Candida spp. especially Candida albicans is considered as one of the most common cause of fungal infections. The aim of our study was to determine epidemiology of candiduria in children who were referred to an Iranian referral hospital. During May 2011 to February 2013, among 4813 urine culture positive, 209 candida spp. isolates (4.3%) was found. Forty-one percent of cadiduria infection was seen in patients between 1 month and 1 year, 24% in neonatant and 24% in patients 1 to 5 years. Cadiduria was mainly found in patients who had received more than 2 or 3 antibiotic during their hospitalization (37% and 24%, respectively). In our study, the highest frequency of cadiduria was seen in patients who had received more than 2 antibiotics and more than 3 antibiotics during their hospitalization; therefore, the strategic goals to opti- mize antimicrobial use including optimizing choice and duration of empiric therapy as well as monitoring and providing feedback regarding antibiotic resistance are recommended

Gholampour, Jamshid

Haghi Ashtiani, Mohammad Taghi

Mahmoudi, Shima

Mamishi, Setareh

Pourakbari, Babak

Sabouni, Farah

Teymuri, Mostafa

PubMed

Journal of Preventive Medicine and Hygiene (JPMH)

J prev med hyg 2014; 55: 54-5754Candida spp. especially Candida albicans is considered as one of the most common cause of fungal infections. The aim of our study was to determine epidemiology of candiduria in children who were referred to an Iranian referral hospital. During May 2011 to February 2013, among 4813 urine culture positive, 209 candida spp. isolates (4.3%) was found. Forty-one percent of cadiduria infection was seen in patients between 1 month and 1 year, 24% in neonatant and 24% in patients 1 to 5 years. Cadiduria was mainly found in patients who had received more than 2 or 3 antibiotic during their hospitalization (37% and 24%, respectively). In our study, the highest frequency of cadiduria was seen in patients who had received more than 2 antibiotics and more than 3 antibiotics during their hospitalization; therefore, the strategic goals to opti-mize antimicrobial use including optimizing choice and duration of empiric therapy as well as monitoring and providing feedback regarding antibiotic resistance are recommended. Original articleCandiduria in children: a first report  from an Iranian referral pediatric hospitalP. GHOLAMIPOUR1, S. MAHMOUDI2, B. POURAKBARI2, M. TAGHI HAGHI ASHTIANI3, F. SABOUNI1, M. TEYMURI2, S. MAMISHI1,21Department of Infectious Diseases, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; 2 Pediatrics Infectious Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran; 3 Department of Pathology, School of Medicine, Tehran University of Medical Sciences, Tehran, IranKey wordsCandiduria • Children • IranSummaryIntroductionCandida spp. especially Candida albicans consider as one of the most common cause of fungal infections lead-ing to a range of life-threatening invasive to non-life-threatening mucocutaneous diseases [1].According to nosocomial Infection Surveillance systems of the United State, candida spp. are the 7th most com-mon nosocomial pathogens  [2]. Several reports over the last 30 years has been reported not only in dramatic increase in the prevalence of candiduria but also in the incidence of candida urinary tract infections (UTI) [3].The recognition of differences in incidence, populations at greater risk, species distribution is important in order to establish appropriate measures of infection control and the management of this disease [4]. The aim of our study was to determine epidemiology of candiduria in children in an Iranian referral hospital.MethodThe diagnosis of a UTI due to Candida species is much more difficult and it has not been established the im-portance of quantitative urine cultures for UTI due to Candida [5]. In our study, urine samples were col-lected from patients who had symptoms suggesting a UTI. However, there is no consensus cut-off limit to define candiduria and investigators use different definitions, quantitation of the number of organisms in the urine to define infection was considered ≥104 yeast cfu/ml.Each urine sample was cultured on CHROM agar can-dida plates and incubated at 37°C for 24-48h aerobically. The number of colonies on each plate were counted and recorded based on colony colors. Furthermore, a direct smear was prepared from each colony and confirmed as yeasts. Candida isolates were identified based on colony morphology on CHROM agar candida and germ tube production. The following data were collected from the medical records of patients: gender, age, hospital unit, duration of hospitalization, use of central venous and urinary catheters during the hospitalization, the use of antibiotics at time of diagnosis of candiduria, previous usage of antifungal drugs and clinical finding.Statistical analysesThe Statistical Package for the Social Sciences (Win-dows version 16.0; SPSS Inc, Chicago, US) was used for all analyses. Descriptive statistics were used to sum-marize patient variables.ResultsFrom May 2011 to February 2013, among 4813 urine culture positive, 209 candida spp. isolates (4.3%) was found (150 Candida albicans  (72%) and 57 Candida Candiduria in Children: a first report from an iranian referral pediatriC hospital55spp. (28%)). The demographic data of patients with can-diduria was shown in Tab.  I. Candiduria was found in 66 girls (32%) and 143 boys (68%). The majority of ca-diduria infection was seen in patients less than 5 years. Forty-one percent of reported infection was in patients between 1 month and 1 year, 24% in neonatant and 24% in patients 1 to 5 years (Tab. I).The highest frequency of cadiduria was seen in patients who had been hospitalized over a month (73 cases, 35%), between 2 weeks to 1 month (57 cases, 27%), be-tween 5 day to 2 week (52 case, 25%) followed by 27 cases (13%) that were hospitalized less than 5 day. The highest frequency of cadiduria was seen in patients who received more than 2 antibiotics (37%) or more than 3 antibiotics (24%) during their hospitalization (Tab. I).The majority of children with candiduria were hospi-talized in ICUs (pediatric intensive care unit (24.5%), neonatal intensive care unit (12%), and coronary care unit (10%) (Tab. I). Among underlying diseases, the highest frequency belonged to cardiovascular dis-order (18%), respiratory diseases (10%), anomaly of urinary tract (10%), UTI or nephrogenic disease (10%), Gastrointestinal and liver diseases (9%), in-fectious diseases (8.5%) and neurologic disorders (8.5%) (Tab. II).Among all patients, 38 (18%) and 25 (12%) had central catheter and urine catheter, respectively.Diaper rash and oral thrush was reported in 70 (34%) and 12 (6%) of patients, respectively. In addition, 25 cases (12%) had genital anomalies and candidemia was present in 5 cases (2%). Thirty- four patients (16%) were treated with systemic antifungal drugs. Fluconazole was prescribed for 23 cases (11%), clotrimazol for 16 patients, nistatin for 12 cases and amphotericin B for 7 cases. Four cases were treated with combination of fluconazole and amphotericin B and the others did not receive any treatment for their infection.DiscussionIn the present study, candiduria was diagnosed in 4.3% of the patients with UTI. It has been reported that 11 to 52% of nosocomial urinary tract infections (UTIs) are caused by Candida spp.  [6-11]. Increased age, fe-male sex, antibiotic use, urinary drainage devices and prior surgical procedures are considered as risk factors for candiduria  [12, 13]. Although females have higher risk for developing candiduria, In our study, similar to Jain et al. report, candiduria was more common in Tab. I. demographic data of patients with candiduria.    N %Sex male 143 68Female 66 32Age Neonate 49 241 month to 1 year 86 411 year to5year 50 246year to10year 13 611year to15year 11 5Ward pICU 51 24.5Urology 30 14NICU 26 12Surgery 21 10CICU 20 10gastroenterology 14 7rheumatology 10 5Nephrology 10 5Infectious 9 4Neonatal 6 3Cardiology 5 2emergency 4 2Oncology 2 1Neurology 1 0.5duration of hospitalization<5 days 27 135-10 days 27 1310-15 days 25 1215-30 days 57 27>30 days 73 35Antibiotic usageNo 14 72 or more antibiotic 78 373 or more antibiotic 51 24Cephalosporins 37 18meropenem 8 4penicilin 7 3piperacillin/tazobactam 4 2vancomycin 1 0.5Aminoglycoside 1 0.5Others 8 4pICU: pediatric intensive care unit, NICU: Neonatal intensive care unit, CICU: Cardiovascular Intensive Care Unit.Tab. II. Underlying diseases of patients with candiduria.Diagnosis N %Cardiovascular disease 37 18respiratory disease 22 10Anomaly of urinary tract 21 10UTI or nephrogenic disease 21 10gastrointestinal and liver diseases 19 9Infectious disease 18 8.5Nervous system 18 8.5Neurosurgery 15 7metabolic diseases 8 4rheumatologic disease 7 4endocrine diseases 7 4Immunodeficiency 4 2Leukemia or Lymphoma 3 1prematurity and rdS 3 1Other blood diseases 2 1Surgical-site infections 2 1Others 2 1Total 209 100UTI: Urinary Tract Infections, rdS: respiratory distress Syndrome.P. GHOLAMIPOUR et AL.56males (68%) than females (32%)  [14]. Candiduria has been dramatically increased among hospitalized patients especially among those patients with indwelling drain-age devices [15, 16]. In our study, long-term indwelling urethral catheters or other urinary drainage devices were present in 40% of patients and all of the patients with candiduria had a known underlying illness. A study per-formed by Platt et al. showed that 26.5% of all urinary infections related to indwelling catheters were caused by fungi [15]. Philips et al. reported that Candida spp. were responsible for 25 of 60 (42%) UTI in infants admit-ted to a neonatal intensive care unit [17]. The frequency of candidemia in our study was 2% that was less than Philips et al. study that reported 52% [17]. Our result, confirm the Binelli et al. report which was reported that in the majority of patients the urinary tract was not the source of candidemia [16].It has been reported that the prevalence of candiduria in the ICU population is increasing ranges from 19 to 44% of urine specimens depending upon different population and definition of candiduria [18-20]. Can-diduria and candidemia occur commonly in neonatal and pediatric ICUs and particularly in premature in-fants  [12, 17, 21-25]. Candida spp. were the patho-gens identified in 42% of hospital-acquired urinary tract infections in a neonatal intensive care unit [17]. In this study, the majority of children with candiduria were hospitalized in ICUs (PICU (24.5%), NICU (12%), CICU (10%). The higher number of candiduria cases in patients of ICUs might be due to concurrent factors that contribute to the selection of these patho-gens such as underlying diseases, immunodeficiency, and multiple manipulations by health care personnel and altered bacterial flora as well as use of antibiotics and long hospital stay [18, 19].Use of antibiotics consider as a chief risk factor to de-velop Candida urinary tract infection [26]. In our study, the highest frequency of cadiduria was seen in patients who had received more than 2 antibiotics and more than 3 antibiotics during their hospitalization; Although C. albicans is frequently reported as the most prevalent species infecting the urinary tract  [16], non-albicans Candida spp. which better adapted to the uri-nary tract environment accounted for more than 50% of urinary Candida isolates [13, 27]; consequently, identi-fication of Candida spp. isolates as well as monitoring and providing feedback regarding antifungal resistance is suggested. In addition, the strategic goals to optimize antimicrobial use including optimizing choice and dura-tion of empiric therapy as well as monitoring and pro-viding feedback regarding antibiotic resistance are rec-ommended.References[1] Achkar JM, Fries BC. Candida infections of the genitourinary tract. Clin Microbiol Rev 2010;23:253-73.[2] Saha R, Das SD, Kumar A, et al. Pattern of Candida isolates in hospitalized children. Indian J Pediatr 2008;75:858-60.[3] Sobel JD, Fisher JF, Kauffman CA, et al. Candida urinary tract infections-epidemiology. Clin Infect Dis 2011;52(sup-pl. 6):S433-S6.[4] Nucci M, Queiroz-Telles F, Alvarado-Matute T, et al. Epide-miology of Candidemia in Latin America: a laboratory-based survey. PloS one 2013;8:e59373.[5] Kauffman CA. Candiduria. Clin Infect Dis 2005;41(Sup-pl. 6):S371-6.[6] Febre N, Silva V, Medeiros E, et al. Microbiological character-istics of yeasts isolated from urinary tracts of intensive care unit patients undergoing urinary catheterization. J Clin Microbiol 1999;37:1584-6.[7] Weinstein RA, Lundstrom T, Sobel J. Nosocomial candiduria: a review. Clin Infect Dis 2001;32:1602-7.[8] Richards MJ, Edwards JR, Culver DH, et al. Nosocomial infec-tions in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol 2000;21:510-5.[9] Brindha S, Jayashree M, Singhi S, et al. Study of nosocomial urinary tract infections in a pediatric intensive care unit. J Trop Pediatr 2011;57:357-62.[10] Pourakbari B, Rezaizadeh G, Mahmoudi S, et al. Epidemiol-ogy of nosocomial infections in pediatric patients in an Iranian referral hospital. J Prev Med Hyg 2012;53:204-6.[11] Bouza E, San Juan R, Munoz P, et al. A European perspective on nosocomial urinary tract infections II. Report on incidence, clinical characteristics and outcome (ESGNI− 004 study). Clin Microbiol Infect 2001;7:532-42.[12] Rivett A, Perry J, Cohen J. Urinary candidiasis: a prospective study in hospital patients. Urol Res 1986;14:183-6.[13] Kauffman CA. Candiduria. Clin Infect Dis 2005;41(Sup-pl. 6):S371-S6.[14] Jain M, Dogra V, Mishra B, et al. Candiduria in catheterized intensive care unit patients: Emerging microbiological trends. Indian J Pathol Microbiol 2011;54:552.[15] Platt R, Polk BF, Murdock B, et al. Risk factors for nosocomial urinary tract infection. Am J Epidemiol 1986;124:977-85.[16] Binelli C, Moretti M, Assis R, et al. Investigation of the possible association between nosocomial candiduria and candidaemia. Clin Microbiol Infect 2006;12:538-43.[17] Phillips JR, Karlowicz MG. Prevalence of Candida species in hospital-acquired urinary tract infections in a neonatal inten-sive care unit. Pediatr Infect Dis J 1997;16:190-4.[18] Richards MJ, Edwards JR, Culver DH, et al. Nosocomial in-fections in pediatric intensive care units in the United States. Pediatrics 1999;103:e39-e.[19] Alvarez-Lerma F, Nolla-Salas J, Leon C, et al. Candiduria in critically ill patients admitted to intensive care medical units. Intensive Care Med 2003;29:1069-76.[20] Passos XS, Sales WS, Maciel PJ, et al. Candida colonization in intensive care unit patients’ urine. Mem Inst Oswaldo Cruz 2005;100:925-8.[21] Shay AC, Miller LG. An Estimate of the Incidence of Candi-duria Among Hospitalized Patients in the United States. Infec-tion control and hospital epidemiology 2004;25:894-5.[22] Hamory B, Wenzel R. Hospital-associated candiduria: predisposing factors and review of the literature. J Urol 1978;120:444.[23] Triolo V, Gari-Toussaint M, Casagrande F, et al. Fluconazole therapy for Candida albicans urinary tract infections in infants. Pediatr Nephrol 2002;17:550-3.Candiduria in Children: a first report from an iranian referral pediatriC hospital57[24] Hitchcock R, Pallett A, Hall M, et al. Urinary tract candidiasis in neonates and infants. Br J Urol 1995;76:252-6.[25] Pappu LD, Purohit DM, Bradford BF, et al. Primary renal can-didiasis in two preterm neonates: report of cases and review of literature on renal candidiasis in infancy. Archives of Pediat-rics & Adolescent Medicine 1984;138:923.[26] Bukhary Z. Candiduria: a review of clinical significance and management. Saudi J Kidney Dis Transpl 2008;19:350.[27] Bochicchio GV, Joshi M, Shih D, et al. Reclassification of uri-nary tract infections in critically ill trauma patients: a time-dependent analysis. Surg Infect 2003;4:379-85. ■ Received on March 9, 2014. Accepted on April 13, 2014. ■ Correspondence: Setareh Mamishi, Department of Pediatric Infec-tious Disease, Children Medical Center Hospital, School of Medi-cine, Tehran University of Medical Sciences No.62, Gharib St., Keshavarz Blvd., Tehran, Iran - Tel: +98 021 6642 8996 - Fax: +98 021 6642 8996 - E-mail: smamishi@sina.tums.ac.ir

Candiduria in children: a first reportfrom an Iranian referral pediatric hospital

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Candiduria in children: a first reportfrom an Iranian referral pediatric hospital

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