Abstract
Background: Candida parapsilosis is the most common non-albicans candida species that causes invasive candidiasis, but little is known about its impacts on the outcomes of pediatric patients. We aimed to characterize the clinical characteristics, risk factors and outcomes of C. parapsilosis bloodstream infections (BSIs) in children. Methods: All pediatric patients with Candida parapsilosis BSIs between 2005 and 2020 from a medical center in Taiwan were enrolled and analyzed. The antifungal susceptibility, clinical manifestations, management and outcomes were investigated. Cases of Candida parapsilosis BSIs were compared between patients with C. albicans BSIs and other Candida spp. BSIs. Results: During the study period, 95 episodes (26.0% of total cases) of Candida parapsilosis BSIs were identified and analyzed. No significant difference was found between pediatric patients with C. parapsilosis BSIs and those with C. albicans BSIs in terms of patients’ demographics, most chronic comorbidities or risk factors. Pediatric patients with C. parapsilosis BSIs were significantly more likely to have previous azole exposure and be on total parenteral nutrition than those with C. albicans BSIs (17.9 vs. 7.6% and 76.8 vs. 63.7%, p = 0.015 and 0.029, respectively). The duration of C. parapsilosis candidemia was relatively longer, and therefore patients often required a longer duration of antifungal treatment when compared with those of C. albicans candidemia, although the candidemia-attributable mortality rates were comparable. Of the C. parapsilosis isolates, 93.7% were susceptible to all antifungal agents, and delayed appropriate antifungal treatment was an independent factor in treatment failure. Conclusions: Pediatric patients with C. parapsilosis BSIs were more likely to have previous azole exposure and be on total parenteral nutrition, and the clinical significances included a longer duration of candidemia and patients often required a longer duration of antifungal treatment.
Keywords: candidemia, intensive care unit, Candida parapsilosis, bloodstream infection, mortality
1. Introduction
Critically ill patients with long-term hospitalization in the intensive care unit (ICU), those with underlying immunocompromised status, the presence of artificial devices and the use of broad-spectrum antibiotics are vulnerable to Candida bloodstream infections (BSIs) [1,2,3]. A high mortality rate of 28–46% has been reported in pediatric patients with Candida BSIs, especially in extremely preterm neonates or those in the hematology/oncology ward [3,4,5]. In pediatric patients, multiple chronic comorbidities, breakthrough candidemia, delayed catheter removal and initial inappropriate antifungal treatment have been reported to be independently associated with treatment failure and final mortality. [6,7]. Additionally, recent studies have documented that there is an emerging trend of Candida isolates with antifungal resistance and the changing epidemiology from C. albicans to non-albicans candidemia is noted in the era of greater antifungal prescription [8,9,10].
Candida parapsilosis is an important non-albicans Candida species and accounts for 18–46% of all Candida BSIs [11,12]. Candida parapsilosis is well known to develop biofilm on the surfaces of artificial devices, the hands and the vulvovaginal mucosa, which results in the high likelihood of indwelling catheter-associated BSIs caused by C. parapsilosis [11,12,13,14]. Extremely preterm neonates need long-term central venous catheter (CVC) placement, and implanted Port-A-Cath catheters are common in pediatric hematology/oncology patients, which puts them at a higher risk of having C. parapsilosis-associated BSIs [15,16]. Additionally, there is an emerging resistance to azoles among C. parapsilosis isolates, and an increasing incidence of C. parapsilosis BSIs has been reported, which may pose a therapeutic challenge to clinicians [17,18]. However, the impacts of Candida parapsilosis BSIs on the outcomes of pediatric patients with candidemia deserve further investigation [19]. In this study, we aim to characterize C. parapsilosis BSIs in children and investigate the influences of therapeutic strategies on outcomes.
2. Patients and Methods
2.1. Study Design, Setting and Ethics Approval
All pediatric patients less than 18 years old who had Candida BSIs during hospitalization at the Linkou Chang Gung Memorial Hospital (CGMH) between January 2005 and December 2020 were enrolled and analyzed. Cases of Candida parapsilosis BSIs were compared with patients with C. albicans BSIs and other Candida spp. BSIs. The Linkou CGMH is the university-affiliated teaching hospital in northern Taiwan and the pediatric department of Linkou CGMH has several ICUs and a specialized hematology/oncology ward. There are a total of 24 beds and 107 beds in the pediatric ICU (PICU) and three neonatal intensive care units (NICUs) of Linkou CGMH, respectively. We continued the series of pediatric candidemia studies after the initial approval by the institutional Review Board of the CGMH (the certificate number: 202201214B0) over seven years ago. Additionally, a waiver of informed consent was also approved for anonymous data collection and the retrospective design of this study.
2.2. Definitions and Data Collection
In this study, we applied the following criteria to define Candida BSI: a patient had signs or symptoms of sepsis and ≥1 positive blood culture of Candida species. The Candida BSI episode was excluded if an unidentified Candida spp. was identified in the blood culture. In our institute, the clinicians usually repeat the blood cultures in cases of invasive candidiasis every 2 to 3 days until they are negative or when it is clinically indicated. The onset of Candida BSI was defined as the first positive blood culture of Candida spp. All bacterial pathogens or fungal species that were isolated while the patients were on antifungal therapy were reviewed and analyzed. If a bacterial pathogen was isolated within two days of the positive Candida spp. blood culture or two days after, it was considered as mixed Candida/bacteria BSIs. When a new infectious focus, such as an abscess, fungus ball, meningitis or end organ damage, were noted 48 h after the onset of the Candida BSI episode until the patient had completed the antifungal therapy or died, we considered it an infectious complication of the Candida BSI.
We applied the standard criteria of previous publications for the diagnosis of neonatal severe sepsis and septic shock [20,21]. When the patient completed antifungal therapy with at least two negative blood cultures from the last positive culture of the Candida isolate and resolution of all clinical symptoms, it was considered a new episode of Candida BSI if positive Candida spp. was isolated in the blood culture again [22]. Breakthrough candidemia was diagnosed if the new onset of Candida BSI occurred while this patient was still on antifungal therapy or antifungal prophylaxis [2,15].
Medical records were reviewed to determine response to antifungal therapy at two weeks after the onset of Candida BSIs, based on the guidelines for assessing treatment responses published by the Mycoses Study Group and the European Organization for Research and Treatment of Cancer as follows: complete response was the resolution of candidemia and clinical symptoms within 3 days; partial response was within 7 days; and progression of disease and death were considered “treatment failure” [23]. The demographic data, chronic comorbidities, hospital courses including use of antifungal agents and artificial devices and predisposing risk factors within 30 days before the onset of Candida BSI were also reviewed and analyzed. When the case had mortality before the resolution of signs and symptoms related to Candida BSIs or the patient died within 14 days after the onset of the Candida BSI without other explanation, it was defined as Candida BSI-attributable mortality [15,22]. For subsequent bacteremia following candidemia, it was defined as isolation of the bacterial pathogen between 48 h after the onset of Candida BSI and the time the patient completed antifungal therapy [23].
2.3. Microbiology and In Vitro Antifungal Susceptibility Testing
In Linkou CGMH, the BACTEC 9240 (Becton Dickinson Microbiology Systems, Franklin Lakes, NJ, USA) system is used to process all blood cultures. All Candida isolates from pediatric patients with Candida BSIs were retrieved from the central laboratory and re-identified using matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF, Bruker Biotype, software version 3.0, Rochester, NY, USA). The in vitro antifungal susceptibilities of isolates were evaluated according to the EUCAST-Antifungal Susceptibility Testing microdilution method [24,25]. Candida krusei ATCC® 6258 and Candida parapsilosis ATCC® 22019 were used as quality control strains for antifungal drug susceptibility testing.
2.4. Statistical Analysis
All episodes of pediatric C. parapsilosis BSIs during the study period were analyzed and compared with all episodes of C. albicans BSIs in hospitalized children from our institute. The clinical characteristics, treatment and outcomes were compared between the two groups. The demographic, clinical, outcome variables and in vitro susceptibility data were summarized using descriptive statistics. Categorical variables were compared using the χ2 or Fisher’s exact test, and continuous variables by the Mann-Whitney U test. p-Values < 0.05 were considered statistically significant.
The clinical significance and impacts of pediatric Candida parapsilosis BSIs were investigated and independent risk factors for candidemia-attributable mortality were evaluated. A univariate logistic regression was fitted for each variable to test its relationship with mortality outcomes. Variables that were clinically relevant and statistically significant (p < 0.1) on univariate analysis were considered for the multivariate regression model. Clinical interventions were maintained in the final model as a fixed variable. All statistical analyses were performed using IBM SPSS software (version 22.0; IBM SPSS Inc., New York, NY, USA).
3. Results
In the study period, there were a total of 365 episodes of Candida BSIs in 320 pediatric patients hospitalized in our institute, with all the Candida isolates re-confirmed. There were 95 episodes of C. parapsilosis BSIs in 88 patients, accounting for 26.0% of all pediatric Candida BSIs in the study period. The most common Candida species that caused pediatric Candida BSIs were C. albicans (n = 171, 46.8%), followed by C. tropicalis (n = 21, 5.8%), C. glabrata (n = 20, 5.5%), and C. guilliermondii (n = 18, 4.9%). The trends of different Candida species that caused pediatric Candida BSIs during the study period are illustrated in Figure 1. The demographics and underlying chronic comorbidities of pediatric patients with C. parapsilosis BSIs are summarized in Table 1. Most of the pediatric patients (89.8%) had underlying chronic comorbidities at the onset of candidemia, and 44.3% had multiple chronic comorbidities. The distributions of C. parapsilosis BSIs between NICU, PICU or general wards and the infectious sources were comparable with those of C. albicans BSIs or other Candida species.
Figure 1.
The case distributions of different Candida species that caused pediatric Candida bloodstream infections (BSIs) in the study period, 2005–2020, in Chang Gung Memorial Hospital.
Table 1.
Demographic and clinical data of pediatric patients with Candida parapsilosis bloodstream infections in CGMH, 2005–2020.
| Patients Characteristics (Total n = 88) |
Neonates (Age < 3 months) (n = 29) |
Pediatric Patients (n = 59) |
p-Value |
|---|---|---|---|
| Patients demographics | |||
| Birth body weight (g), median (IQR) | 1220.0 (740.0–2150.0) | - | - |
| Gestational age (weeks), median (IQR) | 29.0 (26.5–35.5) | - | - |
| Age (years old), median (IQR) | - | 4.7 (1.8–13.5) | - |
| Gender (male/female) | 18 (62.1)/11 (37.9) | 33 (55.9)/26 (44.1) | 0.625 |
| NSD/Cesarean section | 13 (44.8)/16 (55.2) | - | - |
| Inborn/outborn | 23 (79.3)/6 (20.7) | - | - |
| 5 min Apgar score ≤ 7, n (%) | 11 (37.9) | - | - |
| Perinatal asphyxia, n (%) | 2 (6.9) | - | - |
| Respiratory distress syndrome (≥Gr II), n (%) | 16 (55.2) | - | - |
| Intraventricular hemorrhage (≥Stage II), n (%) | 6 (20.7) | - | - |
| Day of life at onset of candidemia (day), median (IQR) | 28.0 (13.0–68.0) | - | - |
| Duration of hospitalization before onset of candidemia (day), median (IQR) | - | 32.5 (14.0–51.0) | - |
| Underlying chronic comorbidities, n (%) | - | ||
| Neurological sequelae | 8 (27.6) | 23 (39.0) | 0.213 |
| Bronchopulmonary dysplasia or chronic lung disease | 14 (48.3) | 10 (16.9) | 0.012 |
| Complicated cardiovascular diseases | 2 (6.9) | 3 (5.1) | 0.726 |
| Symptomatic patent ductus arteriosus | 6 (20.7) | 0 (0) | - |
| Gastrointestinal sequelae | 4 (13.8) | 20 (33.9) | 0.041 |
| Renal disorders | 3 (10.3) | 6 (10.1) | 0.976 |
| Hematological/Oncology | 0 (0) | 10 (16.9) | - |
| Immunodeficiency | 0 (0) | 2 (3.4) | - |
| Autoimmune disorders | 0 (0) | 3 (5.1) | - |
| Congenital anomalies | 4 (13.8) | 10 (16.9) | 0.408 |
| Presence of any chronic comorbidities | 23 (79.3) | 56 (94.9) | 0.075 |
| Presence of more than one comorbidities | 11 (37.9) | 28 (47.5) | - |
| Case years | - | ||
| 2005–2008 | 8 (24.2) | 18 (29.0) | |
| 2009–2012 | 11 (33.3) | 19 (30.6) | - |
| 2013–2016 | 6 (18.2) | 10 (16.1) | - |
| 2017–2020 | 8 (24.2) | 15 (24.2) | - |
| Candidemia-attributable mortality | 10/33 (30.3) | 13/62 (21.0) | 0.185 |
| Overall final in-hospital mortality | 13 (44.8) | 16 (27.1) | 0.147 |
BSI: bloodstream infection; IQR: interquartile range; NSD: normal spontaneous delivery.
At the onset of candidemia, most C. parapsilosis BSIs were primary bloodstream infections, but 29.5% (n = 28) were catheter-related BSIs (CRBSI), and a total of 14 (14.7%) episodes had positive C. parapsilosis isolates cultured from the intra-abdominal space, abscess (n = 10), pleural fluid (n = 2) and urinary source (n = 2). The Candida isolates were identified from more than two sterile sites in four cases of C. parapsilosis BSIs and were considered as disseminated candidemia. (Table 2). A total of 17 episodes of C. parapsilosis BSIs were breakthrough candidemia; that is, the patients were on therapeutic antifungals or antifungal prophylaxis at their disease onset.
Table 2.
Comparisons of Candida parapsilosis bloodstream infections (BSIs) and Candida albicans and other Candida spp. BSIs in CGMH, 2005–2020.
| Candida parapsilosis BSIs (n = 95) | Candida albicans BSIs (n = 171) | Other Candida spp. BSIs (n = 99) | p-Value * | |
|---|---|---|---|---|
| Neonatal episodes | 33 (34.7) | 53 (31.0) | 29 (29.3) | 0.744 |
| Pediatric episodes | 62 (65.3) | 118 (69.0) | 70 (70.7) | |
| Source of candidemia ** | 0.526, 0.028 | |||
| Primary bloodstream infection (BSI) | 53 (55.8) | 103 (60.2) | 70 (70.7) | 0.517, 0.037 |
| Catheter-related BSI | 28 (29.5) | 38 (22.2) | 12 (12.1) | 0.236, 0.004 |
| Abdominal | 10 (10.5) | 15 (8.8) | 12 (12.1) | |
| Urological | 2 (2.1) | 6 (3.5) | 1 (1.0) | |
| Pulmonary | 2 (2.1) | 6 (3.5) | 1 (1.0) | |
| Meningitis | 0 (0) | 3 (1.8) | 3 (3.1) | |
| Clinical presentation | ||||
| Sepsis | 78 (82.1) | 140 (81.9) | 83 (83.8) | 0.918, 0.884 |
| Severe sepsis | 44 (46.3) | 64 (37.4) | 41 (41.4) | 0.457, 0.866 |
| Septic shock | 27 (27.3) | 50 (29.2) | 28 (28.3) | 0.982, 0.874 |
| Progressive and deteriorated ¶ | 22 (23.2) | 38 (22.2) | 12 (12.1) | 0.873, 0.082 |
| Disseminated candidiasis $ | 4 (4.2) | 10 (5.8) | 3 (3.0) | 0.461, 0.555 |
| Duration of candidemia (days), median (range) | 3.0 (1.0-32.0) | 3.0 (1.0–20.0) | 3.0 (1.0–30.0) | 0.068, 0.830 |
| Breakthrough candidemia | 17 (17.9) | 12 (7.0) | 18 (18.2) | 0.012, 0.846 |
| Predisposing risk factors # | ||||
| Receipt of systemic antibiotics & | 88 (92.6) | 158 (92.4) | 94 (94.9) | 1.000, 0.562 |
| Previous azole exposure & | 17 (17.9) | 13 (7.6) | 10 (10.1) | 0.015, 0.147 |
| Previous bacteremia & | 45 (47.3) | 80 (46.8) | 59 (59.6) | 1.000, 0.113 |
| Presence of CVC | 94 (98.9) | 162 (94.7) | 98 (99.0) | 0.102, 1.000 |
| Receipt of parenteral nutrition | 73 (76.8) | 109 (63.7) | 68 (68.7) | 0.029, 0.259 |
| Receipt of immunosuppressants | 10 (10.5) | 33 (19.3) | 27 (27.3) | 0.081, 0.003 |
| Artificial device other than CVC | 48 (50.5) | 75 (43.9) | 57 (57.6) | 0.307, 0.387 |
| Prior surgery & | 26 (27.4) | 52 (30.4) | 33 (33.3) | 0.578, 0.436 |
| Neutropenia (ANC < 0.5 × 103/μL) | 23 (24.2) | 35 (20.5) | 29 (29.3) | 0.536, 0.517 |
All data are expressed as case number (%), unless otherwise stated. * p-Values are comparisons between patients with C. parapsilosis BSIs and C. albicans BSIs, and those with C. parapsilosis BSIs and other Candida spp. BSIs. ** Source of candidemia was defined as the first sterile site to have a positive culture for the Candida species in the episode. ¶ Defined as candidemia episodes with more disseminated candidiasis and/or progressive multi-organ failure even after effective antifungal agents. # Indicated the presence of an underlying condition or risk factor at the onset of Candida BSI, and most episodes occurred in patients with >1 underlying condition or risk factor. & Within one month prior to the onset of invasive candidemia. $ Indicated positive Candida isolates recovered from more than two sterile sites in addition to primary bloodstream infection. CVC: central venous catheter; ANC: absolute neutrophil count.
3.1. Microbiological Characteristics and Clinical Features
The antifungal susceptibility results of C. parapsilosis isolates are summarized in Table 3. The minimum inhibitory concentrations of C. parapsilosis (MIC50) to fluconazole and voriconazole were 0.5 mg/L and 0.015 mg/L, respectively. All C. parapsilosis isolates were susceptible to fluconazole, voriconazole, amphotericin B and echinocandin-based antifungal regimens. There were only 1, 2 and 6 C. parapsilosis isolates that were resistant to itraconazole, micafungin and posaconazole, respectively. Overall, 93.7% C. parapsilosis isolates were susceptible to all antifungal agents.
Table 3.
Distributions of Candida parapsilosis isolates from pediatric patients of CGMH according to minimum inhibitory concentration values calculated for different antifungals.
| Pathogens/Antifungals | No. of Isolates with MIC (mg/L) of Candida parapsilosis (n = 95 Tested) |
MIC (mg/L) | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 0.008 | 0.015 | 0.03 | 0.06 | 0.12 | 0.25 | 0.5 | 1.0 | 2.0 | 4.0 | ≥8.0 | GM | MIC50 | MIC90 | |
| Fluconazole | 2 | 7 | 40 | 36 | 10 | 0.569 | 0.5 | 2.0 | ||||||
| Itraconazole | 2 | 19 | 44 | 29 | 1 | 0.063 | 0.06 | 0.12 | ||||||
| Voriconazole | 19 | 44 | 26 | 6 | 0.017 | 0.015 | 0.03 | |||||||
| Posaconazole | 2 | 11 | 47 | 29 | 6 | 0.037 | 0.03 | 0.06 | ||||||
| 5-Flucytosine | 17 | 43 | 29 | 4 | 2 | 0.148 | 0.12 | 0.25 | ||||||
| Amphotericin B | 8 | 55 | 32 | 0.598 | 0.5 | 1.0 | ||||||||
| Micafungin | 1 | 17 | 53 | 22 | 2 | 1.015 | 1.0 | 2.0 | ||||||
| Caspofungin | 1 | 1 | 6 | 56 | 27 | 4 | 0.592 | 0.5 | 1.0 | |||||
| Anidulafungin | 1 | 1 | 1 | 16 | 60 | 16 | 1 | 0.928 | 1.0 | 2.0 | ||||
MIC: minimum inhibitory concentration. MIC50 and MIC90: MIC required to inhibit 50% and 90% of the isolates, respectively. GM: geometric mean. The MIC cutoff values of C. parapsilosis with antifungal resistance to micafungin, itraconazole and posaconazole are ≥4.0, ≥0.25 and ≥0.12 mg/L, respectively.
Most of the clinical presentations, including severity of illness and percentages of severe sepsis, septic shock and disseminated candidemia, were comparable between C. parapsilosis BSIs and the control groups, including the C. albicans BSIs or other Candida spp. BSIs (Table 2). Most predisposing risk factors for candidemia were also comparable between the C. parapsilosis BSIs and the control groups. However, pediatric patients with C. parapsilosis BSIs were significantly more likely to have previous azole exposure and be on total parenteral nutrition (TPN) than those with C. albicans BSIs (17.9 vs. 7.6% and 76.8 vs. 63.7%, p = 0.015 and 0.029, respectively). Of note, the duration of C. parapsilosis BSIs was relatively longer than that of C. albicans BSIs (3.0 (1.0–10.0) vs. 3.0 (1.0–6.0) days, p = 0.068) (median [IQR] duration of candidemia).
Antifungal therapy was initiated after a median of 2 days (range, 0–7) after the onset of Candida parapsilosis BSIs. The initial antifungal agents and final therapeutic regimens were comparable between C. parapsilosis BSIs and C. albicans BSIs. The percentages of delayed appropriate antifungal agents and modifications of antifungal treatment were also comparable between the two groups. The median duration of antifungal treatments in patients with C. parapsilosis BSIs was 18.0 (IQR, 14–24) days, which was significantly longer than that of C. albicans BSIs (15.0 [14.0–22.0] days, p = 0.021). The longer duration of treatment was associated with a longer duration of candidemia and a higher rate of persistent candidemia in patients with C. parapsilosis BSIs. However, the candidemia-attributable mortality rates were comparable between C. parapsilosis BSIs, C. albicans BSIs and other Candida spp. BSIs. (Table 4). The median time between the onset of the next nosocomial infection and the previous episode of C. parapsilosis BSIs was 10 days (range: 4–31 days).
Table 4.
Therapeutic strategies and outcome comparisons of Candida parapsilosis bloodstream infections (BSIs) and Candida albicans and other Candida spp. BSIs in CGMH, 2005–2020.
| Variable | Candida parapsilosis BSIs (n = 95) | Candida albicans BSIs (n = 171) | Other Candida spp. BSIs (n = 99) | p-Value * |
|---|---|---|---|---|
| Final treatment regimens | 0.134, 0.011 | |||
| Fluconazole/Voriconazole | 39 (41.1) | 70 (40.9) | 28 (28.3) | 0.989, 0.050 |
| Amphotericin B | 30 (31.6) | 50 (29.2) | 26 (26.3) | 0.780, 0.545 |
| Echinocandin-based regimen | 20 (21.1) | 40 (23.4) | 43 (43.4) | 0.847, 0.009 |
| Combined antifungal treatment | 5 (5.3) | 2 (1.2) | 1 (1.0) | |
| No treatment | 1 (1.1) | 9 (5.3) | 1 (1.0) | |
| Modification of antifungal agents | 35 (36.8) | 64 (37.4) | 58 (58.6) | 0.790, 0.003 |
| Duration of antifungal treatment (d), median (IQR) | 18.0 (14.0–24.0) | 15.0 (14.0–22.0) | 18.0 (14.0–24.0) | 0.021, 0.568 |
| Early removal of a central venous catheter ** | 29 (30.5) | 67 (39.2) | 32 (32.3) | 0.183, 0.877 |
| Appropriate antifungal treatment within 48 h | 52 (54.7) | 94 (55.0) | 59 (59.6) | 0.794, 0.559 |
| Treatment outcomes | ||||
| Responsiveness after effective antifungals & | 0.248, 0.123 | |||
| Within 72 h | 33 (34.7) | 81 (47.4) | 22 (22.2) | |
| 4–7 days | 17 (17.9) | 27 (15.8) | 28 (28.3) | |
| More than 7 days | 17 (17.9) | 23 (13.5) | 23 (23.2) | |
| Treatment failure | 28 (29.5) | 40 (23.4) | 26 (26.3) | |
| Subsequent bacteremia | 27 (28.4) | 36 (21.1) | 25 (25.3) | 0.180, 0.631 |
| Candidemia-attributable mortality | 23 (24.2) | 40 (23.4) | 24 (24.2) | 0.881, 1.000 |
* p-Values are comparisons between patients with C. parapsilosis BSIs and C. albicans BSIs, and those with C. parapsilosis BSIs and other Candida spp. BSIs. ** Within 3 days after the onset of candidemia. & Responsiveness to antifungal agents was defined according to the consensus criteria of the Mycoses Study Group and the European Organization for Research and Treatment of Cancer [23].
3.2. Therapeutic Outcomes and Independent Risk Factors of Mortality
Overall, the attributable mortality rate of C. parapsilosis BSIs was 24.2% (23 of 95 episodes), and the in-hospital mortality rate was 33.0% (29 of 88 patients died). The therapeutic outcomes were not significantly different between different study periods, although echinocandins have been more commonly prescribed in our institute since 2010. There was no increasing trend or emergence of antifungal-resistant C. parapsilosis isolates during the study period in our cohort, although routine antifungal prophylaxis has been implemented for very low birth weight (VLBW, birth weight ≤ 1500 g) neonates in our NICUs since 2015. Additionally, the therapeutic responses were comparable between patients with C. parapsilosis BSIs and those with C. albicans BSIs and other Candida spp. BSIs.
The independent risk factors of candidemia-attributable mortality were investigated in this study (Table 5). Neonates had relatively higher rates of sepsis-attributable mortality and in-hospital mortality than children with C. parapsilosis BSIs (Table 1). Delayed catheter removal (>72 h after onset of Candida BSIs), subsequent bacteremia after Candida BSIs, breakthrough candidemia, more chronic comorbidities and septic shock at onset were enrolled into the multivariable regression model for their significant association with an increased risk of candidemia-attributable mortality. After multivariate logistic regression analyses, the independent risk factors for candidemia attributable mortality in pediatric patients with C. parapsilosis BSIs were septic shock at onset (OR, 5.75; 95% CI: 2.08–10.14, p < 0.001), breakthrough candidemia (OR, 3.58; 95% CI: 1.93–8.87, p = 0.002), and delayed catheter removal (OR, 2.86; 95% CI: 1.16–7.05, p = 0.022).
Table 5.
Univariate and multivariate logistic regression analysis for independent risk factors of candidemia-attributable mortality in pediatric patients with Candida parapsilosis bloodstream infection.
| Variables | Univariate Analyses | Multivariate Regression Analysis | ||||
|---|---|---|---|---|---|---|
| Odds Ratio | 95% CI | p-Value # | Odds Ratio | 95% CI | p-Value # | |
| Patients’ age | ||||||
| Neonates (<3 months old) | 2.05 | 1.14–3.67 | 0.016 | |||
| Pediatric patients | 1 | (reference) | ||||
| Underlying chronic comorbidities | ||||||
| No | 1 | (reference) | 1 | (reference) | ||
| One | 1.03 | 0.44–3.08 | 0.433 | 1.04 | 0.54–3.34 | 0.219 |
| More than one chronic comorbidity | 2.34 | 0.74–7.37 | 0.090 | 2.81 | 0.71–6.64 | 0.118 |
| Septic shock at onset | 10.44 | 4.76–25.36 | <0.001 | 5.75 | 2.08–10.14 | <0.001 |
| Delayed CVC removal (>72 h) | 4.60 | 2.49–8.78 | <0.001 | 2.86 | 1.16–7.05 | 0.022 |
| Subsequent bacteremia | 1.73 | 0.92–3.24 | 0.087 | 1.55 | 0.45–3.61 | 0.644 |
| Breakthrough candidemia | 4.35 | 2.63–9.17 | <0.001 | 3.58 | 1.93–8.87 | 0.002 |
| Delayed effective antifungal agents (>48 h) | 1.57 | 0.85–2.85 | 0.150 | |||
| Pathogens | ||||||
| Candida albicans | 1 | (reference) | ||||
| Candida parapsilosis | 0.956 | 0.53–1.72 | 0.880 | |||
CI: confidence interval; CVC: central venous catheter. # Hosmer-Lemeshow p = 0.671 for candidemia attributable mortality.
4. Discussion
The trend of increasing non-albicans candidemia was noted in our institute and has also been documented in other countries in the literature [11,12,26]. Although C. parapsilosis BSIs in children were not significantly associated with worse outcomes, we found that pediatric patients with C. parapsilosis BSIs were more likely to have a longer duration of candidemia, slower responses to antifungal treatment and require a longer duration of antifungal treatment when compared with those with C. albicans BSIs. In children with Candida parapsilosis BSIs, the antifungal resistance rate was only 14% of all episodes [7], and only a few episodes had delayed initial appropriate treatment. We were unable to identify any independent risk factors for C. parapsilosis BSIs because most characteristics were comparable with the controls. However, C. parapsilosis candidemia deserves more concern since the high percentage of NICU patients with CVCs could potentially cause its increasing prevalence in the future.
The proportion of C. parapsilosis candidemia ranged between 14% and 34% of all Candida BSIs in both children and adults [11,12,13,14,18,26]. In recent years, non-albicans candidemia has outnumbered C. albicans candidemia, especially among critically ill patients, neonates with long-term CVC placement, those on TPN and those with antifungal prophylaxis [1,4,5,26,27]. Previous studies have found the use of CVC or other artificial devices, such as urinary catheters or mechanical ventilators, to be associated with C. parapsilosis candidemia [19,28,29,30], while other studies also found patients receiving TPN were more likely to have C. parapsilosis CRBSI [11,31]. Our results were consistent with previous studies, although we could not find significant associations between CVC use and C. parapsilosis BSIs, which may be explained by the presence of CVC in almost all pediatric patients at the onset of candidemia. Additionally, a history of prior antifungal therapy was found to be associated with C. parapsilosis candidemia [30,32], which may be due to the effects of antifungal prophylaxis on the selection of non-albicans species, especially after echinocandin administration [32,33].
C. parapsilosis is known to exhibit a strong biofilm forming capability on the surfaces of a CVC or other artificial devices, which accounts for its higher prevalence among neonates with low birth weight, ICU patients with long term use of CVC and those who are immunocompromised [11,12,13,14,34]. Therefore, the most effective control strategy to avoid persistent candidemia is early catheter removal [7,16,34], although sometimes it is not applicable. Based on our results, we found C. parapsilosis BSIs had a significantly longer duration of candidemia, and delay in catheter removal was independently associated with final adverse outcomes. Previous studies have also found that patients with recurrent or breakthrough candidemia were more likely to have persistent candidemia and final treatment failure [15,35,36], which are supposed to be associated with the placement of CVCs. Given the inevitable requirement of a CVC in VLBW neonates, cases of C. parapsilosis BSIs deserve greater attention and further research for species-specific strategies is warranted.
Most studies found that patients with C. parapsilosis BSIs have comparable outcomes when compared with those with C. albicans BSIs or other non-parapsilosis candidemia [14,28,29,34], while others even found that the mortality rate was lower than that of C. albicans BSIs [37,38]. Overall, the different therapeutic strategies, study cohorts and different underlying demographics may account for the controversial results [11,12,13,14,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38]. The candidemia-attributable mortality rate in our cohort was relatively higher than that of previous studies [4,5,30,31,32,33,34], especially in extremely preterm neonates. Although a new antifungal agent, echinocandin or caspofungin, has been launched in our institute since nearly a decade ago, this anti-biofilm agent did not significantly improve outcomes. We suspected that high percentages of chronic comorbidities, especially multiple chronic comorbidities, may account for the poor outcomes in our cohort. Although only a few C. parapsilosis isolates were antifungal-resistant, there has been an emergence of antifungal resistant C. parapsilosis isolates worldwide [39,40]. Therefore, C. parapsilosis BSIs deserves greater attention and specific therapeutic strategies for cases with a high risk of treatment failure should be investigated to optimize outcomes in the future.
There were some limitations in this study. The retrospective nature and single-center data limit the conclusion to being generalizable and applicable to other institutes or countries. Due to the long study period, there was inevitably some missing data and lost Candida parapsilosis isolates, which would make the incidence rate less reliable. The therapeutic strategies may have changed during the long study period, although the outcomes of C. parapsilosis BSIs were similar in the past two decades. Additionally, the pediatric cases of Candida BSIs in our institute did not have a regular schedule of follow-up blood cultures and the therapeutic strategies depended on the decisions of the attending physicians. Therefore, a further large-scale prospective study is required to address the risk factors and real impacts of C. parapsilosis on the outcomes of pediatric patients with Candida BSIs.
In conclusion, C. parapsilosis isolates are the most common non-albicans candidemia in children, and the use of CVC and other artificial devices, as well as the current antifungal prophylaxis policy, may predispose children to have C. parapsilosis BSIs. The mortality rate of pediatric patients with Candida BSIs in children was high, and the chance of increasing azole resistance in Candida isolates deserves more concern. Since early catheter removal is especially important to avoid persistent candidemia and significantly affect final outcomes, clinicians should not treat C. parapsilosis BSIs with catheters in situ. In cases of multiple chronic comorbidities or septic shock, clinicians should consider more aggressive therapies.
Acknowledgments
All authors thank Chiao-Ching Chiang for keeping the database of our NICU and all nursing staff working in our NICUs for keeping extremely detailed patient records, which contributed greatly to the completion of this research.
Author Contributions
Conceptualization: Y.-S.W., J.-F.H., W.-J.L. and M.-H.T. Data collection and verification: Y.-S.W., W.-J.L., J.-F.H., S.-M.C. and H.-R.H. Formal analysis: J.-F.H., W.-J.L. and S.-H.W. Funding acquisition: J.-F.H. and P.-H.Y. Investigation: J.-F.H., H.-R.H., R.-H.F. and S.-H.W. Methodology: P.-H.Y., S.-M.C. and H.-R.H. Supervision: J.-F.H. and M.-H.T. Writing—original drift: Y.-S.W. and J.-F.H. Writing—review and editing: M.-H.T. All authors have read and agreed to the published version of the manuscript.
Institutional Review Board Statement
This study was approved by the Institutional Review Board of Chang Gung Memorial Hospital with a waiver of informed consent because all patient records and information were anonymized and deidentified prior to analysis.
Data Availability Statement
The datasets used/or analyzed during the current study are available from the corresponding author on reasonable request.
Conflicts of Interest
The authors declare that they have no competing interest.
Funding Statement
This work was supported by a grant from the Ministry of Science and Technology in Taiwan (grant no. NMRPG3H0011 and MOST 107-2314-B-182A-005).
Footnotes
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.
References
- 1.Zheng Y.-J., Xie T., Wu L., Liu X.-Y., Zhu L., Chen Y., Mao E.-Q., Han L.-Z., Chen E.-Z., Yang Z.-T. Epidemiology, species distribution, and outcome of nosocomial Candida spp. bloodstream infection in Shanghai: An 11-year retrospective analysis in a tertiary care hospital. Ann. Clin. Microbiol. Antimicrob. 2021;20:34. doi: 10.1186/s12941-021-00441-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Lee W.-J., Hsu J.-F., Chen Y.-N., Wang S.-H., Chu S.-M., Huang H.-R., Yang P.-H., Fu R.-H., Tsai M.-H. Pediatric Candida Bloodstream Infections Complicated with Mixed and Subsequent Bacteremia: The Clinical Characteristics and Impacts on Outcomes. J. Fungi. 2022;8:1155. doi: 10.3390/jof8111155. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Montravers P., Perrigault P., Timsit J., Mira J., Lortholary O., Leroy O., Gangneux J., Guillemot D., Bensoussan C., Bailly S., et al. Antifungal therapy for patients with proven or suspected Candida peritonitis: Amarcand2, a prospective cohort study in French intensive care units. Clin. Microbiol. Infect. 2016;23:117.e1–117.e8. doi: 10.1016/j.cmi.2016.10.001. [DOI] [PubMed] [Google Scholar]
- 4.Piqueras A., Ganapathi L., Carpenter J.F., Rubio T., Sandora T.J., Flett K.B., Köhler J.R. Trends in Pediatric Candidemia: Epidemiology, Anti-Fungal Susceptibility, and Patient Characteristics in a Children’s Hospital. J. Fungi. 2021;7:78. doi: 10.3390/jof7020078. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Silvester E.J., Watanabe M.M.Y., Pittet L.F., Boast A., Bryant P.A., Haeusler G.M., Daley A.J., Curtis N., Gwee A. Candidemia in Children: A 16-year Longitudinal Epidemiologic Study. Pediatr. Infect. Dis. J. 2021;40:537–543. doi: 10.1097/INF.0000000000003082. [DOI] [PubMed] [Google Scholar]
- 6.Tsai M.-H., Wang S.-H., Hsu J.-F., Lin L.-C., Chu S.-M., Huang H.-R., Chiang M.-C., Fu R.-H., Lu J.-J., Huang Y.-C. Clinical and molecular characteristics of bloodstream infections caused by Candida albicans in children from 2003 to 2011. Clin. Microbiol. Infect. 2015;21:1018.e1–1018.e8. doi: 10.1016/j.cmi.2015.06.024. [DOI] [PubMed] [Google Scholar]
- 7.Tsai M.H., Hsu J.F., Chu S.M., Chang P.J., Lai M.Y., Wu I.H., Huang H.R., Chuang M.C., Fu R.H., Lu J.J. Clinical and microbiological characteristics, and impact of therapeutic strategies on the outcomes of children with candidemia. Sci. Rep. 2017;7:1083. doi: 10.1038/s41598-017-01123-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Won E.J., Choi M.J., Kim M.N., Yong D., Lee W.G., Uh Y., Taek S.K., Byeon S.A., Lee S.Y., Kim S.H., et al. Fluconazole-resistant Candida glabrata bloodstream isolates, South Korea, 2008–2018. Emerg. Infect. Dis. 2021;27:779–788. doi: 10.3201/eid2703.203482. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Won E.J., Choi M.J., Jeong S.H., Kim D., Shin K.S., Shin J.H., Kim Y.R., Kim H.S., Kim Y.A., Uh Y., et al. Nationwide Surveillance of Antifungal Resistance of Candida Bloodstream Isolates in South Korean Hospitals: Two Year Report from Kor-GLASS. J. Fungi. 2022;8:996. doi: 10.3390/jof8100996. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Fernadez-Ruiz M., Guinea J., Lora-Pablos D., Zaragoza O., Puig-Asensio M., Almirante B., Cuenca-Estrella M., Aguado J.M. Impact of fluconazole susceptibility on the outcome of patients with candidemia: Data from a population-based surveillance. Clin. Microbiol. Infect. 2017;23:672.e1–672.e11. doi: 10.1016/j.cmi.2017.01.014. [DOI] [PubMed] [Google Scholar]
- 11.Yamin D.H., Husin A., Harun A. Risk Factors of Candida parapsilosis Catheter-Related Bloodstream Infection. Front. Public Health. 2021;9:631865. doi: 10.3389/fpubh.2021.631865. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Tóth R., Nosek J., Mora-Montes H.M., Gabaldon T., Bliss J.M., Nosanchuk J.D., Turner S.A., Butler G., Vágvölgyi C., Gácser A. Candida parapsilosis: From Genes to the Bedside. Clin. Microbiol. Rev. 2019;32:e00111-18. doi: 10.1128/CMR.00111-18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Chen C.Y., Sheng W.H., Huang S.Y., Chou W.C., Yao M., Tang J.L., Tsay W., Tien H.F., Hsueh P.R. Clinical characteristics and treatment outcomes of patients with candidemia due to Candida parapsilosis sensu lato species at a medical center in Taiwan. J. Antimicrob. Chemother. 2015;70:1531–1538. doi: 10.1093/jac/dku540. [DOI] [PubMed] [Google Scholar]
- 14.Stefanek M., Wenner S., Borges V., Pinto M., Gomes J.P., Rodrigues J., Isabel F., Pessanha M.A., Martins F., Sabino R., et al. Antimicrobial resistance and biofilms underlying catheter-related bloodstream coinfection by Enterobacter cloacae complex and Candida parapsilosis. Antibiotics. 2022;11:1245. doi: 10.3390/antibiotics11091245. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Lai M.-Y., Hsu J.-F., Chu S.-M., Wu I.-H., Huang H.-R., Lin C.-C., Lee I.-T., Chiang M.-C., Fu R.-H., Tsai M.-H. Breakthrough candidemia in children: Clinical and microbiological characteristics, therapeutic strategies and impact on outcomes. Futur. Microbiol. 2017;12:695–705. doi: 10.2217/fmb-2016-0223. [DOI] [PubMed] [Google Scholar]
- 16.Chen Y.-N., Hsu J.-F., Chu S.-M., Lai M.-Y., Lin C., Huang H.-R., Yang P.-H., Chiang M.-C., Tsai M.-H. Clinical and Microbiological Characteristics of Neonates with Candidemia and Impacts of Therapeutic Strategies on the Outcomes. J. Fungi. 2022;8:465. doi: 10.3390/jof8050465. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Trevijano-Contador N., Torres-Cano A., Carballo-González C., Puig-Asensio M., Martín-Gómez M.T., Jiménez-Martínez E., Romero D., Nuvials F.X., Olmos-Arenas R., Moretó-Castellsagué M.C., et al. Global Emergence of Resistance to Fluconazole and Voriconazole in Candida parapsilosis in Tertiary Hospitals in Spain During the COVID-19 Pandemic. Open Forum Infect. Dis. 2022;9:ofac605. doi: 10.1093/ofid/ofac605. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Yamin D., Husin A., Harun A. Distribution of candidemia in Malaysian tertiary care hospital revealed predominance of Candida parapsilosis. Trop. Biomed. 2020;37:903–910. doi: 10.47665/tb.37.4.903. [DOI] [PubMed] [Google Scholar]
- 19.Dotis J., Prasad P.A., Zaoutis T., Roilides E. Epidemiology, Risk Factors and Outcome of Candida parapsilosis Bloodstream Infection in Children. Pediatr. Infect. Dis. J. 2012;31:557–560. doi: 10.1097/INF.0b013e31824da7fe. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Tsai M.-H., Hsu J.-F., Chu S.-M., Lien R., Huang H.-R., Chiang M.-C., Fu R.-H., Lee C.-W., Huang Y.-C. Incidence, Clinical Characteristics and Risk Factors for Adverse Outcome in Neonates with Late-onset Sepsis. Pediatr. Infect. Dis. J. 2014;33:e7–e13. doi: 10.1097/INF.0b013e3182a72ee0. [DOI] [PubMed] [Google Scholar]
- 21.Tsai M.-H., Chu S.-M., Hsu J.-F., Lien R., Huang H.-R., Chiang M.-C., Fu R.-H., Lee C.-W., Huang Y.-C. Risk Factors and Outcomes for Multidrug-Resistant Gram-Negative Bacteremia in the NICU. Pediatrics. 2014;133:e322–e329. doi: 10.1542/peds.2013-1248. [DOI] [PubMed] [Google Scholar]
- 22.Tsai M.-H., Chu S.-M., Lee C.-W., Hsu J.-F., Huang H.-R., Chiang M.-C., Fu R.-H., Lien R., Huang Y.-C. Recurrent late-onset sepsis in the neonatal intensive care unit: Incidence, clinical characteristics and risk factors. Clin. Microbiol. Infect. 2014;20:O928–O935. doi: 10.1111/1469-0691.12661. [DOI] [PubMed] [Google Scholar]
- 23.Donnelly J.P., Chen S.C., Kauffman C.A., Steinbach W.J., Baddley J.W., Verweij P.E., Clancy C.J., Wingard J.R., Lockhart S.R., Groll A.H., et al. Revision and Update of the Consensus Definitions of Invasive Fungal Disease from the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Clin. Infect. Dis. 2020;71:1367–1376. doi: 10.1093/cid/ciz1008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Orasch C., Marchetti O., Garbino J., Schrenzel J., Zimmerli S., Mühlethaler K., Pfyffer G., Ruef C., Fehr J., Zbinden R., et al. Candida species distribution and antifungal susceptibility testing according to European Committee on Antimicrobial Susceptibility Testing and new vs. old Clinical and Laboratory Standards Institute clinical breakpoints: A 6-year prospective candidaemia survey from the fungal infection network of Switzerland. Clin. Microbiol. Infect. 2014;20:698–705. doi: 10.1111/1469-0691.12440. [DOI] [PubMed] [Google Scholar]
- 25.Arendrup M.C., Meletiadis J., Mouton J.W., Guinea J., Cuenca-Estrella M., Lagrou K., Howard S.J., Arendrup M.C., Howard S.J., Mouton J., et al. EUCAST technical note on isavuconazole breakpoints for Aspergillus, itraconazole breakpoints for Candida and updates for the antifungal susceptibility testing method documents. Clin. Microbiol. Infect. 2016;22:571.e1–571.e4. doi: 10.1016/j.cmi.2016.01.017. [DOI] [PubMed] [Google Scholar]
- 26.Siopi M., Tarpatzi A., Kalogeropoulou E., Damianidou S., Vasilakopoulou A., Vourli S., Pournaras S., Meletiadis J. Epidemiological Trends of Fungemia in Greece with a Focus on Candidemia during the Recent Financial Crisis: A 10-Year Survey in a Tertiary Care Academic Hospital and Review of Literature. Antimicrob. Agents Chemother. 2020;64:e01516-19. doi: 10.1128/AAC.01516-19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Ngamchokwathana C., Chongtrakool P., Waesamaae A., Chayakulkeeree M. Risk Factors and Outcomes of Non-albicans Candida Bloodstream Infection in Patients with Candidemia at Siriraj Hospital—Thailand’s Largest National Tertiary Referral Hospital. J. Fungi. 2021;7:269. doi: 10.3390/jof7040269. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Garzillo C., Bagattini M., Bogdanovic L., Di Popolo A., Iula V.D., Catania M.R., Raimondi F., Triassi M., Zarrilli R. Risk factors for Candida parapsilosis blood-stream infection in a neonatal intensive care unit: A case-control study. Ital. J. Pediatr. 2017;43:10. doi: 10.1186/s13052-017-0332-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Hirai Y., Asahata S., Ainoda Y., Goto A., Fujita T., Totsuka K. Nosocomial Candida parapsilosis candidaemia: Risk factors, antifungal susceptibility and outcome. J. Hosp. Infect. 2014;87:54–58. doi: 10.1016/j.jhin.2014.02.006. [DOI] [PubMed] [Google Scholar]
- 30.Almirante B., Rodriguez D., Cuenca-Estrella M., Almela M., Sanchez F., Ayats J., Alonso-Tarres C., Rodriguez-Tudela J.L., Pahissa A., Barcelona Candidemia Project Study Group Epidemiology, risk factors, and prognosis of Candida parapsilosis bloodstream infections: Case-control population-based surveillance study of patients in Barcelona, Spain, from 2002 to 2003. J. Clin. Microbiol. 2006;44:1681–1685. doi: 10.1128/JCM.44.5.1681-1685.2006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Phua A.I., Hon K.Y., Kolt A., O’Callaghan M., Bihari S. Candida catheter-related bloodstream infection in patients on home parenteral nutrition- rates, risk factors, outcomes, and management. Clin. Nutr. 2019;31:1–9. doi: 10.1016/j.clnesp.2019.03.007. [DOI] [PubMed] [Google Scholar]
- 32.Wu Y.-M., Huang P.-Y., Lu J.-J., Shie S.-S., Ye J.-J., Wu T.-S., Huang C.-T. Risk factors and outcomes of candidemia caused by Candida parapsilosis complex in a medical center in northern Taiwan. Diagn. Microbiol. Infect. Dis. 2018;90:44–49. doi: 10.1016/j.diagmicrobio.2017.10.002. [DOI] [PubMed] [Google Scholar]
- 33.Papadimitriou-Olivgeris M., Spiliopoulou A., Fligou F., Spiliopoulou I., Tanaseskou L., Karpetas G., Marangos M., D Anastassiou E., Christofidou M. Risk factors and predictors of mortality of candidemia among critically ill patients: Role of antifungal prophylaxis in its development and in selection of non-albicans species. Infection. 2017;45:651–657. doi: 10.1007/s15010-017-1050-z. [DOI] [PubMed] [Google Scholar]
- 34.Branco J., Miranda I.M., Rodrigues A.G. Candida parapsilosis Virulence and Antifungal Resistance Mechanisms: A Comprehensive Review of Key Determinants. J. Fungi. 2023;9:80. doi: 10.3390/jof9010080. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Funaki T., Miyairi I. Breakthrough Candidemia in Children on Micafungin. Pediatr. Infect. Dis. J. 2018;37:1258–1260. doi: 10.1097/INF.0000000000002020. [DOI] [PubMed] [Google Scholar]
- 36.Barrientos A.C.M., Nobrega de Almeida Junior J., Litvinov N., Bain V., Cristofani L.M., Badue Pereira M.F., Sanson Yoshino de Paula C., Lopes Motta A., Rossi F., Bárbaro Del Negro G.M. Breakthrough candidemia in pediatric patients with cancer from a Brazilian center. Pediatr. Infect. Dis. J. 2021;40:251–254. doi: 10.1097/INF.0000000000003027. [DOI] [PubMed] [Google Scholar]
- 37.Jantarabenjakul W., Yodkitudomying C., Chindamporn A., Suchartlikitwong P., Anugulruengkitt S., Pancharoen C., Puthanakit T. Pediatric and neonatal invasive candidiasis: Species distribution and mortality rate in a Thai tertiary care hospital. Pediatr. Infect. Dis. J. 2021;40:96–102. doi: 10.1097/INF.0000000000002912. [DOI] [PubMed] [Google Scholar]
- 38.Dogan O., Yesilkaya A., Menekse S., Guler O., Karakoc C., Cinar G., Kapmaz M., Aydın M., Keske Ş., Şahin S., et al. Effect of initial antifungal therapy on mortality among patients with bloodstream infections with different Candida species and resistance to antifungal agents: A multicenter observational study by the Turkish fungal infections study group. Int. J. Antimicrob. Agents. 2020;56:105992. doi: 10.1016/j.ijantimicag.2020.105992. [DOI] [PubMed] [Google Scholar]
- 39.Alcoceba E., Gómez A., Lara-Esbrí P., Oliver A., Beltrán A.F., Ayestarán I., Muñoz P., Escribano P., Guinea J. Fluconazole-resistant Candida parapsilosis clonally related genotypes: First report proving the presence of endemic isolates harbouring the Y132F ERG11 gene substitution in Spain. Clin. Microbiol. Infect. 2022;28:1113–1119. doi: 10.1016/j.cmi.2022.02.025. [DOI] [PubMed] [Google Scholar]
- 40.Mesini A., Mikuska M., Giacobbe D.R., Del Puente F., Gandolfo N., Codda G., Orsi A., Tassinari F., Beltramini S., Marchese A., et al. Changing epidemiology of candidemia: Increase in fluconazole-resistant Candida parapsilosis. Mycoses. 2020;63:361–368. doi: 10.1111/myc.13050. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used/or analyzed during the current study are available from the corresponding author on reasonable request.