Chest
Volume 138, Issue 5, November 2010, Pages 1186-1195
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Original Research
Cystic Fibrosis
Sputum Candida albicans Presages FEV1 Decline and Hospital-Treated Exacerbations in Cystic Fibrosis

https://doi.org/10.1378/chest.09-2996Get rights and content

Background

The role of Candida albicans in the cystic fibrosis (CF) airway is underexplored. Considered a colonizer, few question its pathogenic potential despite high isolation frequencies from sputum culture. We evaluated the frequency and identified the strongest predictors of C albicans colonization in CF. Independent associations of colonization with clinical outcomes were determined, and the longitudinal effects of C albicans acquisition on BMI and FEV1 were evaluated.

Methods

A prospective observational study of 89 patients with CF was performed (3,916 sputum samples over 11 years). Frequency of C albicans growth in sputum allowed classification of the cohort into colonizers and noncolonizers. BMI, FEV1, hospital-treated exacerbations, and other clinical parameters were followed throughout the study to determine association with colonization status. Multivariate regression determined the strongest predictors of colonization and for clinical effects after adjustment for confounders. Repeated-measures analysis of variance assessed the longitudinal effect of colonization on BMI and FEV1.

Results

Colonization with C albicans was frequent (49.4%) and best predicted by pancreatic insufficiency (P = .014), osteopenia (P = .03), and cocolonization with Pseudomonas species (P = .002). C albicans colonization significantly predicted hospital-treated exacerbations (P = .004) after adjustment for confounders. Exacerbation rate significantly increased in patients with chronic or intermittent colonizations following first acquisition of C albicans. Colonization accelerated rates of decline for BMI (P < .0001) and FEV1 (P < .001).

Conclusion

Airway colonization with C albicans presaged a greater rate of FEV1 decline and hospital-treated exacerbations in CF.

Section snippets

Study Population, Study Period, and Data Collection

A prospective observational study of all patients with CF (confirmed by sweat testing and genotyping) attending our tertiary referral center between January 1998 and December 2008 (11-year period) was performed (N = 89). No exclusion criteria were adopted. Informed consent was obtained from participants and ethical approval from our institutional review board. The presence and frequency of C albicans from sputum culture were recorded. BMI, FEV1, and hospital-treated exacerbations were followed

Study Population Demographics

All demographics are summarized in Table 3. During the study period, 15 patients died, and no patient received a lung transplantation. The F508del homozygous genotype was found at higher frequencies in patients chronically colonized. Four patients (two each from the intermittent and chronic subgroups) had exposure to itraconazole during the study and for no longer than a 6-week period.

Rates of C albicans Colonization

Almost two-thirds (n = 54, 60.7%) of the patients grew C albicans during the study. However, 10 (11.2%) were

Discussion

To our knowledge, this study provides the first suggestion of a pathogenic potential for C albicans in the CF airway, illustrating the delicate balance between commensalism and pathogenicity. We detected high rates of organism isolation and colonization, which may vary among studies because of different culture techniques and the strict criteria we adopted to define colonization.8, 9, 10, 19 Defining a phenotype for airway colonization by C albicans is challenging because the organism is

Acknowledgments

Author contributions: Dr Chotirmall: contributed to the data collection, data analysis, and the writing of the manuscript.

Dr O'Donoghue: contributed to the data collection.

Dr Bennett: contributed to the data analysis.

Dr Gunaratnam: contributed to the data collection.

Dr O'Neill: contributed to the data collection.

Dr McElvaney: contributed to the data collection and the writing of the manuscript.

Financial/nonfinancial disclosure: The authors have reported to CHEST that no potential conflicts of

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