Effective suppression of vancomycin-resistant Enterococcus species in asymptomatic gastrointestinal carriers by a novel glycolipodepsipeptide, ramoplanin

Nosocomial bloodstream infections due to vancomycin-resistant enterococci (VRE) are associated with increased morbidity rates, mortality rates, and hospitalization costs. Gastrointestinal carriage of VRE is an important risk factor for subsequent infections. This 3-arm, phase II, double-blinded, randomized, multicenter, placebo-controlled study evaluated the safety and efficacy of oral ramoplanin (a novel, nonabsorbed glycolipodepsipeptide) versus placebo for suppression of gastrointestinal VRE colonization. Sixty-eight patients who were colonized with VRE were enrolled and received 2 daily doses of ramoplanin (100 mg or 400 mg) or placebo orally for 7 days. The primary end point was the proportion of persons per group from whom VRE were not recovered (VRE-free) on days 7, 14, and 21 after screening. After treatment, VRE-free status was as follows: day 7, none of the 20 patients in the placebo group, and 17 of 21 (P<.001) and 18 of 20 (P<.001) in the 100-mg and 400-mg ramoplanin groups, respectively; on day 14, 2 of 20 patients in the placebo group, and 6 of 21 (P=.134) and 7 of 17 (P=.028), in the 100-mg and 400-mg ramoplanin groups, respectively. By day 21, there were no differences between treatment groups. Adverse events were similar for all treatment groups. Ramoplanin was safe and effective in temporarily suppressing gastrointestinal VRE carriage.

Cryptococcosis in human immunodeficiency virus-negative patients in the era of effective azole therapy

We conducted a case study of human immunodeficiency virus (HIV)-negative patients with cryptococcosis at 15 United States medical centers from 1990 through 1996 to understand the demographics, therapeutic approach, and factors associated with poor prognosis in this population. Of 306 patients with cryptococcosis, there were 109 with pulmonary involvement, 157 with central nervous system (CNS) involvement, and 40 with involvement at other sites. Seventy-nine percent had a significant underlying condition. Patients with pulmonary disease were usually treated initially with fluconazole (63%); patients with CNS disease generally received amphotericin B (92%). Fluconazole was administered to approximately two-thirds of patients with CNS disease for consolidation therapy. Therapy was successful for 74% of patients. Significant predictors of mortality in multivariate analysis included age > or =60 years, hematologic malignancy, and organ failure. Overall mortality was 30%, and mortality attributable to cryptococcosis was 12%. Cryptococcosis continues to be an important infection in HIV-negative patients and is associated with substantial overall and cause-specific mortality.

Fungal infections in older adults

Invasive fungal infections have become an increasing problem in older adults. Infections with opportunistic fungi have increased because older patients are more likely to be considered for transplantation, receive aggressive regimens of chemotherapy for cancer, and take immunosuppressive drugs for nonmalignant diseases. In addition, healthy older adults are now more likely to travel extensively and to indulge in outdoor activities, which put them at risk for exposure to endemic mycoses. Although many of the clinical manifestations of fungal infections in older and younger adults are similar, there are aspects of histoplasmosis, aspergillosis, and cryptococcosis that are unique to older patients. Treatment of older adults with amphotericin B is difficult because of the intrinsic nephrotoxicity of the drug. Although they are less toxic, azoles must be used carefully for treatment of older adults, who are more likely to experience serious drug-drug interactions than are younger persons.

Outbreak of sternal surgical site infections due to Pseudomonas aeruginosa traced to a scrub nurse with onychomycosis

From 19 February 1999 through 31 October 1999, 16 (8.6%) of 185 patients who underwent median sternotomy developed infections with Pseudomonas aeruginosa. Seven patients had mediastinitis, 5 had deep sternal wound infection, 2 had superficial sternal wound infection, 1 had prosthetic valve endocarditis, and 1 had sepsis. Pulsed-field gel electrophoresis confirmed that all 13 isolates that were available for typing were the same strain. Cultures of hand specimens identified 1 nurse from whom the same strain of P. aeruginosa was repeatedly isolated; the nurse had been in contact with all 16 infected patients. Investigation revealed that the nurse had severe onycholysis and onychomycosis of the right thumbnail. Cultures of samples of this nail's subungual region and of multiple cosmetic products from the nurse's home yielded the identical P. aeruginosa strain. This outbreak of surgical site infections due to P. aeruginosa was caused by wound contamination from the thumbnail of this nurse, despite her appropriate use of latex surgical gloves.

Need for alternative trial designs and evaluation strategies for therapeutic studies of invasive mycoses

Studies of invasive fungal infections have been and remain difficult to implement. Randomized clinical trials of fungal infections are especially slow and expensive to perform because it is difficult to identify eligible patients in a timely fashion, to prove the presence of the fungal infection in an unequivocal fashion, and to evaluate outcome in a convincing fashion. Because of these challenges, licensing decisions for antifungal agents have to date depended heavily on historical control comparisons and secondary advantages of the new agent. Although the availability of newer and potentially more effective agents makes these approaches less desirable, the fundamental difficulties of trials of invasive fungal infections have not changed. Therefore, there is a need for alternative trial designs and evaluation strategies for therapeutic studies of invasive mycoses, and this article summarizes the possible strategies in this area.

Deep Candida infections in the neutropenic and non-neutropenic host: an ISHAM symposium

A symposium was held on May 8, 2000 to discuss the management of deep infections with Candida species. Among the findings discussed were the following. Candiduria is most often benign, though it occurs in patients with serious underlying diseases. Candida species are now the fourth most common cause of nosocomial bloodstream infections, usually arising from an intravenous catheter. Candida albicans represents only 50-60% of the isolates. There has been no change in the frequency of fluconazole resistance in C. albicans but some of the other species now being isolated from blood are constitutively more resistant to this drug. Nevertheless, for most non-neutropenic patients with candidemia, fluconazole is a reasonable choice for initial therapy. In the neutropenic patient, candidemia is now uncommon. Deep candida infections in neutropenic patients are usually being treated empirically with an amphotericin B formulation. Hepatosplenic candidiasis is usually detected only after recovery from neutropenia but can be suspected by imaging techniques. Improved diagnostic techniques for deep candidiasis in the neutropenic patient remain a critical requirement.

Effectiveness of a vancomycin restriction policy in changing the prescribing patterns of house staff

After noting a rise in vancomycin-resistant enterococci (VRE) infections, we initiated a program to decrease inappropriate vancomycin use that focused on improvement of house staff prescribing practices. The initial intervention in June, 1995, encouraging house staff to follow hospital guidelines for vancomycin use and eliciting support from service chiefs in this effort, had little impact. A more intensive educational intervention, beginning in January, 1996, involved concurrent review of all vancomycin orders and one-on-one discussion with the house staff regarding the rationale for the order by an infectious diseases clinical pharmacist. When usage was deemed inappropriate, the pharmacist asked that vancomycin be discontinued, but no automatic stop orders were issued. During the next two and one-half years, this second intervention proved effective at decreasing inappropriate use from 39% to 16.8% +/- 2.4% (p = 0.005). This change was primarily due to a decrease in appropriate vancomycin prophylaxis by cardiothoracic surgery. VRE infections decreased from 0.29/100 patients discharged prior to initiating the program to 0.13/100 patients discharged after the second intervention (p = 0.01). This educational program, although labor-intensive, preserved house staff decision-making skills related to antibiotic prescribing at the same time that it decreased inappropriate vancomycin use.

Multicenter case-control study of risk factors for histoplasmosis in human immunodeficiency virus-infected persons

We conducted a multicenter case-control study to identify risk factors for histoplasmosis among persons with acquired immunodeficiency syndrome (AIDS) and to evaluate predictors of a poor outcome (defined as death or admission to the intensive care unit). Patients with histoplasmosis were each matched by age, sex, and CD4 lymphocyte count to 3 controls. From 1996 through 1999, 92 case patients and 252 controls were enrolled. Of the case patients, 81 (89%) were men, 50 (55%) were black, 78 (85%) had a CD4 lymphocyte count of <100 cells/microL, 80 (87%) were hospitalized, and 11 (12%) died. Multivariable analysis found that receipt of antiretroviral therapy and of triazole drugs were independently associated with a decreased risk of histoplasmosis. Chronic medical conditions and a history of infections with herpes simplex virus were associated with poor outcome. Triazoles should be considered for chemoprophylaxis for persons with AIDS, especially those who take part in high-risk activities that involve frequent exposure to soil, who have CD4 lymphocyte counts of <100 cells/microL, and who live in areas where histoplasmosis is endemic.

DNA fingerprinting of serial Candida albicans isolates obtained during itraconazole prophylaxis in patients with AIDS

During a randomized double-blind placebo-controlled study testing the efficacy of itraconazole for prophylaxis of systemic and mucosal fungal infections in patients with acquired immune deficiency syndrome, 298 patients were enrolled with 295 evaluable. Of those, 46 patients were considered prophylaxis failures because of recurrent oral or esophageal candidiasis. Oropharyngeal fungal cultures were taken at the time of suspected thrush or Candida esophagitis, but not at baseline. All of the Candida spp. isolates were cultured on CHROMagar Candida medium then identified using API 20 AUX strips. Antifungal susceptibility testing was performed following the National Committee for Clinical Laboratory Standards M-27A guidelines. Sequential isolates were genotyped using randomly amplified polymorphic DNA. Polymerase chain reaction fingerprints were generated using two repetitive sequence primers, (GGA)7 and (GACA)4. The study group consisted of 23 patients, nine from the itraconazole arm and 14 from the placebo arm, who were prophylaxis failures and had more than two C. albicans isolates. Five of 23 had isolates showing a > or =4-fold reduction in susceptibility; four of these patients were in the itraconazole prophylaxis arm and one was in the placebo arm. Three of the five had yeast isolations showing changes in banding patterns over time. Such changes may indicate genetic changes in the same strain that could be linked to acquired resistance to itraconazole, or acquisition of a new strain, or emergence of a previously minor component of the original population.

Disseminated Dactylaria constricta infection in a renal transplant recipient

We report the case of a 32-year-old renal transplant recipient who developed disseminated Dactylaria constricta infection. The patient died despite treatment with amphotericin B, itraconazole, and fluconazole.

Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers

This study was undertaken to determine differences in microflora on the nails of health care workers (HCWs) wearing artificial nails compared with control HCWs with native nails and to assess the effect on these microflora of hand cleansing with antimicrobial soap or alcohol-based gel. Cultures were obtained from 21 HCWs wearing artificial nails and 20 control HCWs before and after using antimicrobial soap or alcohol-based gel. Before cleansing with soap, 86% of HCWs with artificial nails had a pathogen (gram-negative bacilli, Staphylococcus aureus, or yeasts) isolated, compared with 35% of controls (P=.003); a similar difference was noted before hand cleansing with gel (68% vs. 28%; P=.03). Significantly more HCWs with artificial nails than controls had pathogens remaining after hand cleansing with soap or gel. Of HCWs with artificial nails, only 11% cleared pathogens with soap compared with 38% with gel. Of control HCWs, only 14% cleared with soap compared with 80% with gel. Artificial acrylic fingernails could contribute to the transmission of pathogens, and their use by HCWs should be discouraged.

Epidemiology of yeast colonization in the intensive care unit

In order to investigate the epidemiology of colonization and possible transmission of yeasts among patients and healthcare workers in adult intensive care units (ICUs), 194 patients were followed for a mean of 9 +/- 11 days and 63 healthcare workers were followed for a mean of 132 +/- 52 days. Among the patients, 142 (73%) were colonized by yeast, with Candida albicans being the species most commonly recovered. Most patients (65%) were already colonized with yeast upon admission to the intensive care unit; only 17% became colonized after admission. Persistent colonization occurred in 51 (55%) of 92 patients who had more than three cultures performed; in 75% of them, colonization persisted with the same strain of Candida albicans or Candida glabrata. Bacterial infection in the month preceding entry into the ICU was the only risk factor significantly associated with yeast colonization. Among the healthcare workers, yeasts were isolated from 42 (67%). Candida albicans was most frequently recovered from the oropharynx (19% of occasions), and Candida parapsilosis was most frequently found on hands (8% of occasions). Persistent colonization of the oropharynx occurred in only six healthcare workers, and none had persistence of yeasts on hands. In this non-outbreak setting, 5 (4%) of 123 patient/healthcare worker interactions that were linked epidemiologically yielded the same strain of Candida albicans, providing evidence for possible cross-transmission. No similar link was found between healthcare worker-patient interactions and colonization with Candida glabrata or Candida parapsilosis.

Pathogenic organisms associated with artificial fingernails worn by healthcare workers

OBJECTIVE

To determine differences in the identity and quantity of microbial flora from healthcare workers (HCWs) wearing artificial nails compared with control HCWs with native nails.

DESIGN

Two separate studies were undertaken. In study 1, 12 HCWs who did not normally wear artificial nails wore polished artificial nails on their nondominant hand for 15 days. Identity and quantity of microflora were compared between the artificial nails and the polished native nails of the other hand. In study 2, the microbial flora of the nails of 30 HCWs who wore permanent acrylic artificial nails were compared with that of control HCWs who had native nails. In both studies, nail surfaces were swabbed and subungual debris was collected to obtain material for culture. Staphylococcus aureus, gram-negative bacilli, enterococci, and yeasts were considered to be potential pathogens. All organisms were identified and quantified.

RESULTS

In study 1, potential pathogens were isolated from more samples obtained from artificial nails than native nails (92% vs. 62%; P<.001). Colonization of artificial nails increased over time; by day 15, 71% of cultures yielded a pathogen compared with 21% on day 1 (P=.004). A significantly greater quantity of organisms (expressed as mean log10 colony-forming units +/- standard deviation) was isolated from the subungual area than the nail surface; this was noted for both artificial (5.0+/-1.4 vs. 4.1+/-1.0; P<.001) and native nails (4.9+/-1.3 vs. 3.7+/-0.8; P<.001). More organisms were found on the surface of artificial nails than native nails (P=.008), but there were no differences noted in the quantities of organisms isolated from the subungual areas. In study 2, HCWs wearing artificial nails were more likely to have a pathogen isolated than controls (87% vs. 43%; P=.001). More HCWs with artificial nails had gram-negative bacilli (47% vs. 17%; P=.03) and yeasts (50% vs. 13%; P=.006) than control HCWs. However, the quantities of organisms isolated from HCWs wearing artificial nails and controls did not differ.

CONCLUSIONS

Artificial fingernails were more likely to harbor pathogens, especially gram-negative bacilli and yeasts, than native nails. The longer artificial nails were worn, the more likely that a pathogen was isolated. Current recommendations restricting artificial fingernails in certain healthcare settings appear justified.

Does long-term itraconazole prophylaxis result in in vitro azole resistance in mucosal Candida albicans isolates from persons with advanced human immunodeficiency virus infection? The National Institute of Allergy and Infectious Diseases Mycoses study group

The effects of prolonged itraconazole exposure on the susceptibility of Candida albicans isolates to itraconazole and fluconazole have not been well characterized. A recent placebo-controlled study of long-term itraconazole antifungal prophylaxis in persons with advanced human immunodeficiency virus infection afforded the opportunity to address this question. Mucosal Candida sp. isolates were obtained from subjects who developed oropharyngeal or esophageal candidiasis, and in vitro susceptibilities of the last isolate obtained at removal from the study as a prophylaxis failure were compared in itraconazole and placebo recipients. More subjects in the placebo group (74 of 146 [51%]) than in the itraconazole group (51 of 149 [34%]) developed mucosal candidiasis (P = 0.004). A total of 112 isolates were recovered from 56 of the 74 (76%) subjects with mucosal candidiasis assigned to the placebo group, compared to 97 isolates from 45 of the 51 (88%) subjects in the itraconazole group. C. albicans accounted for 98% of isolates in the placebo group and 89% of isolates in the itraconazole group. The itraconazole MIC at which 50% of the isolates tested were inhibited (MIC(50)) for last-episode isolates from the itraconazole group was 0.125 microg/ml compared to 0.015 microg/ml for the placebo group subjects, P = 0.0001. The MIC(50) of fluconazole for the last isolates from the itraconazole group was 1.5 microg/ml compared to 0.5 microg/ml for the placebo subjects (P = 0.005). A lower proportion of isolates recovered from subjects on itraconazole therapy were classified as susceptible to itraconazole (63%) compared to isolates from the placebo group (96%) (P = 0.001). Similarly, a lower proportion of C. albicans isolates from subjects on itraconazole therapy were susceptible to fluconazole (78%) compared to isolates from the placebo group (96%) (P = 0.01). Also, the proportion of isolates that were not fully susceptible to itraconazole or fluconazole was greater in patients assigned to the itraconazole group than the placebo group (itraconazole susceptibility, 37 and 4%, respectively (P = 0.001); fluconazole susceptibility, 23 and 4%, respectively (P = 0.01). In conclusion, long-term itraconazole prophylaxis in patients with AIDS is associated with reduction in susceptibility to itraconazole and cross-resistance to fluconazole.

Practice guidelines for the management of patients with blastomycosis. Infectious Diseases Society of America

Guidelines for the treatment of blastomycosis are presented; these guidelines are the consensus opinion of an expert panel representing the National Institute of Allergy and Infectious Diseases Mycoses Study Group and the Infectious Diseases Society of America. The clinical spectrum of blastomycosis is varied, including asymptomatic infection, acute or chronic pneumonia, and extrapulmonary disease. Most patients with blastomycosis will require therapy. Spontaneous cures may occur in some immunocompetent individuals with acute pulmonary blastomycosis. Thus, in a case of disease limited to the lungs, cure may have occurred before the diagnosis is made and without treatment; such a patient should be followed up closely for evidence of disease progression or dissemination. In contrast, all patients who are immunocompromised, have progressive pulmonary disease, or have extrapulmonary disease must be treated. Treatment options include amphotericin B, ketoconazole, itraconazole, and fluconazole. Amphotericin B is the treatment of choice for patients who are immunocompromised, have life-threatening or central nervous system (CNS) disease, or for whom azole treatment has failed. In addition, amphotericin B is the only drug approved for treating blastomycosis in pregnant women. The azoles are an equally effective and less toxic alternative to amphotericin B for treating immunocompetent patients with mild to moderate pulmonary or extrapulmonary disease, excluding CNS disease. Although there are no comparative trials, itraconazole appears more efficacious than either ketoconazole or fluconazole. Thus, itraconazole is the initial treatment of choice for nonlife-threatening non-CNS blastomycosis.

Practice guidelines for the management of patients with sporotrichosis. For the Mycoses Study Group. Infectious Diseases Society of America

The recommendations for the treatment of sporotrichosis were derived primarily from multicenter, nonrandomized treatment trials, small retrospective series, and case reports; no randomized, comparative treatment trials have been reported. Most cases of sporotrichosis are non life-threatening localized infections of the skin and subcutaneous tissues that can be treated with oral antifungal agents. The treatment of choice for fixed cutaneous or lymphocutaneous sporotrichosis is itraconazole for 36 months. The preferred treatment for osteoarticular sporotrichosis also is itraconazole, but therapy must be continued for at least 12 months. Pulmonary sporotrichosis responds poorly to treatment. Severe infection requires treatment with amphotericin B; mild to moderate infection can be treated with itraconazole. Meningeal and disseminated forms of sporotrichosis are rare and usually require treatment with amphotericin B. AIDS patients most often have disseminated infection and require life-long suppressive therapy with itraconazole after initial use of amphotericin B.

OVERVIEW

Sporotrichosis is caused by the dimorphic fungus Sporothrix schenckii, which is found throughout the world in decaying vegetation, sphagnum moss, and soil. The usual mode of infection is by cutaneous inoculation of the organism. Pulmonary and disseminated forms of infection, although uncommon, can occur when S. schenckii conidia are inhaled. Infections are most often sporadic and usually associated with trauma during the course of outdoor work. Infection can also be related to zoonotic spread from infected cats or scratches from digging animals, such as armadillos. Outbreaks have been well-described and often are traced back to activities that involved contaminated sphagnum moss, hay, or wood. Most cases of sporotrichosis are localized to the skin and subcutaneous tissues. Dissemination to osteoarticular structures and viscera is uncommon and appears to occur more often in patients who have a history of alcohol abuse or immunosuppression, especially AIDS. Spontaneous resolution of sporotrichosis is rare, and treatment is required for most patients. Although sporotrichosis localized to skin and subcutaneous tissues is readily treated, management of osteoarticular, other localized visceral, and disseminated forms of sporotrichosis is difficult.

OBJECTIVE

The objective of these guidelines is to provide recommendations for the treatment of various forms of sporotrichosis.

OUTCOMES

The desired outcomes of treatment include eradication of S. schenckii from tissues, resolution of symptoms and signs of active infection, and return of function of involved organs. In persons with AIDS, eradication of the organism may not be possible, but clinical resolution should be attained and subsequently maintained with suppressive antifungal therapy.

EVIDENCE

The English-language literature on the treatment of sporotrichosis was reviewed. Although randomized, blinded, controlled treatment trials were sought, none were found to have been performed for the treatment of sporotrichosis. Therefore, most weight was placed on those reports that were derived from multicenter trials of specific treatment modalities for sporotrichosis. Small series from a single institution and individual case reports were accorded less importance.

VALUES

The highest value was placed on clinical efficacy and the ability of the antifungal regimen to eradicate the organism, but safety, tolerability, and cost of therapy were also valued. BENEFITS AND COSTS: The benefits of successfully treating sporotrichosis accrue primarily for the patient. Because this infection is not spread from person-to-person, public health aspects of treatment are of minor importance. Most forms of sporotrichosis are not life-threatening; thus, therapy is aimed at decreasing morbidity, improving quality of life, and allowing the patient to return to occupational and familial pursuits. (ABSTRACT TRUNCATED)

Prevention and prophylaxis of invasive fungal sinusitis in the immunocompromised patient

Fungal infections are a leading cause of morbidity and mortality among immunocompromised patients. Invasive fungal sinusitis is a devastating complication of immunosuppression. Treatment options are limited and often ineffective, making prevention important. Measures to decrease environmental exposure, indications for antifungal prophylaxis, and limitations of current regimens are discussed.

Prospective multicenter surveillance study of funguria in hospitalized patients. The National Institute for Allergy and Infectious Diseases (NIAID) Mycoses Study Group

Although fungal urinary tract infections are an increasing nosocomial problem, the significance of funguria is still not clear. This multicenter prospective surveillance study of 861 patients was undertaken to define the epidemiology, management, and outcomes of funguria. Diabetes mellitus was present in 39% of patients, urinary tract abnormalities in 37.7%, and malignancy in 22.2%; only 10.9% had no underlying illnesses. Concomitant nonfungal infections were present in 85%, 90% had received antimicrobial agents, and 83.2% had urinary tract drainage devices. Candida albicans was found in 51.8% of patients and Candida glabrata in 15.6%. Microbiological and clinical outcomes were documented for 530 (61.6%) of the 861 patients. No specific therapy for funguria was given to 155 patients, and the yeast cleared from the urine of 117 (75.5%) of them. Of the 116 patients who had a catheter removed as the only treatment, the funguria cleared in 41 (35.3%). Antifungal therapy was given to 259 patients, eradicating funguria in 130 (50.2%). The rate of eradication with fluconazole was 45.5%, and with amphotericin B bladder irrigation it was 54.4%. Only 7 patients (1.3%) had documented candidemia. The mortality rate was 19.8%, reflecting the multiple serious underlying illnesses found in these patients with funguria.

Candiduria: a randomized, double-blind study of treatment with fluconazole and placebo. The National Institute of Allergy and Infectious Diseases (NIAID) Mycoses Study Group

Management of candiduria is limited by the lack of information about its natural history and lack of data from controlled studies on the efficacy of treating it with antimycotic agents. We compared fungal eradication rates among 316 consecutive candiduric (asymptomatic or minimally symptomatic) hospitalized patients treated with fluconazole (200 mg) or placebo daily for 14 days. In an intent-to-treat analysis, candiduria cleared by day 14 in 79 (50%) of 159 receiving fluconazole and 46 (29%) of 157 receiving placebo (P<.001), with higher eradication rates among patients completing 14 days of therapy (P<.0001), including 33 (52%) of 64 catheterized and 42 (78%) of 54 noncatheterized patients. Pretreatment serum creatinine levels were inversely related to candiduria eradication. Fluconazole initially produced high eradication rates, but cultures at 2 weeks revealed similar candiduria rates among treated and untreated patients. Oral fluconazole was safe and effective for short-term eradication of candiduria, especially following catheter removal. Long-term eradication rates were disappointing and not associated with clinical benefit.

Colorimetric method for susceptibility testing of voriconazole and other triazoles against Candida species

A microdilution assay using Alamar Blue, a colorimetric indicator, was compared with the NCCLS macrodilution broth assay for voriconazole, fluconazole, and itraconazole against Candida albicans, Candida glabrata, and Candida krusei. Concordance (+/- 2 dilutions) between the two methods was highest for voriconazole (98.3%), and for fluconazole and itraconazole it was 94.3 and 95.4%, respectively. Twenty-six of 32 (81.2%) discordant readings (> or = 3 dilutions different) were noted in C. glabrata isolates, and all but two isolates showing discordance had higher minimum inhibitory concentration readings with the colorimetric method.

Itraconazole prophylaxis for fungal infections in patients with advanced human immunodeficiency virus infection: randomized, placebo-controlled, double-blind study. National Institute of Allergy and Infectious Diseases Mycoses Study Group

In a prospective, randomized, double-blind trial, 149 patients with advanced human immunodeficiency virus (HIV) infection were randomized to receive itraconazole capsules (200 mg daily) and 146 to receive a matched placebo. Both groups were monitored for evidence of fungal infections. Baseline characteristics of the two groups were similar. Failure of prophylaxis occurred in 29 (19%) of the itraconazole recipients and 42 (29%) of the placebo recipients (P = .004; log-rank test). There were 6 invasive fungal infections in the itraconazole group (4, histoplasmosis; 1, cryptococcosis; 1, aspergillosis) and 19 in the placebo group (10, histoplasmosis; 8, cryptococcosis; 1, aspergillosis) (P = .0007; log-rank test). Itraconazole significantly delayed time to onset of histoplasmosis (P = .03; log-rank test) and cryptococcosis (P = .0005; log-rank test). Prophylaxis failure due to recurrent or refractory mucosal candidiasis occurred with similar frequency in the two groups (itraconazole, 15%; placebo, 16%). A survival benefit was not demonstrated. Itraconazole generally was well tolerated. Primary prophylaxis with itraconazole capsules prevents histoplasmosis and cryptococcosis in patients with HIV infection.