Candida in burns: risk factors and outcomes

Sepsis due to Candida is an uncommon but a significant cause of death in burns patients. Colonization is common, but consensus guidelines for prophylaxis and empirical therapy do not specifically include this cohort. Our aim was to define predictive factors for candidaemia in a burns unit, to guide protocols for prevention and early treatment. We conducted a 10-year review (July 1998-December 2007) of patients admitted to the Victorian Adult Burns Service, Melbourne, Australia. Of 1929 patients admitted with acute burn injury, 143 had Candida isolated at any site, most commonly Candida albicans. There were 12 episodes of candidaemia. Prior colonization was an important risk factor for candidaemia, and the risk increased substantially with the number of colonized sites; indeed 43% of patients colonized at more than three sites (and not on antifungals) developed candidaemia. Other risk factors were higher total burn surface area, higher full-thickness surface area, prolonged admission, number and duration of intensive care unit admissions, number of visits to the operating theatre, alcohol as a contributing factor to burn, prior treatment with total parenteral nutrition, or certain antibiotics (ceftriaxone, vancomycin, amikacin, co-trimoxazole). The attributable mortality of candidaemia was 15% (n = 2). Initiation of antifungal therapy was often delayed. Our results support early empirical antifungal therapy in septic burns patients who are colonized, before the results of cultures become known. The role of prophylactic antifungals is less clear, but should be strongly considered for patients colonized at multiple sites.