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Open Access Highly Accessed Research article

A risk factor analysis of healthcare-associated fungal infections in an intensive care unit: a retrospective cohort study

Su-Pen Yang14, Yin-Yin Chen25, Han-Shui Hsu34, Fu-Der Wang16, Liang-yu Chen67 and Chang-Phone Fung14*

Author affiliations

1 Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan

2 Department of Infection control and Department of nursing, Taipei Veterans General Hospital, Taipei, Taiwan, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan

3 Division of Chest Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan

4 Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan, No.155, Sec. 2, Linong Street, Taipei, 112, Taiwan

5 College of Nursing, National Yang-Ming University, Taipei, Taiwan, No.155, Sec. 2, Linong Street, Taipei, 112, Taiwan

6 Institute of Public Health, National Yang-Ming University, Taipei, Taiwan, No.155, Sec. 2, Linong Street, Taipei, 112, Taiwan

7 Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan

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Citation and License

BMC Infectious Diseases 2013, 13:10  doi:10.1186/1471-2334-13-10

Published: 9 January 2013

Abstract

Background

The incidence of fungal healthcare-associated infection (HAI) has increased in a major teaching hospital in the northern part of Taiwan over the past decade, especially in the intensive care units (ICUs). The purpose of this study was to determine the factors that were responsible for the outbreak and trend in the ICU.

Methods

Surveillance fungal cultures were obtained from “sterile” objects, antiseptic solutions, environment of infected patients and hands of medical personnel. Risk factors for comparison included age, gender, admission service, and total length of stay in the ICU, Acute Physiology and Chronic Health Evaluation (APACHE) II scores at admission to the ICU, main diagnosis on ICU admission, use of invasive devices, receipt of hemodialysis, total parenteral nutrition (TPN) use, history of antibiotic therapy before HAI or during ICU stay in no HAI group, and ICU discharge status (ie, dead or alive). Univariable analysis followed by multiple logistic regression analysis was performed to identify the independent risk factors for ICU fungal HAIs and ICU mortality.

Results

There was a significant trend in ICU fungal HAIs from 1998 to 2009 (P < 0.001). A total of 516 episodes of ICU fungal HAIs were identified; the rates of various infections were urinary tract infection (UTI) (54.8%), blood stream infection (BSI) (30.6%), surgical site infection (SSI) (6.6%), pneumonia (4.5%), other sites (3.5%). The fungi identified were: yeasts (54.8%), Candida albicans (27.3%), Candida tropicalis (6.6%), Candida glabrata (6.6%), Candida parapsilosis (1.9%), Candida species (0.8%), and other fungi (1.9%). Candida albicans accounted for 63% of all Candida species. Yeasts were found in the environment of more heavily infected patients. The independent risk factors (P < 0.05) of developing ICU fungal HAIs from all sites were TPN use, sepsis, surgical patients, mechanical ventilation and an indwelling urinary catheter. The independent risk factors for ICU fungal UTI included TPN use, mechanical ventilation and an indwelling urinary catheter. The independent risk factors for ICU fungal BSI included TPN use, sepsis, and higher APACHE II score. The independent risk factors for ICU fungal pneumonia included TPN use, surgical patients. The independent risk factors for ICU fungal SSI included surgical patients, and TPN use. The odds ratios of TPN use in various infection types ranged from 3.51 to 8.82. The risk of mortality in patients with ICU fungal HAIs was over 2 times that of patients without ICU HAIs in the multiple logistic regression analysis (P < 0.001).

Conclusions

There was a secular trend of an increasing number of fungal HAIs in our ICU over the past decade. Patients with ICU fungal HAIs had a significantly higher mortality rate than did patients without ICU HAIs. Total parenteral nutrition was a significant risk factor for all types of ICU fungal HAIs, and its use should be monitored closely.

Keywords:
Intensive care unit; Fungal infection; Outbreak surveillance; Candida; Total parenteral nutrition