Trends in Pediatric Candidemia: Epidemiology, Anti-Fungal Susceptibility, and Patient Characteristics in a Children's Hospital

Abstract

Candida bloodstream infections (CBSIs) have decreased among pediatric populations in the United States, but remain an important cause of morbidity and mortality. Species distributions and susceptibility patterns of CBSI isolates diverge widely between children and adults. The awareness of these patterns can inform clinical decision-making for empiric or pre-emptive therapy of children at risk for candidemia. CBSIs occurring from 2006-2016 among patients in a large children's hospital were analyzed for age specific trends in incidence rate, risk factors for breakthrough-CBSI, and death, as well as underlying conditions. Candida species distributions and susceptibility patterns were evaluated in addition to the anti-fungal agent use. The overall incidence rate of CBSI among this complex patient population was 1.97/1000 patient-days. About half of CBSI episodes occurred in immunocompetent children and 14% in neonatal intensive care unit (NICU) patients. Anti-fungal resistance was minimal: 96.7% of isolates were fluconazole, 99% were micafungin, and all were amphotericin susceptible. Liposomal amphotericin was the most commonly prescribed anti-fungal agent included for NICU patients. Overall, CBSI-associated mortality was 13.7%; there were no deaths associated with CBSI among NICU patients after 2011. Pediatric CBSI characteristics differ substantially from those in adults. The improved management of underlying diseases and antimicrobial stewardship may further decrease morbidity and mortality from CBSI, while continuing to maintain low resistance rates among Candida isolates.

Keywords: Candida; anti-fungal; bloodstream infection; neonatal; pediatric.

Figure 1

Number of Candida bloodstream infections (BSIs) per year, stratified by Candida species. Bloodstream infection episodes were tallied for each species and graphed for each year.

Figure 2

Annual Candida bloodstream infection rates. Overall annual CBSI rates (cases of CBSI/1000 patient days), by age group (2006–2016) and rate of Candida CLABSI (CLABSI/1000 line days) from 2011 to 2016. Incidence rate ratio (IRR) of total Candida BSI: 0.84 (95% CI: 0.81–0.88), p < 0.001; IRR of Candida BSI for <1 year olds: 0.78 (95% CI 0.71–0.85), p < 0.001; IRR of Candida BSI for 1–4 year olds: 0.87 (95% CI: 0.80–0.95), p = 0.002; IRR of Candida BSI for >4 year olds: 1.00 (95% CI 0.94–1.06), p = 0.96. IRR of Candida CLABSI: 0.87 (95% CI: 0.70–1.09), p = 0.22.