Echinocandin-Resistant Candidemia, the Next Upcoming Threat in the Era of Echinocandin Prophylaxis Among Pediatric Hematological Malignancies in Limited Resources Countries

Background: Hematological cancer patients are at risk for developing candidemia, and echinocandins are commonly employed for prophylaxis in those patients. The rising resistance of Candida spp. to echinocandins poses an emerging threat. Our study aims to identify echinocandin-resistant Candida patterns and their impact on clinical outcomes among pediatric hematological malignancies in limited-resource countries.

Patients and Methods:From 2014 to 2020, Echinocandins were the primary antifungal prophylaxis for children with acute and relapsing leukemias. We conducted a retrospective analysis of patients with candidemia at the Children's Cancer Hospital Egypt (CCHE). The analysis included patterns of resistant Candida species and their outcomes. Breakthrough candidemia was defined as candidemia occurring during antifungal agent administration. Identification of Candida spp. was performed using the Vitek and Vitek2 systems.

Results: Three hundred fifty (350) pediatric cancer patients with candidemia were included in the study, with a median age of 4 years (range: 4 months to 18 years). The main underlying diseases were hematological malignancies (70%) with acute lymphoblastic leukemia being the most prevalent, followed by acute myeloid leukemia. Non-Albicans candida species constituted the majority (73%) of isolates compared to Candida Albicans (27%). The most frequently isolated species included: C. Albicans (27%), C.Tropicalis(29%), C.parapsilosis (21%), C. krusei (7%), C.glabrata(3%), C. famata (2%) and C. guilliermondii (1.5%). Resistant candida was reported among 74 (21%) patients. Echinocandin-resistant candida strains reported in 17(5%) patients: C. parasitosis (7), C. albicans (4), C. tropicalis (2), C. krusei (3) and C. lipolytica (1). Breakthrough candidemia occurred in 62 (17%) patients receiving echinocandin prophylaxis, with C. parapsilosis being the most common isolated pathogen (31 cases, 50%). Unfortunately, ten patients (16%) with breakthrough candidemia died secondary to candida sepsis syndrome. The overall 30 -day mortality rate was 24% (85/350 patients). Patients with Echinocandin-resistant candida were associated with high-risk mortality (20%).

Conclusion: Echinocandin-resistant Candida is a major threat in high-risk hematological pediatric cancer patients with a high mortality rate. Therefore, clinicians should pay attention to resistance and Breakthrough Candida even in patients under echinocandin prophylaxis. Antifungal stewardship may be helpful.

No relevant conflicts of interest to declare.