When to suspect fungal infection in neonates: A clinical comparison of Candida albicans and Candida parapsilosis fungemia with coagulase-negative staphylococcal bacteremia

Objectives. To determine the epidemiology of candidemia in our neonatal int ensive care unit; to compare risk factors, clinical presentation, and outco mes for neonates infected with Candida albicans, Candida parapsilosis, and coagulase-negative staphylococcus (CoNS); and to suggest a rational approac h to empiric antifungal therapy of neonates at risk for nosocomial infectio n. Design. Retrospective chart review of all neonatal intensive care unit pati ents with systemic candidiasis or CoNS infection between January 1, 1995 an d July 31, 1998 at Duke University Medical Center. Results. Fifty-one patients were reviewed. Nine of 19 patients infected wit h C parapsilosis and 5 of 15 patients infected with C albicans died of fung emia. Seventeen neonates had >2 positive cultures for CoNS obtained within 96 hours and 1 died. There was no statistically significant difference in b irth weight, gestational age, or age at diagnosis between patient groups; h owever, candidemic patients had a sevenfold higher mortality rate. Before d iagnosis, candidemic patients had greater exposure to systemic steroids, an tibiotics, and catecholamine infusions. Of the 51 patients, 32 received thi rd-generation cephalosporins in the 2 weeks before diagnosis and 19 did not . Twenty-nine of the 32 who were treated with third-generation cephalospori ns subsequently developed candidemia, while candidemia occurred in only 5 o f 19 patients who were not treated with cephalosporins. At the time of diag nosis, candidemic patients were more likely to have required mechanical ven tilation and were less likely to be tolerating enteral feeding. Multivariat e clustered logistic regression analysis revealed that candidemic patients had more exposure to third-generation cephalosporins. Once the clinician wa s notified of a positive blood culture for Candida, patients infected with C parapsilosis retained their central catheters longer than patients infect ed with C albicans. Conclusions. In this retrospective review, we were able to identify aspects of the clinical presentation and medication history that may be helpful in differentiating between candidemia and CoNS bacteremia. Those key features may be used by clinicians to initiate empiric amphotericin B therapy in pr emature neonates at risk for nosocomial infections. Prolonged use of third- generation cephalosporins was strongly associated with candidemia. There wa s no statistically significant difference in the morbidity and mortality be tween patients infected with C parapsilosis and those infected with C albic ans. Observed delays in removal of the central venous catheter may have con tributed to finding a mortality rate from C parapsilosis that was higher th an was previously reported.