Reports From the Field

Decreasing Overutilization of Echocardiograms and Abdominal Imaging in the Evaluation of Children with Fungemia

Journal of Clinical Outcomes Management. 2019 November;26(6):270-276

References

1. Benjamin DK Jr, Poole C, Steinbach WJ, et al. Neonatal candidemia and end-organ damage: a critical appraisal of the literature using meta-analytic techniques. Pediatrics. 2003;112:634-640.

2. Wynn JL, Tan S, Gantz MG, et al. Outcomes following candiduria in extremely low birth weight infants. Clin Infect Dis. 2012;54:331-339.

3. Noyola DE, Fernandez M, Moylett EH, et al. Ophthalmologic, visceral, and cardiac involvement in neonates with candidemia. Clin Infect Dis. 2001;32:1018-1023.

4. Phillips JR, Karlowicz MG Prevalence of Candida species in hospital-acquired urinary tract infections in a neonatal intensive care unit. Pediatr Infect Dis J. 1997;16:190-194.

5. Pagano L, Mele L, Fianchi L, et al. Chronic disseminated candidiasis in patients with hematologic malignancies. Clinical features and outcome of 29 episodes. Haematologica. 2002;87:535-541.

6. Zaoutis TE, Greves HM, Lautenbach E, et al. Risk factors for disseminated candidiasis in children with candidemia. Pediatr Infect Dis J. 2004;23:635-641.

7. Levy I, Shalit I, Birk E, et al. Candida endocarditis in neonates: report of five cases and review of the literature. Mycoses. 2006;49:43-48.

8. Aspesberro F, Beghetti M, Oberhansli I, et al. Fungal endocarditis in critically ill children. Eur J Pediatr. 1999;158:275-280.

9. Fernandez-Cruz A, Cruz Menarguez M, Munoz P, et al. The search for endocarditis in patients with candidemia: a systematic recommendation for echocardiography? A prospective cohort. Eur J Clin Microbiol Infect Dis. 2015;34:1543-1549.

10. Hernandez-Torres A, Garcia-Vazquez E, Laso-Ortiz A, et al. [Candida sp endocarditis. Experience in a third-level hospital and review of the literature]. Rev Esp Quimioter. 2013;26:51-55.

11. Pappas PG, Kauffman CA, Andes DR, et al. Clinical practice guideline for the management of candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62:e1-50.

12. Bow EJ, Evans G, Fuller J, et al. Canadian clinical practice guidelines for invasive candidiasis in adults. Can J Infect Dis Med Microbiol. 2010;21:e122-50.

13. Ruhnke M, Rickerts V, Cornely OA, et al. Diagnosis and therapy of Candida infections: joint recommendations of the German Speaking Mycological Society and the Paul-Ehrlich-Society for Chemotherapy. Mycoses. 2011;54:279-310.

14. Cornely OA, Bassetti M, Calandra T, et al. ESCMID* guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients. Clin Microbiol Infect. 2012;18 Suppl 7:19-37.

15. Hope WW, Castagnola E, Groll AH, et al. ESCMID* guideline for the diagnosis and management of Candida diseases 2012: prevention and management of invasive infections in neonates and children caused by Candida spp. Clin Microbiol Infect. 2012;18 Suppl 7:38-52.

16. Ullmann AJ, Akova M, Herbrecht R, et al. ESCMID* guideline for the diagnosis and management of Candida diseases 2012: adults with haematological malignancies and after haematopoietic stem cell transplantation (HCT). Clin Microbiol Infect. 2012;18 Suppl 7:53-67.

17. Colombo AL, Guimaraes T, Camargo LF, et al. Brazilian guidelines for the management of candidiasis - a joint meeting report of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical. Braz J Infect Dis. 2013;17:283-312.

18. Kohno S, Tamura K, Niki Y, et al. Executive Summary of Japanese Domestic guidelines for management of deep-seated mycosis 2014. Med Mycol J. 2016;57:E117-E163.

19. Kojic EM, Darouiche RO. Candida infections of medical devices. Clin Microbiology Rev. 2004;17:255-267.

Of those 7 episodes, the average age was 6.8 years (57% female). There were no patients with multiple episodes. The most common presenting complaint was fever. The most common organism was Candida albicans (3 of the 7 episodes). All episodes involved a central line, which was removed in all cases except for one. Of the risk factors, 2 episodes were in neutropenic patients, and 1 episode had a history of bacterial endocarditis (not related to fungemia). No episodes occurred in patients with prior fungal renal infection, urogenital malformations, or recent cardiac/urogenital surgery. No episodes had clinical symptoms suggestive of fungal endocarditis or renal infection. No episodes of fungal endocarditis or renal infection were identified.

On average, a patient at our institution undergoing abdominal US and echo with a cardiology consult results in medical waste of approximately $3200 per patient. This cost does not take into account other miscellaneous charges possibly incurred, such as the radiologist interpreting the findings and transportation. Baseline data calculations show that patients waste on average 55 minutes in physical transport, and this does not take into account wait times.

Discussion

Candidemia contributes to 10% of central-line associated blood stream infections (CLABSI).¹⁹ Increased usage of indwelling central catheters for administration of parenteral nutrition will inevitably result in practitioners encountering cases of candidemia when caring for this population. As seen from our results, the majority of episodes of candidemia at our institution occurred on the pediatric gastroenterology service, and thus redefining standard work on this service will be impactful.

Candida parapsilosis and Candida albicans were the most common causative agents before and after intervention, respectively, but overall the most common organism was Candida albicans, which is in keeping with that of CLABSI in the literature.¹⁹ Growth of Candida parapsilosis has been particularly linked to CLABSI.¹⁹ The third most common organism in our study was Candida glabrata, which is the second most common cause of candidemia in CLABSI.¹⁹

The cases of positive abdominal imaging in fungemia in the literature are limited to the neonatal population^1-4 and chronic disseminated candidiasis in patients with hematologic malignancies/neutropenia/immunosuppression.^5,6 In fungal endocarditis, the reported cases were generally in neonates,^1,3,7 critically ill patients,⁸ patients with hematologic malignancies/neutropenia/immunosuppression,^6,9 or those with a cardiac history.^9,10This population differs from the patient population on the pediatric gastroenterology service. Patients on this service may not need US or echo. Performing abdominal US and echo in fungemia patients in whom such imaging is not indicated may result in medical waste of approximately $3200 per patient. There is also a waste of medical resources and time.