Emergence of Invasive Fungal Infections (IFI) as Healthcare-Associated Infections (HAI) in Hospitalized Neonates

Background: Emergence of HAI due to multi-drug resistant organisms (MDROs) has led to an increased usage of broad spectrum antimicrobials & has led to silent increase in IFI. Candida species are presently the fourth leading cause of HAI in the U.S. The role of IFI in HAI occurring in children in India has not been well established.

Objective: (1) To determine occurrence of IFI in neonates. (2) To study the epidemiological & microbiological profile of these infections. (3) Antifungal susceptibility patterns of invasive yeast isolates.

Methods: Cohort study was performed in a Level III outborn neonatal ICU from Jan to Oct 2009. All infants admitted to NICU had sepsis work up performed. In infants on artificial ventilation, tracheal aspirates were sent within 12 hours of intubation. Repeat blood cultures (BC), respiratory & urinary cultures were sent when clinically indicated. Bactec system was used for BC. Fungal isolates were identified by Vitek2 compact system along with slide cultures. Antifungal susceptibility testing was done for fluconazole, voriconazole, amphotericin B & flucytosine using Vitek2 compact system. All positive cultures were traced back & were recorded on HAI assessment sheet. To look for clinical Ventilator Associated Pneumonia (VAP), VAP score sheets were also employed for each patient.

Results: During the 10 month study period 486 neonates were admitted & 40 (9%) had IFI. Mean age of the infants with fungal HAI was 13 days (range 0 days to 28 days). Among the babies with IFI (n= 40) 53% of the babies were full term. Among fungal isolates, C. tropicalis (12 cases; 30%) was most common followed by C. glabrata (8 cases; 20%) & C. albicans (6 cases; 15%). In two cases yeast could not be identified. Among these 40 cases of IFI, 17 cases were attributed to HAI at our hospital while rest from referred hospitals. Antifungal susceptibility results revealed most of the isolates were susceptible to all the antifungal agents tested except C. krusei (resistant [R] to amphotericin B, fluconazole & flucytosine), & one C. albicans R to flucytosine. When compared total HAIs in NICU (n=59) 28% of the episodes were due to fungal & rest were due to bacteria. Attributable mortality in patients with invasive fungal disease was 20%, while 4 cases are still undergoing treatment at the hospital. Average length of stay for these babies was 26.6 days. Common complications among these neonates included cholestasis (8 cases), endocarditis (2 cases) & renal fungal balls (2 cases). None of the babies developed endophthalmitis.

Conclusions: Occurrence of IFI among term neonates is increasing. Usage of broad spectrum antimicrobials has been challenge to the neonatologists as it leads to emergence of MDROs at one end, &, increase risk of IFI on other end. Initiation of antimicrobial stewardship program can minimize risk of acquiring HAI due to fungal pathogens in hospitalized infants.