Association between hollow viscous injury and invasive candidiasis in critically ill trauma patients.
Author(s):
Mehreen Kisat; Manuel Castillo-Angeles ; Adil Haider; Ali Salim; Reza Askari MD
Background:
Invasive candidiasis is associated with high mortality in critically ill patients. The use of empiric antifungal therapy is controversial in patients with traumatic injury to the gastrointestinal tract (GI).
Hypothesis:
We hypothesized that injury to the proximal bowel (stomach, duodenum) is associated with a greater risk of invasive candidiasis than more distal bowel injury.
Methods:
Adult ICU patients (≥ 16 years) in the National Trauma Data Bank (2010-2015) were categorized by site of injury to the gastrointestinal tract (stomach, duodenum, jejunum, colon/rectum). The primary outcome was a diagnosis of invasive candidiasis. Multivariable logistic regression was used to determine associations between the site of injury and invasive candidiasis while controlling for patient (age, gender), injury (injury severity score, injury type) and clinical characteristics (hypotension, ventilator dependency, need for blood transfusion, total parental nutrition, and dialysis).
Results:
Among the 835,024 patients included, 0.02% (n=142) had invasive candidiasis, with an associated mortality rate of approximately 11%. Patients with gastric injury were more likely to have invasive candidiasis (Table 1). Other factors independently associated with invasive candidiasis were hypotension, ventilator dependency, need for transfusion and dialysis.
Table 1: Adjusted odds ratios for predictors of Candidiasis using site of GI injury as a covariate (n=819,156).
| Invasive Candidiasis | |
| Logistic Regression | OR (95% CI) |
| Age | |
| 16-25 | 1 |
| 26-35 | 0.65 (0.33-1.25) |
| 36-45 | 1.32 (0.84-2.08) |
| 46-55 | 1.12 (0.64-1.97) |
| 56-65 | 0.76 (0.37-1.56) |
| 66-75 | 1.26 (0.61-2.57) |
| 76-85 | 1.14 (0.49-2.66) |
| >85 | 0.58 (0.15-2.21) |
| Male gender | 1.19 (0.76-1.86) |
| ISS | |
| 0-8 | 1 |
| 9-15 | 1.03 (0.49-2.17) |
| 16-24 | 1.35 (0.65-2.81) |
| 25-75 | 1.82 (0.81-4.12) |
| Hypotensive on arrival to ED | 1.73 (1.16-2.58) |
| Penetrating Injury | 1.34 (0.90-1.99) |
| Site of GI injury | |
| Stomach | 2.88 (1.17-7.07) |
| Duodenum | 1.06 (0.36-3.12) |
| Jejunum | 1.53 (0.77-3.05) |
| Colon, Rectum | 1.80 (0.82-3.96) |
| Need for ventilator | 3.79 (1.93-7.43) |
| Transfusion | 2.01 (1.11-3.63) |
| Parenteral Nutrition | 1.07 (0.25-4.52) |
| Dialysis | 3.72 (1.52-9.12) |
Conclusions:
Invasive candidiasis is associated with significant mortality in trauma patients with hollow viscous injury. Gastric injuries are associated with increased risk of invasive candidiasis. These results highlight strong consideration for empiric antifungal therapy in trauma patients with gastric injuries and the other known risk factors.
Association between hollow viscous injury and invasive candidiasis in critically ill trauma patients.
Author(s):
Christopher Towe, Nathaly Llore, Nathalie Hirsch, Jessica Donington, Harvey Pass, Vanessa Ho, NYU Langone Medical Center
Background: Empyema can result as a complication of bacterial pneumonia or thoracic surgery procedures with mortality as high as 15%. Empyema pathogens are poorly described in the modern era. Greater understanding of common pathogens and risk factors is required to improve empiric treatment. The primary aim of this study is to describe the microbiology of empyema in the modern era.
Hypothesis: We hypothesize that parapneumonic empyema (PNE) and post-surgical empyema (PSE) will be clinically and microbiologically distinct.
Methods: All patients with positive pleural cultures between 4/2007 and 6/2012 were identified from microbiological records. Patient demographics, clinical course and microbiological information were collected. Each acute empyema was classified as PNE or PSE and differences between groups were assessed using the Chi-square test.
Results: A total of 227 microorganisms from 28 genus classes were isolated from 125 patients (74 (64%) male, mean age 61). 120 (97%) required drainage and/or decortication, while 5 were treated with antibiotics alone. Common comorbidities included: a history of immunosuppression (29%), diabetes (19%), and renal disease (14%). Mortality was 15%. Half (47.7%) of the index cultures were polymicrobial. 152 isolates (67%) were gram positive, 56 (25%) were gram negative, 16 (7%) were fungal, and 3 (1%) were unclassified. Only 7% of isolates were obligate anaerobes. The most common organisms were Streptococcus spp (27%) and Staphylococcus spp (25%), followed by Enterococcus spp (9%), Candida (6%), and Pseudomonas (6%). Of 31 isolates of S. aureus, 14 (45%) were methicillin resistant. 29% of the infections were postoperative. Patients with PSE were less likely to have had a preceding pneumonia (28% vs 65%, p<0.05). Patients with PSE had a slightly higher incidence of gram-negative pathogens but this did not reach statistical significance (40% vs 26%, p=0.1). There was no difference in outcome between the PNE and PSE patients. Conclusions: A wide variety of pathogens were isolated from infected pleural cultures. The most common pathogens isolated were aerobes and gram positives. Polymicrobial infections were common. There was no significant difference in clinical course or pathogens isolated from parapneumonic and post-surgical empyema.