Open Access

Risk factors for Candida colonization and Co-colonization with multi-drug resistant organisms at admission

  • Danielle M. Schulte1, 2,
  • Ajay Sethi1,
  • Ronald Gangnon1,
  • Megan Duster2,
  • Dennis G. Maki2 and
  • Nasia Safdar2, 3, 4Email author
Antimicrobial Resistance and Infection Control20154:46

DOI: 10.1186/s13756-015-0089-9

Received: 29 June 2015

Accepted: 1 November 2015

Published: 14 November 2015

Abstract

Introduction

Candida species are major causes of healthcare-associated infections with colonization preceding infection. Understanding risk factors for colonization by Candida species is important in prevention. However, data on risk factors for colonization by Candida species alone or with other healthcare-associated pathogens is limited.

Methods

From 2002 to 2006, 498 patients were enrolled into a prospective cohort study at our institution. Surveillance perirectal, nasal and skin swab samples were obtained upon enrollment. Samples were cultured for the presence of Candida species, Methicillin Resistant Staphylococcus aureus, Vancomycin Resistant Enterococcus, and Resistant Gram Negative organisms. Data on demographics, comorbidities, device use, and antibiotic use were also collected for each subject and analyzed using univariate and multivariate logistic regression.

Results

Factors associated with Candida colonization at admission in univariate analysis included ambulatory status, a history of Candida colonization and the use of antibiotics prior to enrollment. In multivariate analysis, ambulatory status (odds ratio; OR = 0.45, 95 % CI: 0.27–0.73) and fluroquinolone use (OR = 3.01, 95 % CI: 1.80–5.01) were associated with Candida colonization at admission. Factors predicting Candida co-colonization with one or more MDROs at admission in univariate analysis included, older age, malnutrition, days spent in an ICU in the 2 years prior to enrollment, a history of MRSA colonization, and using antibiotics prior to enrollment. In multivariate analysis malnutrition (OR = 3.97, 95 % CI: 1.80–8.78) a history of MRSA (OR = 5.51, 95 % CI: 1.89–16.04) and the use of macrolides (OR = 3.75, 95 % CI: 1.18–11.93) and other antibiotics (OR = 4.94, 95 % CI: 1.52–16.03) were associated with Candida co-colonization at admission.

Discussion

Antibiotic use was associated with an increased risk of colonization by Candida species alone and in conjunction with other multidrug-resistant organisms (MDROs). Antibiotic stewardship may be an important intervention for preventing colonization and subsequent infection by Candida and other MDROs.

Keywords

Candida Colonization Multi-drug resistant organisms Healthcare-associated infections

Introduction

In the U.S. healthcare-associated infections (HAI) affect about 1.7 million individuals and play a role in approximately 99,000 deaths per year [1, 2]. Candida species are an important healthcare-associated pathogen with bloodstream infections resulting from Candida being the fourth most common cause of hospital acquired bloodstream infection [3]. There is also frequent co-colonization by Candida and other healthcare-associated pathogens [4] which has implications for treatment and can result in various adverse outcomes [58].

Colonization precedes infection [9]. Therefore, an understanding of risk factors for colonization is essential to devise effective preventive strategies for infection. However, data on factors predicting colonization by Candida at admission are limited, with most literature focusing on colonization in patients with critical illnesses, long term hospital stays, intensive care unit (ICU) patients or neonates. We undertook an observational cohort study to examine risk factors for rectal colonization by Candida species alone or in conjunction with Methicillin resistant Staphylococcus aureus (MRSA), Vancomycin resistant Enterococcus (VRE) and antibiotic resistant Gram-negative organisms (RGN) at admission to our academic facility.

Methods

Study setting and protocol

The University of Wisconsin hospital is a 592 bed tertiary care hospital with active solid organ and bone marrow transplant programs. There are 6 ICUs and the patient population comes from all over Wisconsin as well as parts of Illinois and Minnesota. We do not undertake systematic screening for MRSA, VRE or resistant gram negative bacteria. Initiatives to improve hand hygiene have been in place but began after this study had ended. No other specific infection control interventions were in place.

From April 2002 to June 2006, 498 patients were enrolled into a prospective cohort study at the University of Wisconsin hospital. A daily census of hospital admissions was obtained and subjects were randomly selected to be approached for participation. Patients on the psychiatry floor or those in the observation unit (anticipated length of stay < 1 day) were excluded. Consenting patients were enrolled within 1 day of admission to the hospital and were followed until hospital discharge. This study was approved by the institutional review board at our institution.

Surveillance swab samples were obtained from the subject’s nose, rectal area, underarm area, groin, and if applicable, open wound sites upon enrollment and once a week thereafter until discharge. Each rectal area sample was cultured for the presence of Candida, MRSA, VRE, and RGN organisms and the nose, underarm and groin samples were cultured for the presence of MRSA. Data on baseline demographics, comorbidities and device use, and pre- and post-hospital admission antibiotic use were also collected for each subject.

Laboratory methods

To test for the presence of MRSA, the nasal, underarm, groin, peri-rectal, and wound swabs were inoculated into tryptic soy broth with 6.5% NaCl for 24 h. Fifty microliters were then plated onto Mannitol salt agar plates with 4ug/ml Oxacillin. The plates were then incubated for 48 h and examined for growth. Gram positive cocci were tested for catalase and coagulase for identification of S. aureus. All isolates were also tested for resistance to oxacillin using Kirby Bauer Disk Diffusion. To test for the presence of VRE, the rectal swabs were inoculated into bile esculin broth and incubated for 24 h. Fifty microliters were then plated onto bile esculin agar with 6ug/ml vancomycin . Plates were incubated for 48 h and examined for growth. Gram positive cocci were tested for catalase and pyrrolidonyl arylamidase (PYR) for identification of enterococcus. All isolates were tested for resistance to vancomycin by E-test. To test for the presence of RGN organisms, the perirectal swabs were inoculated onto MacConkey agar with 0.5 mg/L of cefotaxime. Gram negative rods were identified using oxidase and analytical profile index (API) testing for enteric and non-enteric bacteria. All isolates were also tested for resistance using Kirby Bauer methods. To test for the presence of Candida, the rectal swabs were inoculated onto Sabouraud’s dextrose agar with chloramphenicol and gentamicin. Each yeast isolate was then identified using API testing for yeast species.

Definitions

Colonization with Candida was defined as a positive rectal culture for any Candida species. Co-colonization with Candida was defined as a positive rectal culture for any Candida species along with a positive rectal culture for VRE or RGN or a positive rectal, nasal, underarm or groin culture for MRSA. A history of MRSA or Candida was defined as having a previous positive culture with the specified organism.

Statistical methods

Exploratory data analyses and univariate logistic regression were performed to examine factors associated with Candida colonization alone and with its co-colonization with other MDROs. Factors for which the association with the outcomes of interest were suggestive (p < 0.10) were examined for possible retention in multivariate logistic regression. Parsimonious models were constructed using statistically significant variables and included clinically relevant factors that did not compromise model fit. Unadjusted and adjusted odds ratios and corresponding confidence intervals (CI) were estimated for factors associated with Candida colonization and its co-colonization with MDROs. Subjects with missing data were removed from analysis. Data were analyzed using SAS version 9.4.

Results

The University of Wisconsin hospital is a 592 bed facility with a patient population that averages 86 % percent white and 5 % African-American 3 % Hispanic/Latino, 1 % Asian and 5 % other. Four-hundred and ninety-eight individuals were enrolled in the study and 8 were ultimately removed from multivariate analysis due to missing data. 275 subjects were male (56 %) and 217 subjects were female (44 %). The average patient age was 56.5 (15.2) years (Table 1). Nineteen percent of subjects were colonized with Candida species at baseline, 4.3 % were colonized with VRE, 1.8 % were colonized with RGN, 1.4 % were colonized with MRSA, and 8.6 % were colonized with multiple organisms.

In univariate analysis, a patient’s need for ventilator support (OR = 3.32, 95 % CI: 1.30–8.50), history of Candida colonization (OR = 2.07, 95 % CI: 1.11–3.84), and use of penicillin combinations (OR = 2.44, 95 % CI: 1.33–4.47) and fluoroquinolone use (OR = 3.25, 95 % CI: 1.98–5.32) prior to admission were significantly associated with higher odds of being colonized by Candida species only, at the time of hospital admission (Table 2). A patient’s ambulatory status (OR = 0.44, 95 % CI: 0.27–0.70) and chemotherapy use (OR = 0.26, 95 % CI: 0.09–0.75) were associated with lower odds of colonization by Candida species.
Table 1

Characteristic totals at hospital admission

Characteristic

N

Total with characteristic (SDӨ,%)

With Candida (% of total)

Without Candida (% of total)

Age (avg., yr)

491

56.5 (15.2)

58.2 (15.3)

56.0 (15.1)

Body mass index (avg.)

486

28.6 (8.3)

28.3 (8.5)

28.7 (8.3)

Gender (male)

492

275 (55.9 %%)

52 (18.9 %)

223 (81.1 %)

Gender (female)

492

217 (44.1 %)

41 (18.9 %)

176 (81.1 %)

Ambulatory Status (ambulatory)

492

353 (71.7 %)

53 (15.0 %)

300 (85.0 %)

Alcohol use

492

154 (31.3 %)

34 (22.1 %)

120 (77.9 %)

Surgery

492

69 (14.0 %)

7 (10.1 %)

62 (89.9 %)

Coronary artery disease

492

109 (22.2 %)

25 (22.9 %)

84 (77.1 %)

Chemotherapy

492

62 (12.6 %)

4 (6.5 %)

58 (93.5 %)

Lung Disease

492

62 (12.6 %)

13 (21.0 %)

49 (79.0 %)

Hypertension

492

291 (59.1 %)

56 (19.2 %)

235 (80.8 %)

Immunosuppression

492

192 (39.0 %)

35 (18.2 %)

157 (81.8 %)

Malnutrition

492

77 (15.7 %)

20 (26.0 %)

57 (74.0 %)

Cancer

491

152 (31.0 %)

21 (13.8 %)

131 (86.2 %)

Peripheral vascular disease

492

35 (7.1 %)

10 (28.6 %)

25 (71.4 %)

Renal Failure

492

106 (21.5 %)

15 (14.2 %)

91 (85.8 %)

Steroids

492

172 (35.0 %)

29 (16.9 %)

143 (83.1 %)

Abdominal drain

491

21 (4.3 %)

4 (19.0 %)

17 (81.0 %)

Non-insulin dependent diabetes

492

60 (12.2 %)

13 (21.7 %)

37 (61.7 %)

Insulin-dependent diabetes

491

105 (21.4 %)

19 (18.1 %)

86 (81.9 %)

Foley Catheter

492

116 (23.6 %)

24 (20.7 %)

92 (79.3 %)

Hemodialysis

491

29 (5.9 %)

7 (24.1 %)

22 (75.9 %)

Neutropenia

490

14 (2.9 %)

3 (21.4 %)

11 (78.6 %)

Open wound

486

101 (20.8 %)

20 (19.8 %)

81 (80.2 %)

Transplant

490

111 (22.7 %)

21 (18.9 %)

90 (81.1 %)

Vascular catheter

490

462 (94.5 %)

89 (19.3 %)

373 (80.7 %)

Vent support

492

19 (3.9 %)

8 (42.1 %)

11 (57.9 %)

History of Candida

492

56 (11.4 %)

17 (30.4 %)

39 (69.6 %)

History of MRSAӨ

492

28 (5.7 %)

5 (17.9 %)

23 (82.1 %)

History of VREӨ

492

8 (1.6 %%)

0 (0 %)

8 (100 %)

History of RGNӨ

492

41 (8.3 %)

8 (19.5 %)

33 (80.5 %)

Days in hospital in 2 years. prior (avg,. days)

489

33.8 (108.1)

44.2 (141.6)

31.7(99.6)

Days in ICU in 2 years. prior (avg,. days)

492

1.5 (4.5)

2.1 (4.1)

1.3 (5)

Aminoglycosidesa

492

11 (2.2 %)

3 (27.3 %)

8 (72.7 %)

Carbapenemsa

492

4 (0.8 %)

0 (0 %)

4 (100 %)

1st Gen Cephalosporinsa

492

41 (8.3 %)

5 (12.2 %)

36 (87.8 %)

2nd Gen Cephalosporinsa

492

10 (2.0 %)

1 (10.0 %)

9 (90.0 %)

3rd Gen Cephalosporinsa

492

34 (6.9 %)

7 (20.6 %)

27 (79.4 %)

4th Gen Cephalosporinsa

492

12 (2.4 %)

2 (16.7 %)

10 (83.3 %)

Glycopeptidesa

492

32 (6.5 %)

7 (21.9 %)

25 (78.1 %)

Lincosamidesa

492

23 (4.7 %)

7 (30.4 %)

16 (69.6 %)

Macrolidesa

492

29 (5.9 %)

6 (20.7 %)

23 (79.3 %)

Nitrofuransa

492

5 (1.0 %)

1 (20.0 %)

4 (80.0 %)

Penicillinsa

492

26 (5.3 %)

5 (19.2 %)

21(80.8 %)

Penicillin Combinationsa

492

57 (11.6 %)

19 (33.3 %)

38 (66.7 %)

Fluoroquinolonesa

492

101 (20.5 %)

36 (35.6 %)

65 (64.4 %)

Sulfonamidesa

492

62 (12.6 %)

12 (19.4 %)

50 (80.6 %)

Tetracyclinesa

492

3 (0.6 %)

2 (66.7 %)

1 (33.3 %)

Drugs against mycobacteriaa

492

5 (1.0 %)

1 (20.0 %)

4 (80.0 %)

Other antibioticsb

492

21 (4.3 %)

6 (28.6 %)

15 (71.4 %)

Ө SD standard deviation, MRSA Methicillin resistant Staphylococcus aureus, VRE Vancomycin resistant Enterococcus, RGN antibiotic resistant Gram-negative organisms

All variables are dichotomous, yes vs. no, unless otherwise stated

aAntibiotic use occurred prior to admission to hospital

bOther antibiotics included use of either Metronidazole, Dapsone or Linezolid

Table 2

Univariate odds ratios of Candida colonization at hospital admission

Characteristic

Odds ratio

95 % Confidence interval

Age (yr)

1.01

0.99–1.03

Body mass index

0.99

0.97 – 1.02

Gender (male vs. female)

1.00

0.63–1.57

Ambulatory Status (ambulatory vs non-ambulatory)

0.44

0.27 – 0.70

Alcohol use

1.34

0.84–2.15

Surgery

0.44

0.20–1.00

Coronary artery disease

1.38

0.82–2.31

Chemotherapy

0.26

0.09–0.75

Lung Disease

1.16

0.60–2.24

Hypertension

1.06

0.67–1.67

Immunosuppression

0.93

0.58–1.48

Malnutrition

1.67

0.94 – 2.95

Cancer

0.59

0.35–1.01

Peripheral vascular disease

1.80

0.83–3.90

Renal Failure

0.65

0.36–1.19

Steroids

0.81

0.50–1.32

Abdominal drain

1.01

0.33–3.07

Non-insulin dependent diabetes

1.59

0.81–3.13

Insulin-dependent diabetes

0.93

0.53–1.63

Foley Catheter

1.16

0.69–1.95

Hemodialysis

1.39

0.57 – 3.35

Neutropenia

1.17

0.32–4.28

Open wound

1.09

0.63–1.90

Transplant

1.00

0.58–1.71

Vascular catheter

1.37

0.46 – 4.07

Vent support

3.32

1.30–8.50

History of Candida

2.07

1.11–3.84

History of MRSAӨ

0.93

0.34–2.51

History of VREӨ

<0.001

<0.001– >999.99

History of RGNӨ

1.04

0.47–2.34

Days in hospital in 2 years. prior (days)

1.00

1.00–1.00

Days in ICU in 2 years. prior (days)

1.03

0.99–1.07

Aminoglycosidesa

1.63

0.42– 6.26

Carbapenemsa

<0.001

<0.001– >999.99

1st Gen Cephalosporinsa

0.57

0.22–1.50

2nd Gen Cephalosporinsa

0.47

0.06–3.76

3rd Gen Cephalosporinsa

1.12

0.47–2.66

4th Gen Cephalosporinsa

0.86

0.18–3.97

Glycopeptidesa

1.22

0.51–2.91

Lincosamidesa

1.95

0.78–4.88

Macrolidesa

1.13

0.45–2.85

Nitrofuransa

1.08

0.12–9.72

Penicillinsa

1.02

0.38–2.79

Penicillin Combinationsa

2.44

1.33–4.47

Fluoroquinolonesa

3.25

1.98–5.32

Sulfonamidesa

1.03

0.53–2.03

Tetracyclinesa

8.75

0.79–97.51

Drugs against mycobacteriaa

1.08

0.12–9.72

Other antibioticsb

1.77

0.67–4.68

ӨMRSA = Methicillin resistant Staphylococcus aureus; VRE = Vancomycin resistant Enterococcus; RGN = antibiotic resistant Gram-negative organisms

All variables are dichotomous, yes vs. no, unless otherwise stated

Estimate for each additional day in the hospital/ intensive care unit

aAntibiotic use occurred prior to admission to hospital

bOther antibiotics included use of either Metronidazole, Dapsone or Linezolid

In multivariate analysis, adjusting for age, and other factors included in the model patients who could ambulate had 55 % lower odds of being colonized with only Candida at admission (OR = 0.45, 95 % CI: 0.27–0.73). Patients who used quinolones prior to hospital admission had three times greater odds of being colonized with Candida at admission to the hospital (OR = 3.01, 95 % CI: 1.80–5.014) (Table 3).
Table 3

Multivariate odds ratios of Candida colonization at hospital admission (n = 485)

Characteristic

Multivariate odds ratio

95 % Confidence interval

Univariate odds ratio

95 % Confidence interval

Body mass index

0.99

0.96–1.02

0.99

0.97 – 1.02

Age (yr)

1.01

0.99–1.02

1.01

0.99–1.03

Ambulatory Status (ambulatory vs non-ambulatory)

0.45

0.27–0.73

0.44

0.27 – 0.70

History of Candida

1.75

0.91–3.37

2.07

1.11–3.84

Fluoroquinolonesa

3.01

1.80–5.01

3.25

1.98–5.32

aAntibiotic use occurred prior to admission to hospital

Table 4

Characteristic totals for co-colonization at hospital admission

Characteristic

N

Total (SDӨ,%)

With Co-col (SDӨ, %)

Without Co-col (SDӨ, %)

Age (avg., yr)

491

56.4 (15.1)

58.9 (17.4)

56.3 (15.0)

Body mass index (avg.)

486

28.6 (8.3)

28.9 (9.2)

28.6 (8.2)

Gender (male)

492

275 (55.9 %)

15 (5.8 %)

260 (94.5 %)

Gender (female)

492

217 (44.1 %)

18 (8.3 %)

199 (91.7 %)

Ambulatory Status (ambulatory)

492

353 (71.7 %)

21(5.9 %)

332 (94.1 %)

Alcohol use

492

154 (31.3 %)

12 (7.8 %)

142 (92.2 %)

Surgery

492

69 (14.0 %)

2 (2.9 %)

67 (97.1 %)

Coronary artery disease

492

109 (22.2 %)

8 (7.3 %)

101 (92.7 %)

Chemotherapy

492

62 (12.6 %)

3 (4.8 %)

59 (95.2 %)

Lung Disease

492

62 (12.6 %)

6 (9.7 %)

56 (90.3 %)

Hypertension

492

291 (59.1 %)

18 (6.2 %)

273 (93.8 %)

Immunosuppression

492

192 (39.0 %)

10 (5.2 %)

182 (94.8 %)

Malnutrition

491

77 (15.7 %)

14 (18.2 %)

63 (81.8 %)

Cancer

491

152 (31.0 %)

9 (5.9 %)

143 (94.1 %)

Peripheral vascular disease

492

35 (7.1 %)

3 (8.6 %)

32 (91.4 %)

Renal Failure

492

106 (21.2 %)

11 (10.4 %)

95 (89.6 %)

Steroids

492

172 (35.0 %)

9 (5.2 %)

163 (94.8 %)

Abdominal drain

491

21 (4.3 %)

1 (4.8 %)

20 (95.2 %)

Non-insulin dependent diabetes

492

50 (10.2 %)

4 (8.0 %)

46 (92.0 %)

Insulin-dependent diabetes

491

105 (21.4 %)

8 (7.6 %)

97 (92.4 %)

Foley Catheter

492

116 (24.2 %)

12 (10.3 %)

104 (89.7 %)

Hemodialysis

490

29 (5.9 %)

3 (10.3 %)

26 (89.7 %)

Neutropenia

490

14 (2.9 %)

1 (7.1 %)

13 (92.9 %)

Open wound

486

101 (20.8 %)

10 (9.9 %)

91 (90.1 %)

Surgical wound

490

76 (15.5 %)

6 (7.9 %)

70 (92.1 %)

Transplant

490

111 (22.7 %)

4 (3.6 %)

107 (96.4 %)

Vascular catheter

489

462 (94.5 %)

31 (6.7 %)

431 (93.3 %)

Vent support

492

19 (3.9 %)

2 (10.5 %)

17 (89.5 %)

History of Candida

492

56 (11.4 %)

5 (8.9 %)

51 (91.1 %)

History of MRSAӨ

492

28 (5.7 %)

8 (28.6 %)

20 (71.4 %)

History of VREӨ

492

8 (1.6 %)

1 (12.5 %)

7 (87.5 %)

History of GNӨ

492

41 (8.3 %)

4 (9.8 %)

37 (90.2 %)

Days in hospital in 2 years. prior to admit (avg., days)

489

34.1 (108.8)

34.1 (40.5)

34.1 (112.1)

Days in ICU in 2 years. prior to admit (avg., days)

492

1.5 (4.9)

4.5 (9.6)

1.3 (4.3)

Aminoglycosidesa

492

11 (2.2 %)

1 (9.1 %)

10 (90.9 %)

Carbapenemsa

492

4 (0.8 %)

2 (50.0 %)

2 (50.0 %)

1st Gen Cephalosporinsa

492

41 (8.3 %)

3 (7.3 %)

38 (92.7 %)

3rd Gen Cephalosporinsa

492

34 (6.9 %)

5 (14.7 %)

29 (85.3 %)

4th Gen Caphalosporinsa

492

12 (2.4 %)

1 (8.3 %)

11 (91.7 %)

Glycopeptides

492

32 (6.5 %)

5 (15.6 %)

27 (84.4 %)

Lincosamidesa

492

23 (4.7 %)

1 (4.3 %)

22 (95.7 %)

Macrolidesa

492

29 (5.9 %)

5 (17.2 %)

24 (82.8 %)

Penicillinsa

492

26 (5.3 %)

4 (15.4 %)

22 (84.6 %)

Penicillin Combinationsa

492

57 (11.6 %)

5 (8.8 %)

52 (91.2)

Fluoroquinolonesa

492

101 (20.5 %)

10 (9.9 %)

91 (90.1 %)

Sulfonamidesa

492

62 (12.6 %)

1 (1.6 %)

61 (98.4 %)

Drugs against mycobacteriaa

492

5 (1.0 %)

2 (40.0 %)

3 (60.0 %)

Other antibioticsb

492

21 (4.3 %)

5 (23.8 %)

16 (76.2 %)

Ө SD standard deviation, MRSA Methicillin resistant Staphylococcus aureus, VRE Vancomycin resistant Enterococcus, RGN antibiotic resistant Gram-negative organisms

All variables are dichotomous, yes vs. no, unless otherwise stated

aAntibiotic use occurred prior to admission to hospital

bOther antibiotics included use of either Metronidazole, Dapsone or Linezolid

We examined factors for co-colonization by Candida species and one or more of the other organisms of interest in this study (Table 4). In univariate analysis, malnutrition (OR = 4.62, 95 % CI: 2.21–9.68), history of MRSA colonization (OR = 7.03, 95 % CI: 2.82–17.52), days spent in an ICU in the two years prior to their present hospital admission (OR = 1.07, 95 % CI: 1.03–1.12), and use of carbapenems (OR = 14.74, 95 % CI: 2.01–108.22), glycopeptides (OR = 2.86, 95 % CI: 1.02–7.99), macrolides (OR = 3.24, 95 % CI: 1.15–9.13), drugs against Mycobacteria (OR = 9.81, 95 % CI: 1.58–60.88) and either metronidazole, dapsone, or linezolid (OR = 4.94, 95 % CI: 1.69–14.48) were significantly associated with a higher odds of being co-colonized with Candida and another organism at the time of hospital admission (Table 5).
Table 5

Univariate odds ratios of Candida co-colonization at hospital admission

Characteristic

Odds ratio

95 % Confidence interval

Age (yr)

1.01

0.99–1.04

Body mass index

1.01

0.97 – 1.05

Gender (male vs. female)

1.59

0.77–3.19

Ambulatory Status (ambulatory vs. non-ambulatory)

0.67

0.32 – 1.40

Alcohol use

1.28

0.61–2.66

Surgery

0.38

0.09–1.62

Coronary artery disease

1.13

0.50–2.59

Chemotherapy

0.68

0.20–2.29

Lung Disease

1.60

0.63–4.04

Hypertension

0.82

0.40–1.66

Immunosuppression

0.66

0.31–1.42

Malnutrition

4.62

2.21–9.68

Cancer

0.83

0.37–1.82

Peripheral vascular disease

1.34

0.39–4.61

Renal Failure

1.92

0.90–4.09

Steroids

0.68

0.31–1.50

Abdominal drain

0.68

0.09–5.26

Non-insulin dependent diabetes

1.24

0.42–3.68

Insulin-dependent diabetes

1.19

0.52–2.72

Foley Catheter

1.95

0.93–4.10

Hemodialysis

1.72

0.49 – 6.02

Neutropenia

1.07

0.14 – 8.42

Open wound

1.73

0.80–3.76

Surgical wound

1.23

0.49 – 3.09

Transplant

0.47

0.16–1.37

Vascular catheter

0.90

0.20 – 3.97

Vent support

1.68

0.37–7.59

History of Candida

1.43

0.53–3.86

History of MRSAӨ

7.03

2.82 – 17.52

History of VREӨ

2.02

0.24 – 16.91

History of GNӨ

1.57

0.53–4.72

Days in hospital in 2 years. prior to admit (days)

1.00

1.00–1.00

Days in ICU in 2 years. prior to admit (days)

1.07

1.03–1.12

Aminoglycosidesa

1.41

0.17–11.31

Carbapenemsa

14.74

2.01–108.22

1st Gen Cephalosporinsa

1.11

0.32–3.80

3rd Gen Cephalosporinsa

2.65

0.95–7.37

4th Gen Caphalosporinsa

1.27

0.16 – 10.17

Glycopeptides

2.86

1.02 – 7.99

Lincosamidesa

0.62

0.08–4.75

Macrolidesa

3.24

1.15–9.13

Penicillinsa

2.74

0.89–8.48

Penicillin Combinationsa

1.40

0.52–3.78

Fluoroquinolonesa

1.76

0.81–3.82

Sulfonamidesa

0.20

0.03–1.52

Drugs against mycobacteriaa

9.81

1.58 – 60.88

Other antibioticsb

4.94

1.69–14.48

Ө MRSA Methicillin resistant Staphylococcus aureus, VRE Vancomycin resistant Enterococcus, RGN antibiotic resistant Gram-negative organisms All variables are dichotomous, yes vs. no, unless otherwise stated

Estimate for each additional day in the hospital/ intensive care unit

aAntibiotic use occurred prior to admission to hospital

bOther antibiotics included use of either Metronidazole, Dapsone or Linezolid

In multivariate analysis, adjusting for age, and other factors included in the model, we found that, at admission, malnourished individuals had a four-fold greater odds of being co-colonized (OR = 3.97, 95 % CI: 1.80–8.78) and individuals with a history of MRSA had over a five-fold greater odds of being co-colonized (OR = 5.51, 95 % CI: 1.89–16.04). Individuals who used macrolides prior to admission had almost a four-fold greater odds of being co-colonized (OR = 3.75, 95 % CI: 1.18–11.93) and individuals who used either metronidazole, dapsone, or linezolid had a five-fold greater odds of being co-colonized (OR = 4.94, 95 % CI: 1.52–16.03) (Table 6).
Table 6

Multivariate odds ratios of Candida co-colonization at hospital admission (n = 490)

Characteristic

Multivariate Odds ratio

95 % Confidence limits

Univariate Odds ratio

95 % Confidence limits

Age (yr)

1.03

1.01–1.06

1.01

0.99 - 1.04

Malnutrition

3.97

1.80–8.78

4.62

2.21–9.68

History of MRSA

5.51

1.89–16.04

7.03

2.82 – 17.52

Days in ICU in 2 years prior to admission (days)

1.05

1.00–1.11

1.07

1.03–1.12

Macrolidesa

3.75

1.18v11.93

3.24

1.15–9.13

Other antibioticsb

4.94

1.52–16.03

4.94

1.69–14.48

Estimate for each additional day in the intensive care unit

aAntibiotic use occurred prior to admission to hospital

bOther antibiotics included use of either Metronidazole, Dapsone or Linezolid

Discussion

Infection by Candida species in hospitalized patients is associated with considerable morbidity and mortality. Prevention is essential but a better understanding of the factors that predict colonization by Candida species is needed. Our study expands the current literature in this area. We identified a number of factors that predicted colonization by Candida species alone or in conjunction with other MDROs. Specifically, we found that individuals who were able to ambulate were less likely to be colonized with Candida species at enrollment and those using Fluoroquinolones prior to admission were more likely to be colonized with Candida species at enrollment. Additionally, we identified several factors that predicted co-colonization with other MDROs at enrollment. These included malnutrition, a history of MRSA, and the use of Macrolides or the use of either Metronidazole, Dapsone, or Linezolid prior to hospital admission.

We found that subjects who could ambulate as opposed to those who could not were about 50 % less likely to be colonized with Candida at enrollment. These individuals were more likely to have been mobile, and not been confined to a hospital or long-term care facility. Our findings are consistent with studies that have shown that individuals who can ambulate are less likely to develop infections [1013], one study even suggested that patients who are admitted to long-term care facilities ambulate more frequently as a form of infection prevention [14].

We also found that subjects with a history of Candida colonization were more likely to be colonized with Candida at admission than those without this history. Our findings are in keeping with previous studies which reported that colonization with Candida species may be prolonged [15].

Additionally we identified factors that were associated with an increase in the risk of co-colonization by Candida and at least one other MDRO. Subjects with malnutrition showed an increased risk of being co-colonized at baseline. Malnutrition can impair an individual’s immunity and cause immune dysfunction, thus affecting the body’s ability to fight infection [16, 17]. Accordingly, this impairment of an individual’s immune system as a result of their malnutrition could be the driving force associating malnutrition and a higher likelihood of co-colonization.

Having a history of MRSA colonization was also indicative of being co-colonized at baseline. Previous studies have shown an association between having a history of MRSA and having a positive MRSA screening sample at hospital admission [18] as well as an association between having a history of Staphylococcus colonization and developing a surgical site infection [19]. This suggests then that having a history of MRSA could be a predictor of baseline colonization with not only MRSA but other organisms as well, including Candida. Colonization with MRSA can also be indicative of a previous hospitalization or previous use of antibiotics; these variables have been shown to be associated with colonization and therefore may also be mediating this relationship [20].

The use of certain antibiotics was implicated with a higher likelihood of colonization and co-colonization. Previous studies have also highlighted the association existing between antibiotic use and Candida colonization [2125]. It has been found that the use of antibiotics with broad-spectrum activity were associated with higher levels of C. albicans colonization and accordingly our study also found that subjects taking certain antibiotics prior to admission were more likely to be colonized and co-colonized at enrollment [21]. More specifically, we have observed that the use of quinolones prior to hospitalization was associated with an increase in a subject’s likelihood of being colonized with Candida at baseline and the use of macrolides and either metronidazole, dapsone or linezolid prior to hospitalization was associated with an increase in a subject’s likelihood of being co-colonized with Candida and another organism at baseline. It has been suggested that individuals taking antibiotics were more likely have a reduction in intestinal bacteria, allowing Candida to opportunistically grow, thus resulting in an increase in intestinal Candida counts [22] which would support this observed association. Information on the the duration of antibiotic exposure and whether or not antibiotics were appropriately utilized by each subject was unavailable in this study but would be an important point of interest for future studies. In this regard however, our study has highlighted the possible antibiotics that should be more closely monitored in future studies and in a clinical setting when prescribed to patients.

A limitation of this study was its small sample size, which will restrict the power of our associations. We also lacked information on length of use and date of last dose for pre-admission antibiotics, which limited our ability to fully describe the relationship between these drugs and colonization. Additionally, we repeated surveillance testing no more frequently than every 3 days, so a positive test after the admission test was negative was a priori defined as acquisition. It is possible that our admission testing resulted in false negatives, however we followed procedure similar to that of most studies that have evaluated acquisition. Finally, we lacked information on possible pre- and post-admission antifungal use by the subjects in our dataset and cannot make any assertions about the role these drugs might play on the outcome of colonization and co-colonization. The use of antifungals however is an important factor to analyze in future studies.

Conclusion

Our study has shown that ambulatory status, malnutrition, a history of MRSA colonization, and antibiotic use prior to admission were significant risk factors for Candida colonization and co-colonization at hospital admission. These risk factors are important indicators of colonization to be examined in patients at hospital admission so as to better anticipate and prevent colonization and co-colonization with Candida species and MRSA, VRE and RGN organisms. Also, given that antibiotic use is a directly mutable variable, interventions should be directed at promoting appropriate antibiotic administration and utilization. More research should now be performed to more completely understand the mechanisms by which these risk factors can affect an individual’s colonization status so as to improve prediction and prevention procedures for colonization and ultimately protect patients from avoidable infection.

Abbreviations

API: 

Analytical profile index

CI: 

Confidence intervals

MDROs: 

Multi-drug resistant organisms

MRSA: 

Methicillin resistant Staphylococcus aureus

OR: 

Odds Ratio

RGN: 

Antibiotic resistant Gram negative organisms

VRE: 

Vancomycin resistant Enterococcus

Declarations

Acknowledgements

The authors have no additional acknowledgements to disclose.

Funding

Nasia Safdar is supported by a VA MERIT award.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Population Health Sciences, University of Wisconsin – Madison School of Medicine and Public Health
(2)
Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
(3)
University of Wisconsin Hospitals and Clinics
(4)
William S. Middleton Memorial Veterans Affairs Medical Center

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Copyright

© Schulte et al. 2015

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