Pattern of bacterial and fungal pathogen in patients with high risk for invasive fungal disease in an indonesian tertiary care hospital: an observational study

Introduction In critically ill patients, there is a defect in host defense mechanism resulting in increased susceptibility to bacterial and fungal infection. The pattern of organisms causing infections varies between different countries and hospitals; therefore it is important that every hospital generates antibiograms to guide healthcare professionals during treatment with optimal choice of antibiotics. Our study aimed to described the pattern of fungal and bacterial pathogen in patients with high risk for invasive fungal disease (IFD). Methods An observational study was conducted in Cipto Mangunkusumo Hospital, Jakarta, Indonesia, within March-September 2015. Specimens were taken from blood, sputum, endotracheal aspiration, bronchoalveolar lavage (BAL), urine, pus and drainage fluid/surgical tissue specimen on 5th-7th day of hospitalization. Samples were cultured onto suitable culture media and bacterial isolates were identified using standard biochemical methods. Results Bacteria and Candida sp. were isolated from 153 patients. C. tropicalis (44.31%) was the commonest fungal isolated. Incidence of gram-negative bacteria was higher than gram-positive bacteria. Klebsiella pneumonia was the most common gram-negative bacteria isolated, where as Enterococcus faecalis for gram-positive bacteria. Conclusion Critically ill patients were vulnerable to contracted fungal and bacterial pathogen. Candida non-albicans and Gram-negative bacteria were the most common pathogen detected among critically ill patients with high risk for IFD.


Introduction
Invasive fungal disease (IFD) is a major cause of morbidity and mortality in the critically ill and imunocompromised patients, most commonly caused by Candida sp [1][2][3][4]. To improve patient prognosis, early diagnosis of IFD is needed to start early antifungal therapy. Leon et al created a scoring system called Candida score to identify patients with high risk of IFD, thus patients can be given early antifungal therapy if required. Patients with a Candida score >2.5 are of high risk of contracting IFD [5,6]. Critically ill patients are susceptible not only to fungal infection but also bacterial and opportunistic infections. In critically ill patients, there is a defect in the host defense mechanisms due to immunesuppressive effects of the underlying diseases, recent surgery, trauma and concurrent drug therapy, which results in increased susceptibility to infections. Opportunistic infection also occurs due to exposure to various invasive devices. Furthermore, prior colonization is an important predisposing factor for nosocomial infections in ICU [1,7]. The pattern of organisms causing infections varies between different countries and hospitals; therefore it is important that every hospital generates antibiograms to guide healthcare professionals during treatment with optimal choice of antibiotics. In Europe and US, epidemiological data of pathogens were updated periodically by health agency like Center for Disease Control (CDC) [8]. Data regarding fungal and bacterial pathogens in Indonesia are still scarce. The main objective of this study is to determine the pathogen profile in critically ill patients with high risk of invasive fungal disease in an Indonesian tertiary care hospital. Better understanding of pathological pattern can help determine appropriate antibiotic and antifungal administration especially in critically ill patients in order to decrease the morbidity and mortality.

Methods
Study was conducted in ICU/HCU and common ward of Dr. Cipto Mangunkusumo Hospital, a tertiary care hospital in Jakarta, Indonesia. Samples of patients admitted during March-September 2015 were included in present study. A total of 218 critically ill patients aged ≥ 18 years with high IFD risk factor were taken as a sample. Candida score by Leon [5] was used to determine patients with high IFD risk factor. Patients who had total parenteral nutrition, surgery and multifocal Candida colonization each gained 1 score.
Patients who developed severe sepsis gained 2 score. A total score of ≥ 3 confirmed patients with invasive candidiasis who will benefit from early antifungal treatment, although still highly improbable in patients with Candida score < 3 [5,6]. Exclusion criteria were patient/family who refused to take part in the research, passed away or discharged before sampling on day 5-7 of treatment (drop out), incomplete medical record and patient with no diagnosis of infection. Bacterial and fungal infections were studied in detail.

Results
Two hundred and eighteen subjects were enrolled in this study, 153 subjects fulfilled the inclusion criteria as seen in Figure 1 tropicalis were the most common gram-negative bacterial and fungal pathogen found, respectively. The pattern of pathogen found in community infection patients are described in Table 4, Table 4 (suite).

Discussion
In this study, we describe the bacterial and fungal pathogens found in critically ill patients with high risk for invasive fungal disease. We  Data from this study can be used as a guidance for rationale early antibiotic and antifungal therapy.

Competing interests
The authors declare no competing interests.

Authors' contributions
Gurmeet Singh contributes in study conception or design, data acquisition, data analysis or interpretation, manuscript drafting, critical manuscript revision and final manuscript approval. Stephanie Gita Wulansari contributes in study conception or design, data acquisition, data analysis or interpretation, manuscript drafting, critical manuscript revision and final manuscript approval. All the authors have read and agreed to the final manuscript.

Acknowledgments
We would like to extend our appreciation to each person involved in the completion of this paper. Our special thanks go to Nidya Parasayu for their support and contributions. There is no conflict of interest in this study. No external financial or material support was obtained for this study.