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Características Clínico-Epidemiológicas y Taxonómicas de las Candidiasis Sistémicas en una Unidad de Cuidados Intensivos

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Author(s): Begoña Hernández Sierra | Miguel Ángel Prieto Palomino | Javier Muñoz Bono | Emilio Curiel Balsera | Juan Mora Ordóñez | Lola Arias Verdú

Journal: Medicrit : Revista de Medicina Crítica
ISSN 1690-8686

Volume: 5;
Issue: 1;
Date: 2008;
Original page

Keywords: candidiasis sistémica | candida albicans | candida no albicans | candida parapsilosis | candida ssp | score de sevilla | mortalidad | candida non-albicans | sevilla score | mortality

ABSTRACT
Objetivos. Definir el perfil clínico de los pacientes con candidiasis sistémica ingresados en nuestra UCI, así como las características microbiológicas del agente causal. Realizar un análisis de mortalidad, incluyendo la aplicación del Score de Sevilla. Métodos. Diseño: Serie de casos registrados en estudio retrospectivo durante los años 2002-2004 y prospectivo durante el 2005-2006. Ambito: UCI médico-quirúrgica de un hospital de tercer nivel. Pacientes y métodos: Se incluyeron los 26 pacientes diagnosticados de candidiasis sistémica por hemocultivos positivos para Candida sp., analizando motivo de ingreso en la Unidad, factores de riesgo asociados, estancia, tipo de Candida y mortalidad, entre otras variables. Resultados. 26 casos de candidiasis diseminadas (75% hombres), estancia superior a 14 días en la UCI, APACHE II medio de 22.6. El principal motivo de ingreso fue la sepsis, seguido de politraumatismo. Los factores de riesgo asociados fueron la diabetes mellitus y neoplasias. A todos se les canalizó un catéter venoso central, recibieron antibioticoterapia previo al diagnóstico un 92%, multinstrumentación un 88%, tratamiento esteroideo previo un 7.7%, nutrición parenteral un 66%. Se aisló C. albicans en un 53.8% y C. no albicans en un 46,2% (C. parapsilosis, 34.6%). Hubo un aumento en la incidencia de infecciones fúngicas en los últimos años, con mayor incidencia (p < 0.02) de C. no albicans frente a C. albicans desde el año 2004 con respecto a los previos y casi mayor incidencia significativa de C. no albicans en pacientes con nutrición parenteral (p < 0.07). Las infecciones por C. albicans predominaron en pacientes sépticos, y las de C. no albicans en politraumatizados. La mortalidad fue del 42%, más elevada en infecciones por C. albicans. Se constató incremento de mortalidad (p < 0.026) en los grupos progresivos de riesgo determinados en el "Score de Sevilla". Conclusiones. 1) La candidiasis en nuestra UCI afecta a hombres que ingresan por sepsis o politraumatismo, con APACHE II elevado, multiinstrumentación, estancia superior a dos semanas y frecuente desarrollo de fracaso multiorgánico. La C. no albicans predominó en politraumatizados y la C. albicans en los sépticos. 2) Aumentó la incidencia de candidemia en los últimos años, a expensas de C. no albicans, especialmente C. parapsilosis. 3) Se registró una mortalidad elevada, sobre todo en infección por C. albicans. El score de Sevilla definió la mortalidad en los grupos progresivos de riesgo. Palabras Clave: Candidiasis sistémica; Candida albicans; C. no albicans; Candida parapsilosis; Candida sp; Score de Sevilla; mortalidad. .......................... Clinical, Epidemiological and Taxonomic Aspects of Systemic Candidiasis in an Intensive Care Unit ABSTRACT Objectives. To define the clinical and epidemiological profile of patients admitted into our intensive care unit (ICU), together with the microbiological characteristics of the pathogen. Perform a survival analysis, including the application of the Sevilla score system. Methods. Design: Retrospective-prospective case series from 2002 to 2004 and 2005 to 2006, respectively. Location: Clinical and surgical ICU in a third level University Hospital. Patients and methods: 26 patients were diagnosed with systemic candidiasis, with positive haemoculture of Candida sp. Analysis was done on reason for admission to the unit, associated risk factors, value of APACHE II, length of stay in the ICU and mortality rate among other clinical data. The type of diagnosed Candida, its sensitivity profile, and the existence of previous wide spectrum antibiotic therapy or antifungal therapy were determined. The Sevilla risk score was applied and correlated to observed mortality. Results. Twenty-six cases with disseminated candidiasis were included in the study (75% of the cases were male, mean APACHE II was 22.6 points) whose permanence in the ICU were longer than 14 days. The first motive to enter ICU was sepsis, after which came trauma, which accompanied four organ failure. The associated risk factors were diabetes and neoplasia. Along their stay in the ICU at least one central venous catheter was inserted, 92% of patients had received previously wide spectrum antibiotics before diagnosis, 88% of them underwent multiple instrumentation. Two thirds of all were under parenteral nutrition therapy. Only 7.7% received steroids previously. Haemoculture isolated Candida albicans in 53.8% of cases against 46.2% of other Candida, with a special high incidence of C. parapsilosis (34.6%). Along the last years we observed a progressive higher incidence of systemic candidiasis which was significant looking from 2004 retrospectively (p < 0.02). The higher incidence of C. non albicans in those patients under parenteral nutrition therapy approached statistical significancy (p < 0.07). The infection by C. albicans were registered specially in patients with sepsis, while C. non albicans infected more trauma patients. We registered a specially high mortality rate (42%), though it had no statistical significancy, in patients infected with Candida albicans. Sevilla Score defined the mortality in the progressive risk groups (p < 0.026). Conclusions. Candidiasis affects men who were admitted in our ICU with sepsis or trauma, with a high APACHE II score, who underwent multiple vascular or drainage intervenetions, with a more than two weeks intensive care unit stay and who developed multiple organ failure. Candida non albicans predominated in trauma patients with parenteral nutrition therapy, while Candida albicans overruled those patients with septicaemia. 2) Along the last years we observed a progressive incidence of non albicans candidiasis, preferently Candida parapsilosis. 3) The high mortality in the group of candidiasis was more evident for those infected with Candida albicans. Sevilla Score defined the mortality in risk groups. Key words: Systemic candidiasis; Candida albicans; non-albicans Candida; Candida parapsilosis; Candida sp; Sevilla Score; mortality.
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