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Original Research: RESPIRATORY INFECTION |

Candida Colonization of the Respiratory Tract and Subsequent Pseudomonas Ventilator-Associated Pneumonia*

Elie Azoulay, MD, PhD; Jean-François Timsit, MD, PhD; Muriel Tafflet; Arnaud de Lassence, MD; Michael Darmon, MD; Jean-Ralph Zahar, MD; Christophe Adrie, MD, PhD; Maité Garrouste-Orgeas, MD; Yves Cohen, MD; Bruno Mourvillier, MD; Benoît Schlemmer, MD; the Outcomerea Study Group
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Affiliations: *From the Medical ICU (Drs. Azoulay, Darmon, and Schlemmer), Saint Louis Teaching Hospital, Paris; Medical ICU (Dr. Timsit), Hospital Michallon, Grenoble; Department of Biostatistics (Ms. Tafflet), Outcomerea; Louis Mourier Teaching Hospital (Dr. de Lassence), Colombes; Microbiology Department (Dr. Zahar), Necker Teaching Hospital, Necker; Medical-Surgical ICU (Dr. Adrie), Delafontaine Hospital, Saint Denis; Medical-Surgical ICU (Dr. Garrouste-Orgeas), Saint Joseph Teaching Hospital, Paris; Medical-surgical ICU (Dr. Cohen), Avicenne Teaching Hospital, Bobigny; and Medical ICU (Dr. Mourvillier), Bichat Hospital, Paris, France.,  The members of the Outcomerea study group are listed in the Appendix.

Correspondence to: Elie Azoulay, MD, PhD, Medical ICU, Saint Louis Teaching Hospital, 1 Ave Claude Vellefaux, 75010 Paris, France; e-mail: elie.azoulay@outcomerea.org



Chest. 2006;129(1):110-117. doi:10.1378/chest.129.1.110
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Background: Recovery of Candida from the respiratory tract of a critically ill patient receiving mechanical ventilation (MV) usually indicates colonization rather than infection of the respiratory tract. However, interactions between Candida and bacteria, particularly Pseudomonas, have been reported. Thus, Candida colonization of the respiratory tract may predispose to bacterial ventilator-associated pneumonia (VAP).

Methods: In a multicenter study of immunocompetent critically ill patients receiving MV for > 2 days, we compared the incidence of pneumonia in patients with and without (exposed/unexposed) respiratory-tract Candida colonization, matched on study center, admission year, and MV duration.

Results: Over the 4-year study period, of the 803 patients meeting study inclusion criteria in the six study centers, 214 patients (26.6%) had respiratory tract Candida colonization. Candida albicans was the most common species (68.7%), followed by Candida glabrata (20.1%) and Candida tropicalis (13.1%). Extrapulmonary Candida colonization was more common in exposed patients (39.7% vs 8.3%, p = 0.01). Exposed patients had longer ICU and hospital stays but similar mortality to unexposed patients. The matched exposed/unexposed nested cohort study identified bronchial Candida colonization as an independent risk factor for pneumonia (24.1% vs 17.6%; adjusted odds ratio [OR], 1.58; 95% confidence interval [CI], 0.94 to 2.68; p = 0.0860); the risk increase was greatest for Pseudomonas pneumonia (9% vs 4.8%; adjusted OR, 2.22; 95% CI, 1.00 to 4.92; p = 0.049).

Conclusions: Candida colonization of the respiratory tract is common in patients receiving MV for > 2 days and is associated with prolonged ICU and hospital stays, and with an increased risk of Pseudomonas VAP.

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