaration of Helsinki, 2013. Requirement for patient consent was waived owing to the study design: Patient anonymity was maintained, and the study did not carry any additional risk to the patients.

Data availability statement

The datasets generated and/or analyzed during the current study are not publicly available due to privacy and confidentiality agreements as well as other restrictions but are available from the corresponding author on reasonable request.

Peer review

This article was peer-reviewed by three independent and anonymous reviewers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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