A study on clinical profile of invasive fungal infection in neutropenic children in a tertiary care teaching hospital
Keywords:Children, Neutropenia, Invasive fungal infection
Background: Febrile neutropenia is a common complication of anti-cancer chemotherapy. Invasive fungal infections are found mostly after prolonged neutropenia. Early diagnosis and treatment of these infections are of crucial importance. Hence, there is a need to identify the common causative organisms of fungal sepsis in children and our primary objective was to diagnose invasive fungal infections in children of febrile neutropenia and identify the common fungal etiological agents with clinical profile.
Methods: This study was done as observational, cross-sectional study for 18 months at the department of microbiology, Lady Hardinge Medical College and department of pediatrics, Kalawati Saran Children’s Hospital. All children less than 18 years of age clinically suspected to have invasive fungal infection with absolute neutrophil count <500 /ml, with fever not responding to antibiotics for more than 3-4 days were included in the study.
Results: Hospitalization ≥7 days (100%) was the most common associated risk factor, followed by neutropenia (100%), immunodeficiency (100%), cytotoxic drugs (87.27%) and malignancies (87.27%). Other less commonly associated risk factors were hyperalimentation (23.64%), residence near a construction site (23.64%), presence of urinary catheters (10.91%) and HIV positivity (9.09%). Around 54.54% of sputum samples were positive for fungal culture. A lower positivity was seen in blood culture (14.54%).
Conclusions: Candida spp., Aspergillus spp. and Pneumocystis remain the primary fungal pathogens in this patient population. Early clinical suspicion followed by prompt sampling and evaluation for fungal infections may aid in timely diagnosis and reduction of mortality of these patients.
Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of America. Clin Infect Dis. 2011;52(4):e56-93.
Freifeld AG, Bow EJ, Sepkowitz KA. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52(4):e56-93.
Creutzig U, Zimmermann M, Reinhardt D, Dworzak M, Stary J, Lehrnbecher T. Early deaths and treatment-related mortality in children undergoing therapy for acute myeloid leukemia: analysis of the multicenter clinical trials AML-BFM 93 and AML-BFM 98. J Clin Oncol. 2004;22(21):4384-93.
Basu SK, Fernandez ID, Fisher SG, Asselin BL, Lyman GH. Length of stay and mortality associated with febrile neutropenia among children with cancer. J Clin Oncol. 2005;23(31):7958-66.
Hakim H, Flynn PM, Knapp KM, Srivastava DK, Gaur AH. Etiology and clinical course of febrile neutropenia in children with cancer. J Pediatr Hematol Oncol. 2009;31(9):623-9.
Hoenigl M, Strenger V, Buzina W, Valentin T, Koidl C, Wölfler A, et al. European organization for the research and treatment of cancer/mycoses study group (EORTC/MSG) host factors and invasive fungal infections in patients with haematological malignancies. J Antimicrob Chemother. 2012;67(8): 2029-33.
Giusiano G, Mangiaterra M, Saito VG, Rojas F, Gómez V, Díaz MC. Etiology of fungaemia and catheter colonisation in Argentinean paediatric patients. Mycoses. 2006;49(1):49-54.
Özdemir N, Tüysüz G, Çelik N, Yantri L, Erginöz E, Apak H, et al. Febrile neutropenia in children with acute lymphoblastic leukemia: single center experience. Turk Arch Pediatr Arş. 2016;51(2):79-86
Prasad M, Chinnaswamy G, Arora B, Vora T, Hawaldar R, Banavali S. Risk predictors for adverse outcome in pediatric febrile neutropenia: Single center experience from a low and middle-income country. Indian J Cancer. 2014;51(4):432-7.
Bakhshi S, Padmanjali KS, Arya LS. Infections in childhood acute lymphoblastic leukemia: an analysis of 222 febrile neutropenic episodes. Pediatr Hematol Oncol. 2008;25(5):385-92.
Jain V, Dubey AP, Gupta SK. Nutritional parameters in children with malignancy. Indian Pediatr. 2003;40: 976-84.
Kumar R, Marwaha RK, Bhalla AK, Gulati M. Protein energey malnutrition and skeletal muscle wasting in childhood acute lymphoblastic lukemia. Indian Pediatr. 2000;37(7):720-6.
Juyal D, Sharma M, Pal S, Rathaur VK, Sharma N. Emergence of non-albicans Candida species in neonatal candidemia. North Am J Med Sci. 2013;5(9): 541-5.
Nucci M, Barreiros G, Guimarães LF, Deriquehem VAS, Castiñeiras AC, Nouér SA. Increased incidence of candidemia in a tertiary care hospital with the COVID-19 pandemic. Mycoses. 2021;64(2):152-6.
Becerra MR, Tantaleán JA, Suárez VJ, Alvarado MC, Candela JL, Urcia FC. Epidemiologic surveillance of nosocomial infections in a pediatric intensive care unit of a developing country. BMC Pediatr. 2010;10: 66.
Blyth CC, Chen SC, Slavin MA, Serena C, Nguyen Q, Marriott D, et al. Not just little adults: candidemia epidemiology, molecular characterization, and antifungal susceptibility in neonatal and pediatric patients. Pediatrics. 2009;123(5):1360-8.
Feja KN, Wu F, Roberts K, Loughrey M, Nesin M, Larson E, et al. Risk factors for candidemia in critically ill infants. J Pediatr. 2005;147(2):156-61.
Tüfekçi Ö, Yılmaz Bengoa Ş, Demir Yenigürbüz F, Şimşek E, Karapınar TH, İrken G, et al. Management of invasive fungal infections in pediatric acute leukemia and the appropriate time for restarting chemotherapy. Turk J Hematol. 2015;32(4):329-37.
Lin GL, Chang HH, Lu CY. Clinical characteristics and outcome of invasive fungal infections in pediatric acute myeloid leukemia patients in a medical center in Taiwan. J Microbiol Immunol Infect. 2016;51(2):251-9.
Gülhan B, Kanik-Yuksek S, Ozkaya PA, Yarali N, Tezer H, Özbek N. Invasive fungal infection in children with hematologic malignancy. Turk J Pediatr. 2019;61:159.
Awasthi AK, Jain A, Awasthi S, Ambast A, Singh K, Mishra V. Epidemiology and microbiology of nosocomial pediatric candidemia at a northern Indian tertiary care hospital. Mycopathologia. 2011;172(4): 269-77.
Wang R, Chen Y, Wu J, Wang X, Cao Y, Zhao H, et al. Cryptococcosis in patients with hematological diseases: a 14-year retrospective clinical analysis in a Chinese tertiary hospital. BMC Infect Dis. 2017; 17(1):463.