166. Breakthrough Invasive Candidiasis in Children
Session: Poster Abstract Session: Clinical Mycology
Thursday, October 5, 2017
Room: Poster Hall CD
Posters
  • Slide1.JPG (3.2 MB)
  • Background: Breakthrough invasive candidiasis (bIC) has been described in adults, but the epidemiology and outcomes in children are unknown.   Methods: Retrospective cohort analysis of children diagnosed with IC from 9/1/09-1/30/17. bIC was defined as isolation of Candida spp from sterile site despite receiving ≥3 doses of antifungal (AF) to which isolate is susceptible. Clinical and microbiological data, management, and outcomes were collected.  Non-parametric and logistic regression statistics were applied.   Results: There were 92 patients with IC, 23 of which were bIC (Table 1).  Underlying conditions included GI (n=26), hem/onc (n=17), prematurity (n=16), cardiac (n=15), HCT (n=4), SOT (n=5), other (n= 9).  Patients received an azole (n=17), micafungin (n=5), or amphotericin B (n=1) for median of 20d [3-522] before bIC as: prophylaxis (n=8), targeted therapy (n=5), or empiric fever driven therapy (n=10).  bIC was caused by non-albicans Candida in 16/23 (70%) cases.    Compared with IC controls, children with bIC had increased ICU admission, vasopressor use, mechanical ventilation, and renal failure (all with p<0.01). In multivariate analysis, immunosuppression was an independent risk factor for bIC (OR 39.4, 95% CI 7.5-205).  Death attributable to IC occurred in bIC group (n=3, p=0.04).   Conclusion: bIC in our cohort was caused most frequently by non-albicans Candida spp and associated with significantly worse outcomes, including mortality.  
    Variable (N, %) CONTROLS (N = 69) bIC (N = 23) p-value
    Age, in years; median [range] 3 [4d-32y] 2 [11d-28y] 0.78
    Male 33 (47) 16 (11) 0.09
    Indwelling catheter    
    Central venous 35 (51) 14 (61) 0.03
    Peripherally inserted central 27 (39) 14 (61) 0.09
    Neutropenia (ANC < 500) 4 (6) 5 (22) 0.04
    Corticosteroidsa 6 (9) 19 (83) <0.01
    Chemotherapy 7 (10) 8 (35) 0.01
    TPN 41 (59) 17 (74) 0.32
    Antibiotics 37 (53) 18 (78) 0.03
    Days prior to IC 4 [1-109] 12 [1-56] 0.02
    Clinical diagnosis      
    Primary siteb + Candidemia 1 (1) 4 (17)  
    Isolated candidemia + catheter 48 (70) 13 (57)  
    Isolated candidemia NO catheter 6 (9) 0  
    CNS 4 (6) 0  
    Peritoneal 8 (11) 2 (9)  
    Osteomyelitis 2 (3) 0  
    Disseminated 0 4 (17)  
    Days of IC 2 [1-8] 2 [1-61] 0.25
    a Total dose >20 mg/d or >2 mg/kg/d of prednisone equivalent for ≥2 weeks preceding IC b Pneumonia (n=3), endocarditis (n=1), esophagitis (n=1)  
    Sara Dong, MD, Department of Pediatrics, The Ohio State University & Nationwide Children's Hospital, Columbus, OH, Stella Antonara, PhD, Department of Pathology & Microbiology, Nationwide Children's Hospital, Columbus, OH, Joseph Stanek, MS, Division of Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH and Monica I. Ardura, DO, MSCS, Pediatrics, Infectious Diseases and Immunology, Host Defense Program, The Ohio State University and Nationwide Children’s Hospital, Columbus, OH

    Disclosures:

    S. Dong, None

    S. Antonara, None

    J. Stanek, None

    M. I. Ardura, None

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