High prevalence of asymptomatic nosocomial candiduria due to Candida glabrata among hospitalized patients with heart failure: a matter of some concern?

Abstract

Background and Purpose: Heart failure is a leading cause of hospitalization, and asymptomatic candiduria is common in hospitalized patients with low morbidity. However, in most patients, it is resolved spontaneously on the removal of the catheter. Despite the publication of guidelines, there are still controversies over the diagnosis and management of candiduria. However, in hospitalized patients with heart failure, the decision to treat candiduria is especially important since the nosocomial infections are associated with an increase in morbidity, mortality, length of hospital stay, and healthcare costs. Some species of Candida, such as Candida glabrata, are increasingly resistant to the first-line and second-line antifungal medications. The present study aimed to investigate the incidence of asymptomatic Candida urinary tract infection due to C. glabrata and antifungal susceptibility of Candida isolates in hospitalized patients with heart failure.
 Materials and Methods: In total, 305 hospitalized patients with heart failure were studied to identify asymptomatic nosocomial candiduria during 2016-17 in one private hospital in the north of Iran. The Sabouraud’s dextrose agar culture plates with a colony count of >104 colony-forming unit/ml of urine sample were considered as Candida urinary tract infection. Candida species were identified based on the morphology of CHROMagar Candida (manufactured by CHROMagar, France) and PCR-RFLP method with MspI restriction enzyme. Antifungal susceptibility testing of the isolates was performed using five mediations, including itraconazole, voriconazole, fluconazole, amphotericin B, and caspofungin by broth microdilution method according to CLSI M27-S4.
 Results: In this study, the rate of asymptomatic Candida urinary tract infection was 18.8%, which was more common in people above 51 years old and females (70%). In addition to the urinary and intravascular catheter, the occurrence of candiduria in hospitalized patients had significant relationships with a history of surgical intervention, diastolic heart failure, and use of systemic antibiotics (P>0.05). Among Candida spp., non-albicans Candida species was the most common infectious agent (59.7%). Moreover, C. glabrata (n=27, 40.3%) (alone or with other species) and Candida albicans (n=27, 40.3%) were the most common agents isolated in Candida urinary tract infection. Based on the results of the in vitro susceptibility test, the C. glabrata isolates were 15%, 59%, 70%, 74%, and 85% susceptible to caspofungin, amphotericin B, itraconazole, voriconazole, and fluconazole, respectively.
 Conclusion: According to the findings, there was a high prevalence of asymptomatic Candida urinary tract infection in hospitalized patients with heart failure. Besides, it was suggested that there was a shift towards non-albicans Candida, especially C. glabrata, in these patients. Therefore, asymptomatic candiduria in hospitalized patients with heart failure should be considered significant. Furthermore, the identification of Candida species along with antifungal susceptibility is essential and helps the clinicians to select the appropriate antifungal agent for better management of such cases.

An epidemiologic analysis of Candida spp. urinary infections in intensive care unit

“…In a clinical study in-hospital mortality was 48.8% in patients with candiduria compared to 36.6% in those without candiduria ( p <0.001), they also found significant differences for ICU mortality (38.% vs. 28.1%, p <0.001).8 Researchers found, candiduria detected at any time in the surgical ICU was independently associated with mortality. 24 Our study also revealed candiduria as an independent risk factor for mortality ( p <0.001). The incidence of concurrent candidemia is infrequent and has been encountered in 1-8% of patients with candiduria, even so, ICU patients constitute the high-risk group.…”

Environmental and Social Determinants Related to Candidiasis

“…Invasive candidiasis, which is often associated with hospitalization, involves blood infections (candidemia) and serious infections such as intra-abdominal abscesses, peritonitis and osteomyelitis [39], pneumonia [40], ocular candidiasis [26], endocarditis [41], candiduria [42], and fungal infection in the central nervous system [43]. Almost all organs can become secondarily infected after hematogenous dissemination of the fungus [19].…”

Candida albicans and Antifungal Peptides

“…Patients with acute candidemia are considered if there is evidence of involvement of multiple non-contiguous organs. The colonization and infection of the urinary system is another possible indication of candidemia when the agent is isolated in urine culture [ 40 – 42 ]. Other possible clinical manifestations in fungemia include pyelonephritis, peritonitis, arthritis, hepatosplenic abscesses, myositis, macronodular lesions in the dermis, endophthalmitis, meningitis, and generalized systemic involvement [ 43 , 44 ].…”