Early candida colonization of preterm eonates admitted to special care unit Mulago Hospital: prevalence, associated factors and early outcome
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Background: Candida species are the third most frequent cause of septicaemia after 72 hours of life among preterm neonates with an estimated incidence of 1.6 - 15% in neonatal intensive care units. Candida colonization is the most important predictor for invasive candidiasis among preterm neonates. Of all colonized preterm neonates, 7-25% develop invasive candidiasis which is associated with mortality rate approaching 50%. Prophylactic antifungal agents effectively reduce fungal colonization and invasive disease. Objective: This study was conducted to determine the prevalence of early Candida colonization, associated factors and early outcome among preterm neonates admitted in to the Special Care Unit of Mulago National Referral hospital in Uganda. Methods: A Prospective observational study was conducted in the Special Care Unit of Mulago hospital between November 2008 and February 2009. Consecutively 213 preterm neonates were enrolled; Candida colonization of groin, rectum, and throat were determined by taking swabs for culture on CHROMagar after 72 hours and within first week of life. Colonized neonates were followed up for 2 weeks and for those who developed features of septicaemia by WHO definition: blood was drawn for bacterial and Candida isolation. Data was entered into the computer using EPIDATA package 3.1, and analyzed using STATA version 10. The Fishers exact tests were performed for bivariate analysis and logistic regression was conducted to assess for factors independently associated with Candida colonization. P values of < 0.05 were considered significant and confidence interval of 95% was used. Results: Of the 213 enrolled preterm neonates, 50(23.5%) had early Candida colonization. The most common species was C. albicans 28(40%). Gestational age ≤ 30 weeks was the only factor independently associated with Candida colonization p = 0.005. Forty six (46) Candida colonized preterm neonates were followed up of whom 13(28%) developed Mucocutaneous candidiasis and 14(30%) died. Six (43%) deaths followed bacterial septicaemia, two followed blood culture negative septicaemia, four followed necrotizing enterocolitis and two followed aspiration. All the neonate (l died following necrotizing enterocolitis had Candida rectal colonization and three of them had multiple body sites colonized by Candida. Mortality among colonized neonates was significantly associated with colonization of more than one body site p = 0.035 and gestational age ≤ 30 weeks p = 0.044. Candidemia was not found in this study. Conclusion: Early Candida colonization was highly prevalent (23.5%) among preterm neonates admitted to the Special Care Unit of Mulago Hospital. Irrespective of mode or place of delivery; preterm neonates of gestational age ≤ 30 weeks are more predisposed to early Candida colonization. Candida albicans was the commonest species that colonized these neonates with the rectum and groin being the most frequently colonized sites. In this study candidemia was not found. Although mortality among Candida colonized preterm neonates was high (30%) especially among those with multiple body sites colonized. Most of the deaths were associated with bacterial septicaemia. Recommendations: In view of the high early Candida colonization and high mortality observed among Candida colonized preterm neonates in this study especially among preterm neonates of gestational age ≤ 30 weeks; a study to elucidate on the possible sources of Candida that colonize preterm neonates in the Special Care Unit is very necessary in order to minimize Candida colonization. The use of antifungal prophylaxis among preterm neonates for prevention of candidemia cannot be recommended in Special Care Unit since candidemia was not found in this study. A large study should be conducted to compare outcome of preterm neonates colonized and those not colonized by Candida, since a high mortality was observed among Candida colonized preterm neonates.