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Risk factors and predictors for candidemia in pediatric intensive care unit patients: implications for prevention
Theoklis E Zaoutis1, Priya A Prasad, A Russell Localio
1Division of Infectious Diseases, Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA. Zaoutis@email.chop.edu
Insights
Central venous catheters and malignancy are key risk factors for candidemia in pediatric intensive care unit (PICU) patients. Early identification of these factors can improve outcomes for critically ill children.
Area of Science:
- Pediatric Infectious Diseases
- Critical Care Medicine
- Mycology
Background:
- Candida species are a leading cause of invasive fungal infections in hospitalized children.
- Candidemia is a significant healthcare-associated bloodstream infection in the United States.
- Limited data exist on candidemia risk factors specifically in pediatric intensive care unit (PICU) patients.
Purpose of the Study:
- To identify independent risk factors for candidemia in PICU patients.
- To determine combinations of risk factors associated with high probabilities of candidemia.
- To inform prevention strategies for invasive fungal infections in critically ill children.
Main Methods:
- Population-based case-control study conducted at Children's Hospital of Philadelphia (1997-2004).
- Case patients with candidemia identified via laboratory records.
- Control patients matched by incidence density sampling, with conditional and weighted multivariate analyses performed.
Main Results:
- Identified 101 candidemia cases (3.5 per 1000 PICU admissions).
- Independent risk factors included central venous catheter (OR 30.4), malignancy (OR 4.0), vancomycin use >3 days (OR 6.2), and anti-anaerobic agents >3 days (OR 3.5).
- Predicted candidemia probability ranged from 10.7% to 46%; 30-day mortality was 44% in cases vs. 14% in controls (OR 4.22).
Conclusions:
- This study is the first to identify independent risk factors for candidemia in a PICU population.
- Identified risk factors can help define children at high risk for candidemia.
- Further validation in diverse PICU populations and development of preventive interventions are recommended.
Background:
Candida species are the leading cause of invasive fungal infections in hospitalized children and are the third most common isolates recovered from patients with healthcare-associated bloodstream infection in the United States. Few data exist on risk factors for candidemia in pediatric intensive care unit (PICU) patients.
Methods:
We conducted a population-based case-control study of PICU patients at Children's Hospital of Philadelphia during the period from 1997 through 2004. Case patients were identified using laboratory records, and control patients were selected from PICU rosters. Control patients were matched to case patients by incidence density sampling, adjusting for time at risk. Following conditional multivariate analysis, we performed weighted multivariate analysis to determine predicted probabilities for candidemia given certain risk factor combinations.
Results:
We identified 101 case patients with candidemia (incidence, 3.5 cases per 1000 PICU admissions). Factors independently associated with candidemia included presence of a central venous catheter (odds ratio [OR], 30.4; 95% confidence interval [CI], 7.7-119.5), malignancy (OR, 4.0; 95% CI, 1.23-13.1), use of vancomycin for >3 days in the prior 2 weeks (OR, 6.2; 95% CI, 2.4-16), and receipt of agents with activity against anaerobic organisms for >3 days in the prior 2 weeks (OR, 3.5; 95% CI, 1.5-8.4). Predicted probability of having various combinations of the aforementioned factors ranged from 10.7% to 46%. The 30-day mortality rate was 44% among case patients and 14% among control patients (OR, 4.22; 95% CI, 2.35-7.60).
Conclusions:
To our knowledge, this is the first study to evaluate independent risk factors and to determine a population of children in PICUs at high risk for developing candidemia. Future efforts should focus on validation of these risk factors identified in a different PICU population and development of interventions for prevention of candidemia in critically ill children.
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