Guidelines for Treatment of Candidiasis

Gastrointestinal complications of oncologic therapy

Gastrointestinal complications are common in patients undergoing various forms of cancer treatment, including chemotherapy, radiation therapy, and molecular-targeted therapies. Many of these complications are life-threatening and require prompt diagnosis and treatment. Complications of oncologic therapy can occur in the esophagus (esophagitis, strictures, bacterial, viral and fungal infections), upper gastrointestinal tract (mucositis, bleeding, nausea and vomiting), colon (diarrhea, graft-versus-host disease, colitis and constipation), liver (drug hepatotoxicity and graft-versus-host disease), and pancreas (pancreatitis). Treatment of the different gastrointestinal complications should be tailored to the individual patient and based on the underlying pathophysiology of the complication.

Recommendations for the treatment of established fungal infections

Evidence-based guidelines for the treatment of established fungal infections in the adult haematology/oncology setting were developed by a national consensus working group representing clinicians, pharmacists and microbiologists. These updated guidelines replace the previous guidelines published in the Internal Medicine Journal by Slavin et al. in 2004. The guidelines are pathogen-specific and cover the treatment of the most common fungal infections including candidiasis, aspergillosis, cryptococcosis, zygomycosis, fusariosis, scedosporiosis, and dermatophytosis. Recommendations are provided for management of refractory disease or salvage therapies, and special sites of infections such as the cerebral nervous system and the eye. Because of the widespread use newer broad-spectrum triazoles in prophylaxis and empiric therapy, these guidelines should be implemented in concert with the updated prophylaxis and empiric therapy guidelines published by this group.

Candidemia in the 21st century

The 21st century has brought forth vast innovations in the healthcare field. The availability and use of aggressive chemotherapeutic and immunosuppressive agents as well as broad-spectrum antibacterial agents has created a large population of patients who are at increased risk of acquiring infections with fungal organisms, especially Candida species. This review will focus on the changing epidemiology of candidal bloodstream infections, its impact on healthcare and new advances in the diagnosis and treatment of candidemia.

Population pharmacokinetics of fluconazole in young infants

Fluconazole is being increasingly used to prevent and treat invasive candidiasis in neonates, yet dosing is largely empirical due to the lack of adequate pharmacokinetic (PK) data. We performed a multicenter population PK study of fluconazole in 23- to 40-week-gestation infants less than 120 days of age. We developed a population PK model using nonlinear mixed effect modeling (NONMEM) with the NONMEM algorithm. Covariate effects were predefined and evaluated based on estimation precision and clinical significance. We studied fluconazole PK in 55 infants who at enrollment had a median (range) weight of 1.02 (0.440 to 7.125) kg, a gestational age at birth (BGA) of 26 (23 to 40) weeks, and a postnatal age (PNA) of 2.3 (0.14 to 12.6) weeks. The final data set contained 357 samples; 217/357 (61%) were collected prospectively at prespecified time intervals, and 140/357 (39%) were scavenged from discarded clinical specimens. Fluconazole population PK was best described by a one-compartment model with covariates normalized to median values. The population mean clearance (CL) can be derived for this population by the equation CL (liter/h) equals 0.015 . (weight/1)(0.75) . (BGA/26)(1.739) . (PNA/2)(0.237) . serum creatinine (SCRT)(-4.896) (when SCRT is >1.0 mg/dl), and using a volume of distribution (V) (liter) of 1.024 . (weight/1). The relative standard error around the fixed effects point estimates ranged from 3 to 24%. CL doubles between birth and 28 days of age from 0.008 to 0.016 and from 0.010 to 0.022 liter/kg/h for typical 24- and 32-week-gestation infants, respectively. This population PK model of fluconazole discriminated the impact of BGA, PNA, and creatinine on drug CL. Our data suggest that dosing in young infants will require adjustment for BGA and PNA to achieve targeted systemic drug exposures.

Antifungal therapies in the intensive care unit

Fungal infections are increasing nationwide, paralleling increases in the number of immunosuppressed hosts. Most of the candida infections seen in the intensive care unit are likely due to iatrogenic factors such as hyperalimentation, catheters, broad-spectrum antibiotics, and postprocedure complications that are prevalent in intensive care unit patients. Delays in appropriate therapy are common and may compromise care. Fortunately, the recognition of several clinical syndromes in the intensive care unit that require specialized treatment can improve outcomes. The issue of antifungal prophylaxis has to be balanced against issues of resistance, and current guidelines are reviewed here for prophylactic use of fluconazole only in selected intensive care unit patients. Finally, several new antifungal agents are available to treat the emerging resistant fungi, with better toxic/therapeutic ratios than in the past. Thus, there are an increasing number of safer and more effective options for treating fungal infections in the intensive care unit.

Validation of 24-hour fluconazole MIC readings versus the CLSI 48-hour broth microdilution reference method: results from a global Candida antifungal surveillance program

We performed 24- and 48-h MIC determinations and disk diffusion testing of fluconazole against more than 11,000 clinical isolates of Candida species. By using the reference MIC breakpoints, the categorical agreement between the 24-h and reference 48-h broth microdilution results ranged from 93.8% (all Candida species) to 94.9% (all Candida species minus Candida krusei), with only 0.1% very major errors (VME). The essential agreement (within 2 log(2) dilutions) between the 24-h and 48-h results was 99.6%. The categorical agreement between the 24-h disk diffusion results and the 24-h MIC results, using the previously established breakpoints, was 94.4%, with 0.1% VME. Both the MIC and the disk diffusion results obtained for fluconazole after only 24 h of incubation may be used to determine the susceptibilities of Candida spp. to this widely used antifungal agent.

Successful resolution of cardiac mycetomas by combined liposomal Amphotericin B with Fluconazole treatment in premature neonates

This manuscript reports on two very low birth weight premature infants with respiratory distress, receiving parenteral nutrition and broad-spectrum antibiotics for about 3 weeks, who developed Candida albicans sepsis associated with fungal mycoses and endocarditis, despite treatment with Amphotericin B and Caspofungin. On days 40 and 47, respectively, antifungal therapy was modified to liposomal Amphotericin B combined with Fluconazole 6 mg/kg/day for 4 weeks, resulting in complete resolution of the mycetomas. Our observations suggest that the combination of liposomal Amphotericin B with Fluconazole is able to result in complete resolution of cardiac mycetomas in preterm infants.

Micafungin versus liposomal amphotericin B for pediatric patients with invasive candidiasis: substudy of a randomized double-blind trial

BACKGROUND

Invasive candidiasis is increasingly prevalent in premature infants and seriously ill children, and pediatric data on available antifungal therapies are lacking.

METHODS

We conducted a pediatric substudy as part of a double-blind, randomized, multinational trial to compare micafungin (2 mg/kg) with liposomal amphotericin B (3 mg/kg) as first-line treatment of invasive candidiasis. Treatment success was defined as clinical and mycologic response at the end of therapy. Statistical analyses were descriptive, as the sample size meant that the study was not powered for hypothesis testing.

RESULTS

One hundred six patients were included in the intent-to-treat population; and 98 patients-48 patients in the micafungin group and 50 patients in the liposomal amphotericin B group-in the modified intent-to-treat population. Baseline characteristics were balanced between treatment groups. Overall, 57 patients were <2 years old including 19 patients who were premature at birth; and 41 patients were 2 to <16 years old. Most patients (91/98, 92.9%) had candidemia, and 7/98 (7.1%) patients had other forms of invasive candidiasis. Treatment success was observed for 35/48 (72.9%) patients treated with micafungin and 38/50 (76.0%) patients treated with liposomal amphotericin B. The difference in proportions adjusted for neutropenic status was -2.4% [95% CI: (-20.1 to 15.3)]. Efficacy findings were consistent, independent of the neutropenic status, the age of the patient, and whether the patient was premature at birth. Both treatments were well tolerated, but with a lower incidence of adverse events that led to discontinuation in the micafungin group (2/52, 3.8%) compared with the liposomal amphotericin B group (9/54, 16.7%) (P = 0.05, Fisher exact test).

CONCLUSIONS

Micafungin seems to be similarly effective and as safe as liposomal amphotericin B for the treatment of invasive candidiasis in pediatric patients. (ClinicalTrials.gov number, NCT00106288).

Treatment of invasive candidal infections: systematic review and meta-analysis

OBJECTIVE

To compare available antifungal treatments for invasive candidiasis, a leading cause of nosocomial bloodstream infections.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials that compared different antifungal agents for the treatment of candidemia and other forms of invasive candidiasis. Two reviewers independently appraised the quality of trials and extracted data. The primary outcome was all-cause mortality, and secondary outcomes were microbiological failure, treatment failure, and adverse events. Relative risks (RRs) with 95% confidence intervals (CIs) were pooled.

RESULTS

Of the 15 included trials, 9 compared fluconazole with other drugs (amphotericin B, itraconazole, or a combination of fluconazole and amphotericin B), 4 compared echinocandins with other drugs (fluconazole, amphotericin B, liposomal amphotericin B), 1 compared micafungin and caspofungin, and 1 compared amphotericin B plus fluconazole and voriconazole. No difference in mortality was observed with fluconazole vs amphotericin B (RR, 0.92; 95% CI, 0.72-1.17); however, the rate of microbiological failure increased in the fluconazole arm (RR, 1.52; 95% CI, 1.12-2.07). Anidulafungin decreased the rate of microbiological failure compared with fluconazole (RR, 0.50; 95% CI, 0.29-0.86) with fewer adverse events. Caspofungin was comparable to amphotericin B in mortality and efficacy, with fewer adverse events requiring discontinuation (RR, 0.11; 95% CI, 0.04-0.36). Micafungin was comparable to liposomal amphotericin B in mortality.

CONCLUSION

All assessed antifungal agents showed similar efficacy, but the rate of microbiological failure increased with fluconazole vs amphotericin B or anidulafungin. Amphotericin B is associated with a higher rate of adverse events than fluconazole and echinocandins.

Risk factors in a patient with fungemia caused by fluconazole-resistant Candida albicans

Blood stream infections due to Candida species are becoming increasingly important causes of morbidity and mortality in hospitalized patients. Risk factors that predispose patients to developing invasive Candida infections have been documented as, iatrogenic and/or nosocomial conditions and immunosuppression. In the present report, we want to emphasize the risk factors that predispose individuals to the development of candidemia, particularly those that are relevant to our patient. We describe a female patient with diabetes mellitus who had been receiving glucocorticoids for 20 years as replacement therapy for hypopituitarism resulting from hypophysis adenoma surgery. The patient received antibiotic therapy for recurrent wound infections and was hospitalized for a long time, including a period in the intensive care unit and instrumented. The patient eventually succumbed to fungemia caused by a fluconazole-resistant strain of C. albicans strain.

New options for treatment of candidaemia in critically ill patients

Bloodstream infections caused by Candida spp. are increasingly recognised in critically ill adult and paediatric individuals, with significant associated morbidity and mortality. Candida albicans is the single most common fungal species to cause nosocomial infections. However, non-C. albicans spp., including Candida glabrata and Candida krusei, which are less susceptible to fluconazole, have become more common. Until the 1980s, the therapeutic possibilities for invasive candidosis were limited to amphotericin B, but with the advent of new antifungal agents, such as azoles and echinocandins, less toxic therapeutic options have become available and there are now possibilities for prevention and optimised therapy for documented Candida infections. In this review, the currently available options for the treatment of candidaemia and invasive candidosis are discussed with regard to the role of liposomal amphotericin B in comparison with the echinocandins and azoles.

Combination antifungal therapy: a critical review of the evidence

Invasive fungal infections have extremely high rates of morbidity and mortality, particularly in immunocompromised hosts. Combination antifungal therapy is conceptually attractive as a life-saving measure. However, in-vitro and in-vivo evidence is often conflicting and clinical trials in this area are limited. Most clinical studies show similar outcomes for combination antifungal therapy when compared to monotherapy, although secondary endpoints and sub-analyses often show advantages for the combinations in endpoints such as culture sterilisation. The logistics of large clinical trials of combination therapy are highly complex. Combination of antifungals with immune modulators is an exciting new research area. Until more data are available, clinicians should approach combination antifungal therapy with caution.

Utility of the germ tube test for direct identification of Candida albicans from positive blood culture bottles

We compared the germ tube test for the direct identification of Candida albicans from positive blood culture bottles, with results obtained from subcultured colonies. The direct germ tube test was 87.1% sensitive and 100% specific for the identification of C. albicans when the results obtained from fungal colonies were compared.

Treatment of central venous catheter fungal infection using liposomal amphotericin-B lock therapy

The current standard of care for a fungal central venous catheter infection in a pediatric patient usually requires removal without any other feasible options. Although removal may reduce the rate of Candida-associated complications, literature reviews question whether the outcomes of removal substantiate this being the standard of care. We report 6 cases of central venous catheter fungal infections treated with liposomal amphotericin-B lock therapy. These cases consisted of 4 patients, 2 of whom received recurrent therapy. In 4 of these cases, there was successful eradication of the infectious fungal agent, allowing continued use of the catheter. A controlled study of antifungal lock therapy should be considered as a potential alternative to removal.

Candidemia in nonneutropenic critically ill patients: risk factors for non-albicans Candida spp

OBJECTIVE

The objective of this study was to determine the clinical features associated with candidemia caused by non-albicans Candida spp. and with potentially fluconazole-resistant Candida spp. (C. glabrata and C. krusei) among candidemic intensive care unit patients.

DESIGN

The authors conducted a nationwide prospective cohort study.

SETTING

The study was conducted in Australian intensive care units.

PATIENTS

All patients with intensive care unit-acquired candidemia over a 3-yr period were included in the study.

MEASUREMENTS

Clinical risk factors occurring up to 30 days before candidemia, Candida spp. associated with candidemia, and outcomes were determined. Risk factors associated with either non-albicans Candida spp. or with potentially fluconazole-resistant Candida spp. (C. glabrata or C. krusei) were assessed using multivariate logistic regression.

MAIN RESULTS

Among 179 episodes of intensive care unit-acquired candidemia, C. albicans accounted for 62%, C. glabrata 18%, C. krusei 4%, and other Candida spp. 16%. Independently significant variables associated with non-albicans Candida bloodstream infection included recent prior gastrointestinal surgery (adjusted odds ratio, 2.87; 95% confidence interval, 1.68-4.91) and recent prior systemic antifungal exposure (4.6; 1.36-15.53). Those associated with potentially fluconazole-resistant candidemia included recent prior gastrointestinal surgery (3.31; 1.79-6.11) and recent prior fluconazole exposure (5.47; 1.23-24.32). No significant differences in outcomes were demonstrated for non-albicans or potentially fluconazole-resistant candidemia.

CONCLUSIONS

Among candidemic intensive care unit patients, prior gastrointestinal surgery and systemic antifungal exposure were significantly associated with both a non-albicans Candida spp. and a potentially fluconazole-resistant Candida spp.

Epidemiology and clinical outcome of candidaemia among Jordanian newborns over a 10-year period

This retrospective study includes all newborn patients with culture proved candidaemia who were admitted to the neonatal intensive care unit of Jordan University Hospital through the period January 1995 to June 2006. Among 24 patients included, 13 (54.2%) died. The incidence of candidaemia was 0.27%, the mean age at diagnosis 25.9 d and the mean gestational age at birth 34.6 weeks. Species most frequently isolated were Candida albicans (50%) and C. krusei (20%). Previous gastrointestinal pathology was present in 41.7% of the cases. A comparison of cases due to C. albicans with those due to other species of Candida revealed no statistical differences in terms of demographic factors, age at onset of disease, mortality, clinical manifestations or risk factors. Based on our results, empirical antifungal therapy should be considered in neonates who have gastrointestinal pathology and other risk factors.

Vascular catheter-associated infections: a microbiological and therapeutic update

The increasing incidence of central venous catheter (CVC)-related infections can be ascribed to the wider indications to central venous catheterization, to the higher attention to this issue paid by clinicians and microbiologists, and to the patient population referred to hospitals, increasingly characterized by different degrees of immunosuppression and often in critical clinical conditions. This phenomenon implies a higher health care burden and higher related costs, as well as a significant attributable mortality, that varies however according to the pathogen involved. The microorganisms most frequently involved in CVC-related infections are coagulase-negative staphylococci, Staphylococcus aureus, aerobic Gram-negative bacilli, and Candida albicans. In the management of suspected or proven central venous catheter-related infections, several issues need to be addressed: the need to remove the device or the possibility of salvage, the immediate start of calculated antibiotic therapy or the possibility of waiting for results of microbiological diagnostics and proceeding to etiologically-guided therapy. The preferred conservative method is the "Antibiotic-Lock technique" (ALT), based on the endoluminal application of antibacterials at extremely high concentrations in situ for a period of time long enough to ensure bactericidal activity. On the other hand, immediate catheter removal and initiation of appropriate calculated therapy immediately after an adequate diagnostic work-up are strongly recommended in a clinical setting of severe sepsis or septic shock.

Candida infective endocarditis

Candida infective endocarditis (IE) is uncommon but often fatal. Most epidemiologic data are derived from small case series or case reports. This study was conducted to explore the epidemiology, treatment patterns, and outcomes of patients with Candida IE. We compared 33 Candida IE cases to 2,716 patients with non-fungal IE in the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS). Patients were enrolled and the data collected from June 2000 until August 2005. We noted that patients with Candida IE were more likely to have prosthetic valves (p < 0.001), short-term indwelling catheters (p < 0.0001), and have healthcare-associated infections (p < 0.001). The reasons for surgery differed between the two groups: myocardial abscess (46.7% vs. 22.2%, p = 0.026) and persistent positive blood cultures (33.3% vs. 9.9%, p = 0.003) were more common among those with Candida IE. Mortality at discharge was higher in patients with Candida IE (30.3%) when compared to non-fungal cases (17%, p = 0.046). Among Candida patients, mortality was similar in patients who received combination surgical and antifungal therapy versus antifungal therapy alone (33.3% vs. 27.8%, p = 0.26). New antifungal drugs, particularly echinocandins, were used frequently. These multi-center data suggest distinct epidemiologic features of Candida IE when compared to non-fungal cases. Indications for surgical intervention are different and mortality is increased. Newer antifungal treatment options are increasingly used. Large, multi-center studies are needed to help better define Candida IE.

Treatment of a critically ill child with disseminated Candida glabrata with a recombinant human antibody specific for fungal heat shock protein 90 and liposomal amphotericin B, caspofungin, and voriconazole

OBJECTIVE

To report a case of fungal sepsis treated prospectively with liposomal amphotericin, caspofungin, and a novel monoclonal antibody specific for candidal heat shock protein 90 (Mycograb, Neutec Pharma, Manchester, UK).

DESIGN

Case report.

SETTING

Pediatric intensive care unit in a tertiary care children's hospital.

PATIENT

A 7-yr-old male with a history of global developmental delay, epilepsy, and gastroesophageal reflux, who presented to the emergency department with a transdiaphragmatic herniation of bowel and subsequent Candida glabrata infection.

INTERVENTIONS

Efungumab 1 mg/kg twice daily for 5 days.

MEASUREMENTS AND MAIN RESULTS

C-reactive protein fell from 225 mg/L to 99 mg/L, and physiological monitoring parameters improved when Mycograb was used in conjunction with high-dose antifungals.

CONCLUSIONS

Mycograb therapy was well tolerated, but further experience with this therapy in children is needed.

Reduced biocide susceptibility in Candida albicans biofilms

Candida biofilm formation is common during infection and environmental growth. We tested the impacts of three biocides (ethanol [EtOH], H(2)O(2), and sodium dodecyl sulfate) on Candida albicans, C. parapsilosis, and C. glabrata biofilms. Higher concentrations of the biocides were required for efficacy against biofilms than for efficacy against planktonic controls. A combination study with two biocides (EtOH and H(2)O(2)) and fluconazole demonstrated that the combination had enhanced efficacy.

Micafungin for the prophylaxis and treatment of Candida infections

Invasive fungal infection is a significant cause of morbidity and mortality worldwide. The incidence of these infections is steadily increasing. In addition, strains resistant to many commonly used antifungal agents are becoming more prevalent. Many new antifungals have become commercially available in recent years, which have vastly improved the ability to treat these infections effectively. Micafungin is one of three commercially available echinocandins available for use in the USA. This class of agents possess a unique mechanism of action that helps to reduce toxicity while maintaining potent antifungal activity. Micafungin is currently approved for the treatment of esophageal candidiasis in adults and is the only in its class approved for the prophylaxis of Candida infection in patients who have undergone hematopoietic stem cell transplantation. It was also recently approved in the USA for the treatment of candidemia and other forms of invasive candiaisis (acute disseminated candiaisis, Candida peritonitis and abscess). In general, micafungin is well tolerated and has favorable safety and drug-interaction profiles.

Efficacy of alternative dosing regimens of poly-aggregated amphotericin B

A new poly-aggregated form of amphotericin B was formulated as a non-microencapsulated form (P-AMB) or incorporated in albumin microspheres (MP-AMB) and compared with the conventional amphotericin B formulation (D-AMB). Mice were infected with Candida albicans and treated with two different intermittent dose regimens of the different amphotericin B formulations. Efficacy and toxicity were studied by the determination of survival rate, kidney colony-forming units counts, biochemical parameters and amphotericin B concentrations in plasma and organs. All the treatments significantly (P<0.05) increased the survival rate in relation to the untreated group, although non-statistically significant differences (P>0.05) were found between formulations and dosing regimens. All the treatments produced kidney toxicity, expressed by high urea levels. Kidney toxicity was especially significant for mice treated with the D-AMB formulation where unilateral kidney atrophy was observed in most of the mice, whereas most of the mice treated with P-AMB conserved both kidneys with a normal size and appearance. At 45 days post infection, variable distribution of amphotericin B in the body was obtained depending on the amphotericin B formulation. In conclusion, non-daily dosing regimens of P-AMB, which is less toxic than D-AMB, could be used as an alternative to the conventional D-AMB formulation to treat experimental candidiasis.

Miconazole revisited: new evidence of antifungal efficacy from laboratory and clinical trials

In the past 40 years imidazoles have been used extensively in medicine for their antifungal properties. All members of the azole antifungal family inhibit ergosterol biosynthesis. However, the discovery of an additional fungicidal mode of action for miconazole has drawn renewed attention to this compound. In this article we review recent evidence of mechanistic efficacy, as well as clinical trial results of miconazole in new topical formulations.

Fluconazole prophylaxis: can we eliminate invasive Candida infections in the neonatal ICU?

PURPOSE OF REVIEW

Owing to the high mortality, risk of neurodevelopmental impairment and end-organ involvement with fungal infections in the neonate, prevention of invasive Candida infections in extremely preterm infants should be a priority for each neonatal ICU.

RECENT FINDINGS

Even with prompt or empiric treatment, mortality and neurodevelopmental impairment is high (57%) in infants <1000 g. Multiple studies have been performed with fluconazole prophylaxis, including a recent multicenter randomized controlled trial. All of the studies have demonstrated efficacy and safety with no increase or emergence of fungal resistance. Analysis of these studies demonstrates that fluconazole prophylaxis decreased the incidence of invasive Candida infections in high-risk infants <1000 g by 91% (P = 0.0004) and all infants <1500 g by 85% (P < 0.0001). The mortality rate from all causes was 25% lower (P = 0.029). Furthermore, studies have demonstrated that all Candida-related mortality can be eliminated in an entire neonatal ICU by targeting fluconazole prophylaxis in infants <1000 g.

SUMMARY

Targeting fluconazole prophylaxis to infants who are either <1000 g or < or =27 weeks is highly effective, safe and inexpensive, and can eliminate these infections as a cause of neurodevelopmental impairment and mortality.

Animal models of mucosal Candida infection

Rodent models of oral, vaginal and gastrointestinal Candida infection are described and discussed in terms of their scientific merits. The common feature of all experimental mucosal Candida infections is the need for some level of host immunocompromise or exogenous treatment to ensure quantitatively reproducible disease. A growing literature describes the contributions of such candidiasis models to our understanding of certain aspects of fungal virulence and host response to mucosal Candida albicans challenge. Evidence to date shows that T-lymphocyte responses dominate host immune defences to oral and gastrointestinal challenge, while other, highly compartmentalized responses defend vaginal surfaces. By contrast the study of C. albicans virulence factors in mucosal infection models has only begun to unravel the complex of attributes required to define the difference between strongly and weakly muco-invasive strains.

Fungicidal versus Fungistatic: what's in a word?

BACKGROUND

Historically clinicians have preferred to use 'cidal' antifungal agents, particularly in critically ill patients. However, data to support the belief that the preferential use of a 'cidal' agent results in better patient outcomes has been lacking.

OBJECTIVE

This review examined the in vitro definitions of fungicidal and fungistatic as well as their strengths and limitations.

METHODS

A Medline search was performed in order to identify literature that examined the in vitro or in vivo impact of fungicidal and fungistatic activity. The study examined three common invasive fungal infections, namely cryptococcal meningitis, candidemia and invasive aspergillosis, where sufficient comparisons of fungicidal and fungistatic agents have been performed to allow for the evaluation of the clinical importance of these in vitro findings.

RESULTS AND CONCLUSION

A clear clinical benefit of fungicidal agents over those with fungistatic activity remains elusive. Patients with cryptococcal meningitis clearly benefit from early fungicidal therapy but require long-term suppression. The data in invasive Candida sp. infections are tantalizing and suggest that fungicidal therapy may be important. However, the data for invasive aspergillosis do not support the hypothesis that fungicidal activity improves outcomes.

[The role of anidulafungin therapy in solid organ transplant recipients]

Anidulafungin is a new echinocandin recently approved for the treatment of esophageal candidiasis, candidemia and other forms of invasive candidiasis, such as peritonitis and intra-abdominal abscesses in non-neutropenic patients. It is fungicidal against Candida spp. and fungistatic against Aspergillus spp. It is active against Pneumocystis jirovecii. In contrast, anidulafungin does not have activity against Cryptococcus neoformans, Zygomycetes or molds, other than Aspergillus spp. The drug is well tolerated, even in patients with renal or hepatic impairment. In contrast to other echinocandins, it does not significantly interfere with the cytochrome P450 pathway and has a low drug-drug interaction profile, including calcineurinic agents and other drugs used in transplant recipients. So far, anidulafungin appears to have an excellent safety profile with few adverse events and it promises a special consideration in the management of fungal infections happening in transplant recipients.

Time to blood culture positivity as a marker for catheter-related candidemia

Candida spp. are important causes of nosocomial bloodstream infections. Around 80% of patients with candidemia have an indwelling central venous catheter (CVC). Determining whether the CVC is the source of candidemia has implications for patient management. We assessed whether the time to detection of Candida species in peripheral blood (time to positivity [TTP]) can serve as a marker for catheter-related candidemia. Prospective surveillance of Candida bloodstream infection was conducted in two medical centers. TTP was recorded by the BacT/Alert automated system. Sixty-four candidemia episodes were included. Fifty patients (78%) had an indwelling CVC. Thirteen patients (20.3%) had definite catheter-related candidemia. TTP was shorter for definite catheter-related candidemia (17.3 +/- 2 h) than that for candidemia from other sources (38.2 +/- 3 h; P < 0.001). A TTP cutoff of 30 h was 100% sensitive and 51.4% specific for catheter-related candidemia (area under the receiver-operator characteristic curve of 0.76). We conclude that TTP in peripheral blood is a sensitive but nonspecific marker for catheter-related candidemia and that a TTP of more than 30 h can help exclude an intravascular catheter as the possible source of candidemia.

In vitro susceptibilities of invasive isolates of Candida species: rapid increase in rates of fluconazole susceptible-dose dependent Candida glabrata isolates

Voriconazole, posaconazole, caspofungin, micafungin, and anidulafungin demonstrated potent in vitro activities against 286 invasive Candida isolates. Analysis of the fluconazole susceptibilities of 204 bloodstream Candida glabrata isolates revealed a rapid shift from susceptible (64% in 1999 to 2001 to 19% in 2007) to susceptible-dose dependent (27% in 1999 to 2001 and 75% in 2007).

Oesophageal candidiasis in elderly patients: risk factors, prevention and management

This article reviews risk factors, prevention and management of oesophageal candidiasis (OC) in the elderly. Putative risk factors for OC in the elderly include old age itself, malignant disease, antibacterial and corticosteroid use, chronic obstructive pulmonary disease, acid suppression treatment, oesophageal dysmotility and other local factors, diabetes mellitus and HIV/AIDS. We have found evidence for a risk association between OC in the elderly and malignant disease (both haematological and non-haematological), antibacterial therapy and corticosteroid (including inhaled corticosteroids) use. We also found evidence of an association between OC in the elderly and oesophageal dysmotility or HIV/AIDS, but little direct evidence of an association between diabetes or old age per se. The literature on OC in the elderly is not large. The published series evaluating OC in this age group are small in size, often do not contain controls and mostly contain only limited information about the age of the patients. Prevention of OC is mainly the avoidance of exposure to the risk factors wherever possible. Specific measures such as highly active antiretroviral therapy in AIDS, prophylactic fluconazole when receiving chemotherapy for malignancy, using spacing devices, mouth rinsing soon after inhalation of corticosteroids and avoiding the use of cortiocosteroids just before bedtime are useful. OC is often responsive to a 2- to 3-week course of oral fluconazole, but resistance may be encountered in AIDS or in the presence of uncorrected anatomical factors in the oesophagus. Itraconazole solution, voriconazole or caspofungin may be used in refractory cases. Use of amphotericin B is restricted because of its narrow therapeutic index.

Current options in antifungal pharmacotherapy

Infections caused by yeasts and molds continue to be associated with high rates of morbidity and mortality in both immunocompromised and immunocompetent patients. Many antifungal drugs have been developed over the past 15 years to aid in the management of these infections. However, treatment is still not optimal, as the epidemiology of the fungal infections continues to change and the available antifungal agents have varying toxicities and drug-interaction potential. Several investigational antifungal drugs, as well as nonantifungal drugs, show promise for the management of these infections.

Discordance between perception and treatment practices associated with intensive care unit-acquired bacteriuria and funguria: a Canadian physician survey

OBJECTIVE

To determine physician practice and perception about the management of intensive care unit (ICU)-acquired bacteriuria and funguria.

DESIGN

Cross-sectional, self-administered, Web-based survey.

SETTING

All provinces within Canada.

PARTICIPANTS

Staff ICU physicians who are members of either the Canadian Critical Care Trials Group or the Canadian Critical Care Society.

INTERVENTIONS

Survey items were developed by four ICU clinicians, and survey sensibility was assessed by five independent intensivists. Nonrespondents received three follow-up reminders. Participants were asked questions about general perceptions and practices regarding the management of ICU-acquired bacteriuria and funguria. Clinical scenarios were used to elicit management strategies, including antimicrobial prescriptions.

MEASUREMENTS AND MAIN RESULTS

Ninety of 198 physicians (45%) responded. Bacteriuria was perceived by 63% of the respondents to be a frequent but low-morbidity problem. Most intensivists (98%) did not use a protocol for management. Traditional symptoms were rarely used to interpret the significance of bacteriuria. Presence of systemic inflammatory response syndrome (93%), presence of hemodynamic changes (91%), and urinalysis (69%) were used often. Within clinical scenarios, source control via urinary catheter change was not universal, ranging from 44% to 67% in the various scenarios, even in patients presenting with septic shock. Prescription of antimicrobials was common across scenarios despite the low-morbidity perception. In an asymptomatic patient, 19% of respondents would prescribe antimicrobials. Changing the species from fungus to bacteria and the presence of systemic inflammatory response syndrome or shock increased the likelihood of antimicrobial use up to 70% to 80%.

CONCLUSIONS

ICU physicians perceive bacteriuria to have low morbidity. However, management approaches vary considerably, and systemic antimicrobials are frequently prescribed. Increased clinical instability and bacterial vs. fungal organisms isolated in urine cultures increased the use of antimicrobials. The considerable variability in practice and discordance between likelihood of urinary tract infection and antimicrobial prescription, highlights the need for additional clinical trials.