Candidemia is defined as the isolation of Candida species from at least one blood culture with the presence of symptoms of sepsis. It is the main cause of fungal nosocomial bloodstream infections with its resultant mortality in children ranging from 5% to 71% and sometimes over 80%. A thorough search of the literature in Google, PubMed, Med Facts, using different sets of keywords, viz. candidemia, bloodstream Candida infections, neonates, children, and developing countries showed that candidemia in neonates and children is caused by a variety of species, viz. Candida albicans, C. auris, C. famata, C. glabrata, C. guilliermondii, C. krusei, C. ortholopsis, C. parapsilosis, and C. tropicalis. The predominant etiological agents vary in different countries. Risk factors in most of the reports included prematurity, mechanical ventilation, prolonged use of antibiotic and steroid urinary catheter, hH 2 blockers, neutropenia, leukemia, and malnourishment. The underlying diseases included sepsis, pyogenic meningitis, encephalitis, pneumonia, acute reparatory distress syndrome, chronic liver disease, and kidney disease, etc. A noteworthy observation in the literature is that several investigators employed MALD-TOFE, PCR, and molecular methods including DNA sequencing in addition to the study of phenotypic features for the characterization of Candida species. Antifungal therapy in most studies used liposomal amphotericin B, caspofungin, azoles, or combination therapies The epidemiology of pediatric candidemia varies in different countries. Surveillance of candidaemia in different regions is necessary, especially in neonates and children. Rapid and precise detection of Candida species isolated from the bloodstream by polymerase chain reaction, restriction fragment length polymorphism technique can help in better management of candidemia. The strategies for the prevention of candidemia include improved hand hygiene, optimal catheter placement and care, and prudent hygiene. Prophylactic antifungal therapy is recommended for patients who have not yet been diagnosed with candidemia but are at a high risk of acquiring Candida infections.
Candida infections account for approximately 70 to 90% of total invasive fungal infections (IFI) (Dela-loye and Calandra, 2014). Global estimates indicated that ~ 750,000 cases of invasive candidiaisis occur annually (Bongomin et al., 2017). Candidemia (blood -stream infection due to Candida spp. is the most common clinical presentation of IC and occurs mainly in hospitalized patients with ascribable mor-tality of 15–35% for adults and 10–15% for neonates (Guinea, 2014). In an update on the epidemiology of invasive fungal infections in the Middle East and North African region, (Osman et al., 2009) have dealt with neonatal and pediatric candidemia in these regions. Candidemia caused by uncommon Candida spp with prolonged fungemia and treatment failures is now emerging among hospitalized children (Tsai et al., 2018).
The risk factors for Candida infection include pre-maturity, low birth weight, invasive interventions, prolonged use of antimicrobials, H2 blockers, ste-roids, prior colonization, total parenteral nutrition, preexisting infection, prolonged use of broad-spect-rum antibiotics, immune compromised status, recent surgery, central line dialysis, mechanical ventilation and extended length of stay in the NICU (Bongomin et al., 2017).
DNA-based methods are considered the gold stan-dard for the identification of fungal isolates, but clinical laboratories in resource-constrained countries have limited access to expensive molecular tech-niques. The definitive diagnosis still is based upon the identification of Candida in the blood.
The brief demographic and clinical features including laboratory investigations and treatment described in the reports from different countries are described below in Table 1. It is noteworthy from the reports that investigators from India (Rudhramurhty et al., 2020) used Sanger sequencing targeting internal tran-scribed spacer (ITS) region of ribosomal DNA, and the ones from Iran (Fattahi et al., 2000) employed PCR-RFLP amplification of ITS1-5.8SrDNA-ITS2 region with pun fungal primers ITS1-ITS4 region in addition to phenotypic study of the isolates on rou-tine mycological media and CHRO Magar.
Table 1: Demographic and brief clinical features of cases of pediatric candidemia in different countries
It is noteworthy from the reports that investigators from India (Rudhramurhty et al., 2020) used Sanger sequencing targeting internal transcribed spacer (ITS) region of ribosomal DNA, and the ones from Iran (Fattahi et al., 2000) employed PCR-RFLP amplification of ITS1-5. 8SrDNA-ITS2 region with pun fungal primers ITS1-ITS4 region in addition to phenotypic study of the isolates on routine myco-logical media and CHRO Magar.
Abbreviations
NUPE- Neonatal unit of paediatric emergency, HCW -Health care workers, FAFLP-Fluorescent amplified fragment length polymorphism, ITS- Internal Trans-cribed spaces, ECV-Epidemiological cut off value, MIC-Minimum inhibitory concentration, CLSI-Clini-cal laboratory standards institute, EC-Echinocandins, MF-Micafungin, BA-Blood agar, CHD-Congenital heart disease, and BSAT-Broad-spectrum antibiotic therapy
Given the high mortality rate and the difficulties en-countered in administering early and effective anti-fungal therapy, better methods of prevention will decrease candidemia-associated mortality more effec- tively than will advances in therapy. The strategies for prevention of candidemia include improved hand hygiene, optimal catheter placement and care, and prudent hygiene Guinea, (2014). For hand washing, both alcohol nosocomial candidemia Guinea, (2014). For hand washing, both alcohol Candida species on the hands of health care workers. The role of pro-phylactic or empirical therapy in preventing candied-mia or decreasing mortality rate associated with it is not clear. Because of the high mortality associated with the more delayed therapy in candidemia espe-cially in neutropenic patients, empirical therapy with anti-fungal drugs is usually advocated for such patients. Prophylactic antifungal therapy is recom-mended for patients and those who do not have the suggestive symptoms but are at a high risk of acqui-ring Candida infections. The regional surveillance of the pediatric patients at highest risk and the pattern of causative agents of candidemia in order to develop guidelines for better management of this fatal infec-tion are emphasized.
The author is grateful to Prof. Oliver Conley and Jack Meis, Editors of the Journal Mycoses for sen-ding me the PDFs of some articles needed for com-pleting and improving the manuscript.
The author has no conflict of interest with any indivi-dual or organization.
Academic Editor
Md. Ekhlas Uddin Dipu, Department of Biochemistry and Molecular Biology Gono Bishwabidalay, Dhaka, Bangladesh.
Professor, Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi-110007, India
Gugnani HC. (2022). Pediatric candidemia in the Indian subcontinent, and in parts of the Middle East, Africa, and South America, Eur. J. Med. Health Sci., 4(4), 138-144. https://doi.org/10.34104/ejmhs.022.01380144
