Candidemia in pediatric burn patients: Risk factors and outcomes in a retrospective cohort study

Document Type : Original Articles


1 Department of Pediatrics, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran

2 Department of Plastic Surgery, Burn Research Center, Motahari Hospital, Iran University of Medical Sciences, Tehran, Iran

3 Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran



Background and Purpose: Despite advances in burn care and management, infections are still a major contributor to morbidity and mortality rates in patients with burn injuries. Regarding this, the present study was conducted to investigate the prevalence and importance of candidemia in pediatric burn patients.
Materials and Methods: Blood samples were collected from the patients and cultured in an automated blood culture system. Candida species were identified using specific culture media. The relationship between candidemia and possible risk factors was evaluated and compared to a control group.
Results: A total of 71 patients with the mean age of 4.52±3.63 years were included in the study. Blood cultures showed candidemia in 19 (27%) patients. Based on the results, C. albicans was the most common fungus among patients with and without candidemia. The results of statistical analysis also showed that candidemia was significantly correlated with total body surface area (TBSA), mechanical ventilation, duration of total parenteral nutrition, length of intensive care unit (ICU) stay, presence of neutropenia, and R-Baux score (all P≤0.001). In this regard, TBSA, length of ICU stay, R-Baux score, and Candida score were identified as the determinant factors for mortality due to candidemia.
Conclusion: Candidemia increases the mortality and morbidity rates associated with burn injuries. Prompt diagnostic and prevention measures can reduce the unfortunate outcomes via controlling the possible risk factors.


1. Nunez Lopez O, Cambiaso-Daniel J, Branski LK, Norbury WB, Herndon DN. Predicting and managing sepsis in burn patients: current perspectives. Ther Clin Risk Manag. 2017; 13:1107-17.
2. Zampar EF, Anami EH, Kerbauy G, Queiroz LF, Carrilho CM, Cardoso LT, et al. Infectious complications in adult burn patients and antimicrobialresistance pattern of microorganisms isolated. Ann Burns Fire Disasters. 2017; 30(4):281-5.
3. Sobouti B, Khosravi N, Daneshvar A, Fallah S, Moradi M, Ghavami Y. Prevalence of beta lactamase producing species of pseudomonas and acinetobacter in pediatric burn patients. Ann Burns Fire Disasters. 2015; 28(3):171-7.
4. Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn wound infections. Clin Microbiol Rev. 2006; 19(2):403-34.
5. Cataldi V, Di Campli E, Fazii P, Traini T, Cellini L, Di Giulio M. Candida species isolated from different body sites and their antifungal susceptibility pattern: cross-analysis of Candida albicans and Candida glabrata biofilms. Med Mycol. 2017; 55(6):624-34.
6. Moran C, Grussemeyer CA, Spalding JR, Benjamin DK Jr, Reed SD. Candida albicans and non-albicans bloodstream infections in adult and pediatric patients: comparison of mortality and costs. Pediatr Infect Dis J. 2009; 28(5):433-5.
7. Tortorano AM, Dho G, Prigitano A, Breda G, Grancini A, Emmi V, et al. Invasive fungal infections in the intensive care unit: a multicentre, prospective, observational study in Italy (2006-2008). Mycoses. 2012; 55(1):73-9.
8. Zaoutis TE, Argon J, Chu J, Berlin JA, Walsh TJ, Feudtner C. The epidemiology and attributable outcomes of candidemia in adults and children hospitalized in the United States: a propensity analysis. Clin Infect Dis. 2005; 41(9):1232-9.
9. Luo G, Peng Y, Yuan Z, Cheng W, Wu J, Fitzgerald M. Yeast from burn patients at a major burn centre of China. Burns. 2011; 37(2):299-303.
10. Cochran A, Morris SE, Edelman LS, Saffle JR. Systemic Candida infection in burn patients: a case-control study of management patterns and outcomes. Surg Infect (Larchmt). 2002; 3(4):367-74.
11. Murray CK, Loo FL, Hospenthal DR, Cancio LC, Jones JA, Kim SH, et al. Incidence of systemic fungal infection and related mortality following severe burns. Burns. 2008; 34(8):1108-12.
12. Ballard J, Edelman L, Saffle J, Sheridan R, Kagan R, Bracco D, et al. Positive fungal cultures in burn patients: a multicenter review. J Burn Care Res. 2008; 29(1):213-21.
13. Moore EC, Padiglione AA, Wasiak J, Paul E, Cleland H. Candida in burns: risk factors and outcomes. J Burn Care Res. 2010; 31(2):257-63.
14. Fochtmann A, Forstner C, Hagmann M, Keck M, Muschitz G, Presterl E, et al. Predisposing factors for candidemia in patients with major burns. Burns. 2015; 41(2):326-32.
15. Sobouti B, Riahi A, Fallah S, Ebrahimi M, ShafieeSabet A, Ghavami Y. Serum 25-hydroxyvitamin D levels in pediatric burn patients. Trauma Mon. 2016; 21(1):e30905.
16. Benedict K, Jackson BR, Chiller T, Beer KD. Estimation of direct healthcare costs of fungal diseases in the United States. Clin Infect Dis. 2019; 68(11):1791-7.
17. Rentz AM, Halpern MT, Bowden R. The impact of candidemia on length of hospital stay, outcome, and overall cost of illness. Clin Infect Dis. 1998; 27(4):781-8.
18. Struck MF, Gille J. Fungal infections in burns: a comprehensive review. Ann Burns Fire Disasters. 2013; 26(3):147-53.
19. Horvath EE, Murray CK, Vaughan GM, Chung KK, Hospenthal DR, Wade CE, et al. Fungal wound infection (not colonization) is independently associated with mortality in burn patients. Ann Surg. 2007; 245(6):978-85.
20. Brusselaers N, Monstrey S, Snoeij T, Vandijck D, Lizy C, Hoste E, et al. Morbidity and mortality ofbloodstream infections in patients with severe burn injury. Am J Crit Care. 2010; 19(6):e81-7.
21. Sheridan RL, Weber JM, Budkevich LG, Tompkins RG. Candidemia in the pediatric patient with burns. J Burn Care Rehabil. 1995; 16(4):440-3.
22. Gupta N, Haque A, Lattif AA, Narayan RP, Mukhopadhyay G, Prasad R. Epidemiology and molecular typing of Candida isolates from burn patients. Mycopathologia. 2004; 158(4): 397-405.
23. Ekenna O, Sherertz RJ, Bingham H. Natural history of bloodstream infections in a burn patient population: the importance of candidemia. Am J Infect Control? 1993; 21(4):189-95.
24. Santucci SG, Gobara S, Santos CR, Fontana C, Levin AS. Infections in a burn intensive care unit: experience of seven years. J Hosp Infect. 2003; 53(1):6-13.
25. Still JM Jr, Belcher K, Law EJ. Management of candida septicaemia in a regional burn unit. Burns. 1995; 21(8):594-6.
26. Zorgani A, Franka RA, Zaidi MM, Alshweref UM, Elgmati M. Trends in nosocomial bloodstream infections in a burn intensive care unit: an eight-year survey. Ann Burns Fire Disasters. 2010; 23(2):88-94.
27. Renau Escrig AI, Salavert M, Vivó C, Cantón E, Pérez Del Caz MD, Pemán J. Candidemia in major burns patients. Mycoses. 2016; 59(6):391-8.
28. Lotfi N, Shokohi T, Nouranibaladezaei SZ, NasrolahiOmran A, Kondori N. High recovery rate of non-albicans Candida species isolated from burn patients with candidemia in Iran. Jundishapur J Microbiol. 2015; 8(10):e22929.
29. Sarabahi S, Tiwari VK, Arora S, Capoor MR, Pandey A. Changing pattern of fungal infection in burn patients. Burns. 2012; 38(4):520-8.
30. Fidel PL Jr, Vazquez JA, Sobel JD. Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. Clin Microbiol Rev. 1999; 12(1):80-96.
31. Horn DL, Neofytos D, Anaissie EJ, Fishman JA, Steinbach WJ, Olyaei AJ, et al. Epidemiology and outcomes of candidemia in 2019 patients: data from the prospective antifungal therapy alliance registry. Clin Infect Dis. 2009; 48(12):1695-703.
32. Ha JF, Italiano CM, Heath CH, Shih S, Rea S, Wood FM. Candidemia and invasive candidiasis: a review of the literature for the burns surgeon. Burns. 2011; 37(2):181-95.
33. Mora Carpio AL, Climaco A. Fungemia candidiasis. Treasure Island (FL): StatPearls Publishing; 2020.
34. Madhavan P, Jamal F, Chong PP, Ng KP. Identification of local clinical Candida isolates using CHROMagar Candida™ as a primary identification method for various Candida species. Trop Biomed. 2011; 28(2):269-74.
35. Daef E, Moharram A, Eldin SS, Elsherbiny N, Mohammed M. Evaluation of chromogenic media and seminested PCR in the identification of Candida species. Braz J Microbiol. 2014; 45(1):255-62.
36. Song YB, Suh MK, Ha GY, Kim H. Antifungal susceptibility testing with e-test for Candida species isolated from patients with oral candidiasis. Ann Dermatol. 2015; 27(6):715-20.
37. Trouvé C, Blot S, Hayette MP, Jonckheere S, Patteet S, Rodriguez-Villalobos H, et al. Epidemiology and reporting of candidaemia in Belgium: a multi-centre study. Eur J Clin Microbiol Infect Dis. 2017; 36(4):649-55.
38. Zhou J, Tan J, Gong Y, Li N, Luo G. Candidemia in major burn patients and its possible risk factors: a 6-year period retrospective study at a burn ICU. Burns. 2019; 45(5):1164-71.
39. Ramos A, Romero Y, Sánchez-Romero I, Fortún J, Paño JR, Pemán J, et al. Risk factors, clinical presentation and prognosis of mixed candidaemia: a population-based surveillance in Spain. Mycoses. 2016; 59(10):636-43.
40. Al-Rawahi GN, Roscoe DL. Ten-year review of candidemia in a Canadian tertiary care centre: predominance of non-albicans Candida species. Can J Infect Dis Med Microbiol. 2013; 24(3):e65-8.
41. Vinsonneau C, Benyamina M, Baixench MT, Stephanazzi J, Augris C, Grabar S, et al. Effects of candidaemia on outcome of burns. Burns. 2009; 35(4):561-4.
42. Branski LK, Al-Mousawi A, Rivero H, Jeschke MG, Sanford AP, Herndon DN. Emerging infections in burns. Surg Infect (Larchmt). 2009; 10(5):389-97.
43. O'Mara MS, Reed NL, Palmieri TL, Greenhalgh DG. Central venous catheter infections in burn patients with scheduled catheter exchange and replacement. J Surg Res. 2007; 142(2):341-50.
44. Yoshino Y, Wakabayashi Y, Suzuki S, Seo K, Koga I, Kitazawa T, et al. Clinical features of catheter-related candidemia at disease onset. Singapore Med J. 2014; 55(11):579-82.
45. Ramage G, Martínez JP, López-Ribot JL. Candida biofilms on implanted biomaterials: a clinically significant problem. FEMS Yeast Res. 2006; 6(7):979-86.
46. Gastmeier P, Weigt O, Sohr D, Rüden H. Comparison of hospital-acquired infection rates in paediatric burn patients. J Hosp Infect. 2002; 52(3):161-5.
47. Luo G, Tan J, Peng Y, Wu J, Huang Y, Peng D, et al. Guideline for diagnosis, prophylaxis and treatment of invasive fungal infection post burn injury in China 2013. Burns Trauma. 2014; 2(2):45-52.
48. Swindell K, Lattif AA, Chandra J, Mukherjee PK, Ghannoum MA. Parenteral lipid emulsion induces germination of Candida albicans and increases biofilm formation on medical catheter surfaces. J Infect Dis. 2009; 200(3):473-80.
49. Koh AY, Köhler JR, Coggshall KT, Van Rooijen N, Pier GB. Mucosal damage and neutropenia are required for Candida albicans dissemination. PLoS Pathog. 2008; 4(2):e35.
50. Lu G, Huang J, Yu J, Zhu Y, Cai L, Gu Z, et al. Influence of early post-burn enteral nutrition on clinical outcomes of patients with extensive burns. J Clin Biochem Nutr. 2011; 48(3):222-5.
51. Halgas B, Bay C, Foster K. A comparison of injury scoring systems in predicting burn mortality. Ann Burns Fire Disasters. 2018; 31(2):89-93.
52. Smith DL, Cairns BA, Ramadan F, Dalston JS, Fakhry SM, Rutledge R, et al. Effect of inhalation injury, burn size, and age on mortality: a study of 1447 consecutive burn patients. J Trauma. 1994; 37(4):655-9.
53. Jeschke MG, Pinto R, Kraft R, Nathens AB, Finnerty CC, Gamelli RL, et al. Inflammation and the host response to injury collaborative research program. Morbidity and survival probability in burn patients in modern burn care. Crit Care Med. 2015; 43(4):808-15.
54. Taylor SL, Lawless M, Curri T, Sen S, Greenhalgh DG, Palmieri TL. Predicting mortality from burns: the need for age-group specific models. Burns. 2014; 40(6):1106-15.
55. Wolf SE, Rose JK, Desai MH, Mileski JP, Barrow RE, Herndon DN. Mortality determinants in massive pediatric burns. An analysis of 103 children with > or = 80% TBSA burns (> or = 70% full-thickness). Ann Surg. 1997; 225(5):554-65.
56. Osler T, Glance LG, Hosmer DW. Simplified estimates of the probability of death after burn injuries: extending and updating the baux score. J Trauma. 2010; 68(3):690-7.
57. Woods JF, Quinlan CS, Shelley OP. Predicting mortality in severe burns-what is the score? Evaluation and comparison of 4 mortality prediction scores in an Irish population. Plast Reconstr Surg Glob Open. 2016; 4(1):e606.
58. Heng JS, Clancy O, Atkins J, Leon-Villapalos J, Williams AJ, Keays R, et al. Revised Baux Score and updated Charlson comorbidity index are independently associated with mortality in burns intensive care patients. Burns. 2015; 41(7):1420-7.
59. León C, Ruiz-Santana S, Saavedra P, Almirante B, Nolla-Salas J, Alvarez-Lerma F, et al. A bedside scoring system ("Candida score") for early antifungal treatment in nonneutropenic critically ill patients with Candida colonization. Crit Care Med. 2006; 34(3):730-7.
60. Leroy G, Lambiotte F, Thévenin D, Lemaire C, Parmentier E, Devos P, et al. Evaluation of "Candida score" in critically ill patients: a prospective, multicenter, observational, cohort study. Ann Intensive Care. 2011; 1(1):50.
61. León C, Ruiz-Santana S, Saavedra P, Galván B, Blanco A, Castro C, et al. Usefulness of the "Candida score" for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients: a prospective multicenter study. Crit Care Med. 2009; 37(5): 1624-33.
62. Ahangarkani F, Shokohi T, Rezai MS, Ilkit M, Mahmoodi Nesheli H, Karami H, et al. Epidemiological features of nosocomial candidaemia in neonates, infants and children: a multicentre study in Iran. Mycoses. 2020; 63(4):382-94.
63. Charsizadeh A, Mirhendi H, Nikomanesh B, Eshaghi H, Makimura K. Microbial epidemiology of candidaemia in neonatal and paediatric intensive care units at the Children's Medical Center, Tehran. Mycoses. 2018; 61(1):22-9.
64. Vaezi A, Fakhim H, Khodavaisy S, Alizadeh A, Nazeri M, Soleimani A, et al. Epidemiological and mycological characteristics of candidemia in Iran: a systematic review and meta-analysis. J Mycol Med. 2017; 27(2):146-52.
Volume 6, Issue 3
September 2020
Pages 33-41
  • Receive Date: 05 July 2020
  • Revise Date: 07 September 2020
  • Accept Date: 15 September 2020
  • First Publish Date: 15 September 2020