Medikal yoğun bakım ünitesinde kandidemi ile ilişkili prognostik faktörlerin değerlendirilmesi

Amaç: Candida türleri ile enfeksiyonlar, yoğun bakım ünitelerinde (YBÜ) önemli bir morbidite ve mortalite nedenidir. YBÜ hastalarında kandidemi ile ilişkili prognostik faktörlerle ilgili çalışmalar sınırlı sayıdadır ve ayrıca ülkemizde YBÜ'lerde kandidemi ile ilgili yeterli klinik çalışma bulunmamaktadır. Bu çalışmanın amacı, medikal bir YBÜ'ye kabul edilen yetişkin hastalarda kandideminin epidemiyolojisi ve prognostik faktörlerini değerlendirmektir. Yöntemler: Bu çalışma retrospektif kohort bir çalışmadır. 2016 Ekim-2019 Mart tarihleri arasında 16 yataklı yoğun bakım ünitemizde 48 saatten fazla takip edilen 693 hasta retrospektif olarak değerlendirildi ve 60 kandidemili hasta çalışmaya dahil edildi. Hastalar YBÜ mortalitesine göre (sağ kalan ve ölen) iki gruba ayrıldı ve Candida enfeksiyon risk faktörleri arasından olası prognostik faktörleri belirlemek için karşılaştırıldı. Bulgular: Toplam kandidemi insidansı 46 hasta/1000 başvuru olarak bulundu. En sık görülen mantar izolatı Candida albicans'tı (%57,5). Hastaların 30 günlük mortalitesi %71,7 ve YBÜ mortalitesi %78,3 olarak bulundu. Yaş, cinsiyet, eşlik eden hastalıklar, SOFA ve APACHE II skorları, Glasgow koma skoru, immünsüpresif tedaviler (steroid veya kemoterapi), septik şok, nötropeni, akut karaciğer veya böbrek yetmezliği, vazopresör ihtiyacı, hemodiyaliz, eritrosit transfüzyonu ve total parenteral beslenme bakımından gruplar arasında fark yoktu. Antifungal tedaviye başlama zamanı ile mortalite arasında ilişki bulunamadı (P=0.268). Sağ kalanlar YBÜ öncesinde daha kısa YBÜ yatış ve hastanede kalış süresine sahipti ve hayatta kalmayanlara göre Charlson Komorbidite İndeksi puanları daha düşüktü (sırasıyla P=0,039, P=0,008, P=0,02). Kandidemi hastalarının YBÜ mortalitesi için prognostik faktörler olarak YBÜ öncesi hastanede kalış süresi, invazif mekanik ventilasyon ihtiyacı ve hipoalbüminemi saptandı (sırasıyla P=0,034, P=0,013, P=0,029). Sonuç: Kandidemili kritik hastalarda en yüksek kandidemi insidans oranını ve en yüksek ölüm oranlarından birini bildirdik. Daha önceki raporların çoğunu doğrular şekilde çalışmamızda en sık Candida albicans (%57,5) izolatı saptandı. YBÜ hastalarında kandidemi için prognostik bir gösterge olarak invaziv kandidiyaz için bildirilen risk faktörlerini değerlendirdik. Bunlardan hastanede kalış süresi, invazif mekanik ventilasyon ve hipoalbüminemi prognostik birer gösterge olarak bulundu.

Anahtar Kelimeler:

Kandidemi, mortalite, yoğun bakım, prognostik faktörler

Evaluation of the prognostic factors for candidemia in a medical intensive care unit

Aim: Infections with Candida species are an important cause of morbidity and mortality in intensive care units (ICUs). The studies about the prognostic factors related with candidemia in ICU patients are limited and lacking in our country. The aim of this study is to evaluate the epidemiology and prognostic factors for candidemia in adult patients admitted to a medical ICU. Methods: This is a retrospective cohort study. A total of 693 patients who were followed for more than 48 hours in our 16-bedded medical ICU between 2016 October-2019 March were evaluated retrospectively and 60 candidemia patients were included in the study. The patients were divided into two groups according to ICU mortality (survivor vs. non-survivor) and compared to determine possible prognostic factors among Candida infection risk factors. Results: The total incidence of candidemia was 46 per 1000 admissions. The most common fungal isolate was Candida albicans (57.5%). The 30-day mortality was 71.7% and ICU-mortality was 78.3%. There was no difference for age, gender, co-morbid diseases, SOFA and APACHE II scores, Glasgow Coma Score, immunosuppressive treatments (steroid or chemotherapy), septic shock, neutropenia, acute hepatic or renal failure, need for vasopressors, hemodialysis, erythrocyte transfusion and total parenteral nutrition between groups. No relationship was found between the time of initiation of antifungal therapy and mortality (P=0.268). Survivors had shorter ICU stay and hospital stay before ICU, and lower Charlson Comorbidity Index scores than non-survivors (P=0.039, P=0.008, P=0.02, respectively). Length of hospital stay before ICU, need for invasive mechanical ventilation and hypoalbuminemia were the prognostic factors for ICU mortality of candidemia patients (P=0.034, P=0.013, P=0.029, respectively). Conclusion: We reported the highest incidence rate of candidemia and one of the highest mortality rates in critically ill patients with candidemia. Confirming to most of the previous reports, Candida albicans (57.5%) was the most common isolate in our study. We evaluated reported risk factors for invasive candidiasis as a prognostic indicator for candidemia in ICU patients, and found that the length of hospital stay, invasive mechanical ventilation and hypoalbuminemia were prognostic indicators.

Keywords:

Candidemia, mortality, critical care, prognostic factors,

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