Pediatric Infectious Disease

Register      Login

VOLUME 4 , ISSUE 2 ( April-June, 2022 ) > List of Articles

Original Article

Fungal Sepsis in a Tertiary Neonatal Intensive Care Unit: A Cross-sectional Study

Kheya Ghosh Uttam, Purbasha Gupta, Sumon Poddar

Keywords : Antifungal resistance, Candida albicans, Candida non-albicans, Fungal sepsis, Neonatal, Risk factors

Citation Information : Uttam KG, Gupta P, Poddar S. Fungal Sepsis in a Tertiary Neonatal Intensive Care Unit: A Cross-sectional Study. Pediatr Inf Dis 2022; 4 (2):33-37.

DOI: 10.5005/jp-journals-10081-1320

License: CC BY-NC 4.0

Published Online: 01-06-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Abstract

Aim and background: Fungal infections have emerged as a significant cause of late-onset neonatal sepsis in the last two decades. Epidemiological data on fungal sepsis in neonates especially in the Indian population is scarce. This study aims to determine the epidemiological trend of neonatal fungal infection, the organisms, and their susceptibility pattern to the different antifungal agents and additionally to look for the various risk factors, clinical features, and laboratory manifestation of fungal sepsis in neonates. Materials and methods: This is a retrospective observational study conducted in the NICU of a pediatric tertiary care hospital in Kolkata from January 2018 to December 2020. All the neonates who had a blood culture positive for Candida were included in the study. The type of organisms and susceptibility pattern to antifungal agents were noted. The clinical details like the age and sex of the neonate, gestational age at delivery, birth weight, and other predisposing risk factors like intravascular devices, mechanical ventilation, parenteral nutrition, and the laboratory parameters were noted. Results: Seventy-nine neonates whose blood culture was positive for Candida species were included in the study. Out of them, 65% were preterm (n = 52) and 67% were low birth weight (LBW). The chief presenting feature of the neonates was abdominal distension (39%), lethargy, refusal to feed (34%), respiratory distress (36%), convulsion (20%), and low-grade fever (5%). Sixty-one percent of the neonates required mechanical ventilation. Seventy-six percent (n = 60) of the babies were receiving parenteral nutrition with either peripheral or central line on the day blood culture was sent. Sixty-seven percent (n = 53) of the patients were diagnosed with fungal sepsis based on first blood culture on the day of admission (group I), whereas 33% (n = 26) were diagnosed after a few days of admission to NICU (group II). All the babies in group I were outborn and the average age of referral was day 7. In group II, 61.5% (n = 16) were outborn and 38.5% (n = 10) were inborn and the average age of positive fungal culture was day 12. Among the isolates, 43% were Candida pelliculosa, 31% were Candida parapsilosis, 8% were Candida famata, 7% were Candida tropicalis, 2.9% were Candida krusei, 5.7% Candida guilliermondii, and only 2.3% were Candida albicans. As per the culture sensitivity report, 13% (n = 10) of the Candida species were resistant to antifungal agent fluconazole but 100% were sensitive to voriconazole; 11% (n = 9) resistant to amphotericin B; 2.5% (n = 2) were intermediate sensitive, and 5% (n = 4) resistant to both caspofungin and micafungin. The general mortality rate was 32.9% (n = 26). The babies in group I had a higher mortality rate (37.7%) compared with the babies in group II (23%). Infection with C. tropicalis has the highest mortality (42.3%), followed by C. parapsilosis (30.7%) and C. pelliculosa (27%). Interpretation: Our study revealed that fungal infection in neonates is mostly due to non-albicans Candida species (97.3%), C. pelliculosa was found to be the commonest organism accounting for 43% of infection. Infection with C. tropicalis was associated with maximum mortality. Thirteen percent of the Candida species were resistant to the drug fluconazole, 11% were resistant to amphotericin B, 5% were resistant to caspofungin and micafungin, whereas all of the organisms were sensitive to voriconazole. Preterm, LBW, need for mechanical ventilation, parenteral nutrition, and broad-spectrum antibiotics play a significant role in fungal sepsis-related morbidity and mortality.


PDF Share
  1. Pana ZD, Roilides E, Warris A, et al. Epidemiology of invasive fungal disease in children. J Pediatric Infect Dis Soc 2017;6(Suppl 1):S3–S11. DOI: 10.1093/jpids/pix046
  2. Ballot DE, Bosman N, Nana T, et al. Background changing patterns of neonatal fungal sepsis in a developing country. J Trop Peditr 2013;59(6):460–464. DOI: 10.1093/tropej/fmt053
  3. Zaoutis TE, Prasad PA, Localio AR, et al. Risk factors and predictors for candidemia in pediatric intensive care unit patients: implications for prevention. Clin Infect Dis 2010;51(5):38–45. DOI: 10.1086/655698
  4. Oeser C, Lamgni T, Heath PT, et al. The epidemiology of neonatal and paediatric candidemia in England and Wales, 2000–2009. Pediatr Infect Dis J 2013;32(1):23–26. DOI: 10.1097/INF.0b013e318275612e
  5. Juyal D, Sharma M, Pal S, et al. Emergence of non-albicans Candida species in neonatal candidemia. N Am J Med Sci 2013;5(9):541–545. DOI: 10.4103/1947-2714.118919
  6. Kaur R, Dhakad MS, Goyal R, et al. Emergence of non-albicans Candida species and antifungal resistance in intensive care unit patients. Asian Pacif J Trop Biomed 2016;6(Issue 5):455–460. DOI: 10.1016/j.apjtb.2015.12.019
  7. Lausch KR, Schultz Dungu KH, Dungu MT, et al. Pediatric candidemia epidemiology and morbidities A nationwide cohort. Pediat Infect Dis J 2019;38(5):464–469. DOI: 10.1097/INF.0000000000002207
  8. da Silva CM, de Carvalho Parahym AMR, Leão MPC, et al. Fungemia by Candida pelliculosa in a neonatal intensive care unit: a possible clonal origin. Mycopathologia 2013;175(1–2):175–179. DOI: 10.1007/s11046-012-9605-0
  9. Lin H-C, Lin H-Y, Su B-H, et al. Reporting an outbreak of Candida pelliculosa fungemia in a neonatal intensive care unit. J Microbiol Immunol Infect 2013;46(6):456–462. DOI: 10.1016/j.jmii.2012.07.013
  10. Ishiwada N, Kitajima H, Morioka I, et al. Nationwide survey of neonatal invasive fungal infection in Japan. Med Mycol 2018;56(Issue 6):679–686. DOI: 10.1093/mmy/myx096
  11. Weinberger M, Leibovici L, Perez S, et al. Characteristics of candidemia with Candida albicans compared with non-albicans Candida species and predictors of mortality. J Hospital Infect 2005;61(2):146–154. DOI: 10.1016/j.jhin.2005.02.009
  12. Orasch C, Mertz D, Garbino J, et al. Flucoazole non-susceptible breakthrough candidemia after prolonged low-dose prophylaxix: a prospective FUNGINOS study. J Infect 2018;76(5):489–495. DOI: 10.1016/j.jinf.2017.12.018
  13. Magobo RE, Lockhart SR, Govender NP, et al. Fluconazole – resistant Candida parapsilosis strains with a Y132F substitution in the ERG11 gene causing invasive infections in a neonatal unit, South Africa. Mycoses 2020;63(5):471–477. DOI: 10.1111/myc.13070.
  14. Jajoo M, Manchanda V, Chaurasia S, et al. Alarming rates of antimicrobial resistance and fungal sepsis in outborn neonates in North India. PLoS ONE 2018;13(6):e0180705. DOI: 10.1371/journal.pone.0180705
  15. Laura F-A, Mike S, Adilia W. Management of invasive fungal disease in neonates and children. Pediat Infect Dis J 2019;38(6S):S2–S6. DOI: 10.1097/INF.0000000000002317
  16. Cipolla D, Giuffre M, Mammina C, et al. Prevention of nosocomial infections and surveillance of emerging resistances in NICU. J Matern Fetal Neonatal Med 2011;24(sup1):23–26. DOI: 10.3109/14767058.2011.607567
  17. Zhang X, Ru XF, Wang Y, et al. Clinical characteristics of neonatal fungal sepsis in neonatal intensive care unit. J Pek Univers (Health Sci) 2017;49(5):789–793.
  18. Oeser C, Vergnano S, Naidoo R, et al. Neonatal invasive fungal infection in England 2004–2010. Orig Article Mycol 2014;20(9):936–941. DOI: 10.1111/1469-0691.12578
  19. Garland JS, Uhing MR. Strategies to prevent bacterial and fungal infection in the neonatal intensive care unit. Clin Perinatol 2009;36(1):1–13. DOI: 10.1016/j.clp.2008.09.005
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.