Guidelines for Treatment of Candidiasis

Considerations in the approach to invasive fungal infection in patients with haematological malignancies

Invasive infections because of opportunistic yeasts and moulds have contributed significantly to the morbidity and mortality associated with potentially curative treatment for haematological malignancies. Many risk factors have been identified that permit the clinician to predict the likelihood of these infections. The diagnostic process involves maintaining a high index of suspicion based upon an understanding of the clinical circumstances under which invasive fungal infections occur, of the spectrum of fungal syndromes, and of the advantages and limitations of diagnostic testing strategies now available. Treatment strategies may be categorized as prophylactic, pre-emptive, empiric, or directed based upon the circumstances. The therapeutic options have increased in recent years but are not applicable to all clinical circumstances. These considerations are discussed.

Caspofungin disk diffusion breakpoints and quality control

Interpretive disk diffusion breakpoints for caspofungin are proposed by evaluating 762 isolates of Candida spp., representing 10 different species obtained as part of the caspofungin clinical trials. Standardized broth microdilution reference tests were compared to the zone diameters observed with 5-microg caspofungin disks produced by two different disk manufacturers. Disk diffusion breakpoints of >or=11 mm for susceptible are proposed. Compared to results from MIC testing, these zone diameters produced error rates that were <or=0.3% for all categories. In addition, an eight-laboratory disk diffusion quality control (QC) study was performed, and QC ranges are proposed for the four QC strains recommended by the CLSI.

Management of Candida infections in the adult intensive care unit

The epidemiology of Candida infection in intensive care units (ICUs) and the management strategies for such infections in non-neutropenic intensive care patients are discussed in this review. Candida species are one of the leading causes of nosocomial bloodstream infections and a significant cause of morbidity in patients admitted to the ICU. Prophylactic, pre-emptive and empiric treatment strategies for Candida infections have been explored in ICU patients. Routine prophylaxis should not be administered to the whole population of ICU patients, because the concerns about the selection of azole-resistant Candida strains or the induction of resistance are justified. Treatment of fungal infections is now possible with newer antifungal agents, including newer azoles (e.g., voriconazole, posaconazole) and echinocandins (e.g., micafungin, anidulafungin). However, there is a critical need for improvement in diagnosis of invasive Candida infection in order to provide clinicians the opportunity to intervene earlier in the diseases course.

Posaconazole against Candida glabrata isolates with various susceptibilities to fluconazole

We investigated the in vitro activities of posaconazole (POS), fluconazole (FLC), amphotericin B (AMB), and caspofungin (CAS) against four clinical isolates of Candida glabrata with various susceptibilities to FLC (FLC MICs ranging from 1.0 to >64 microg/ml). POS MICs ranged from < or =0.03 to 0.5 microg/ml; AMB MICs ranged from 0.25 to 2.0 microg/ml, while CAS MICs ranged from 0.03 to 0.25 microg/ml. When FLC MICs increased, so did POS MICs, although we did not observe any isolate with a POS MIC greater than 0.5 mug/ml. Time-kill experiments showed that POS, FLC, and CAS were fungistatic against all isolates, while AMB at eight times the MIC was fungicidal against three out of four isolates of C. glabrata tested. Then, we investigated the activity of POS in an experimental model of disseminated candidiasis using three different isolates of C. glabrata: one susceptible to FLC (S; FLC MICs ranging from 1.0 to 4.0 microg/ml; POS MIC of < or =0.03 microg/ml), one susceptible in a dose-dependent manner (SDD; FLC MICs ranging from 32 to 64 microg/ml; POS MICs ranging from 0.125 to 0.25 microg/ml), and another one resistant to FLC (R; FLC MIC of >64 microg/ml; POS MIC of 0.5 microg/ml). FLC significantly reduced the kidney burden of mice infected with the S strain (P = 0.0070) but not of those infected with the S-DD and R strains. POS was significantly effective against all three isolates at reducing the kidney fungal burden with respect to the controls (P ranging from 0.0003 to 0.029). In conclusion, our data suggest that POS may be a useful option in the management of systemic infections caused by C. glabrata. Additionally, the new triazole may be a therapeutic option in those cases where an FLC-resistant isolate is found to retain a relatively low POS MIC.

Fluconazole prophylaxis in extremely low birth weight neonates reduces invasive candidiasis mortality rates without emergence of fluconazole-resistant Candida species

OBJECTIVE

We evaluated the impact of fluconazole prophylaxis for extremely low birth weight infants on invasive candidiasis incidence, invasive candidiasis-related mortality rates, and fluconazole susceptibility of Candida isolates.

METHODS

Extremely low birth weight infants <5 days of age, except those with liver dysfunction, were eligible for fluconazole prophylaxis. NICU infants (all birth weights) with invasive candidiasis between April 2002 and March 2006 were compared with those with invasive candidiasis before fluconazole prophylaxis (2000-2001).

RESULTS

Twenty-two infants had invasive candidiasis (all candidemia) during fluconazole prophylaxis; before fluconazole prophylaxis, there were 19 cases (candidemia: 17 cases; meningitis: 2 cases). Invasive candidiasis incidence in NICU infants decreased from 0.6% (19 of 3012 infants) before fluconazole prophylaxis to 0.3% (22 of 6393 infants) in 2002-2006 and that in extremely low birth weight infants decreased 3.6-fold. No Candida-attributable deaths occurred during 2002-2006 fluconazole prophylaxis, compared with 4 (21%) before fluconazole prophylaxis. The onset of invasive candidiasis was later during 2002-2006 (23.5 vs 12 days), but risk factors were similar. The invasive candidiasis species distribution remained stable. Of 409 infants who received fluconazole prophylaxis, 119 (29%) received 42 days. Shorter fluconazole prophylaxis duration was related to intravenous access no longer being necessary in 242 cases (59%), noninvasive candidiasis-related death in 29 (7%), hospital transfer in 8 (2%), invasive candidiasis diagnosis in 8 (2%), and transient increase in serum transaminase levels in 4 (1%). One hundred twenty-seven infants (31%) who received fluconazole prophylaxis developed cholestasis during hospitalization, two thirds of whom had other predisposing conditions. On multivariate logistic regression necrotizing enterocolitis and increasing days of total parenteral nutrition, but not increasing number of doses on days of fluconazole, were significantly associated with the development of cholestasis.

CONCLUSION

During 4 years of fluconazole prophylaxis, the incidence of invasive candidiasis and invasive candidiasis-associated mortality rates in extremely low birth weight infants were reduced significantly, without the emergence of fluconazole-resistant Candida species.

Antibiotic Prescribing in Critical Care: Specific Indications

This article outlines recommendations for the treatment of specific infections occurring in the setting of critical care. In the interests of brevity, a limited number of infections are discussed and recommendations are largely confined to empirical therapy. Basic principles of diagnosis and treatment apply in all cases, including appropriate de-escalation when an organism is identified. These aspects of treatment have been dealt with in part one of this article – ‘Antibiotic prescribing in critical care: general principles' published in the winter 2007 edition of JICS.

Positive fungal cultures in burn patients: a multicenter review

Fungal infections are increasingly common in burn patients. We performed this study to determine the incidence and outcomes of fungal cultures in acutely burned patients. Members of the American Burn Association's Multicenter Trials Group were asked to review patients admitted during 2002-2003 who developed one or more cultures positive for fungal organisms. Data on demographics, site(s), species and number of cultures, and presence of risk factors for fungal infections were collected. Patients were categorized as untreated (including prophylactic topical antifungals therapy), nonsystemic treatment (nonprophylactic topical antifungal therapy, surgery, removal of foreign bodies), or systemic treatment (enteral or parenteral therapy). Fifteen institutions reviewed 6918 patients, of whom 435 (6.3%) had positive fungal cultures. These patients had mean age of 33.2 +/- 23.6 years, burn size of 34.8 +/- 22.7%TBSA, and 38% had inhalation injuries. Organisms included Candida species (371 patients; 85%), yeast non-Candida (93 patients, 21%), Aspergillus (60 patients, 14%), other mold (39 patients, 9.0%), and others (6 patients, 1.4%). Systemically treated patients were older, had larger burns, more inhalation injuries, more risk factors, a higher incidence of multiple positive cultures, and significantly increased mortality (21.2%), compared with nonsystemic (mortality 5.0%) or untreated patients (mortality 7.8%). In multivariate analysis, increasing age and burn size, number of culture sites, and cultures positive for Aspergillus or other mold correlated with mortality. Positive fungal cultures occur frequently in patients with large burns. The low mortality for untreated patients suggests that appropriate clinical judgment was used in most treatment decisions. Nonetheless, indications for treatment of fungal isolates in burn patients remain unclear, and should be developed.

Additive action of honey and starch against Candida albicans and Aspergillus niger

A comparative method of adding honey to culture media with and without starch was used to evaluate the action of starch on the antifungal activity of honey. The minimum inhibitory concentration (MIC) expressed in % (v/v) for two varieties of honey without starch against Candida albicans was 42% and 46%, respectively. For Aspergillus niger the MIC without starch was 51% and 59%, respectively. When starch was incubated with honey and then added to media the MIC for C. albicans was 28% and 38%, respectively, with a starch concentration of 3.6% whereas the MIC for A. niger was 40% and 45%, with a starch concentration of 5.6% and 5.1% respectively. This study suggests that the amylase present in honey increases the osmotic effect in the media by increasing the amount of sugars and consequently increasing the antifungal activity.

Management of oral infections in cancer patients

The myelosuppressive and mucosal-damaging consequences of cancer and cancer therapies place patients at high risk for developing infectious complications. Bacterial, fungal, and viral infections are all commonly encountered in the oral cavity, contributing to both morbidity and mortality in this patient population. Prevention, early and definitive diagnosis, and appropriate management are critical to ensure optimal treatment outcomes. With the majority of cancer patients treated as outpatients in the community setting, oral health care professionals play an important role in managing such infectious complications of cancer therapy.

[Medical therapy of urinary tract infection]

Urinary tract infections (UTI) are the most common bacterial infectious diseases seen in the community, in most cases caused by E. coli. The treatment strategy differs depending on localization (lower vs. upper UT), acute uncomplicated vs. complicated infection, as well as for chronic disease and asymptomatic bacteriuria, the known or susceptible causative uropathogen with the (local) resistance pattern and the morbidity of the patient. There is a considerable worrying increase in the resistance rate of E. coli to TMP/SMX, quinolones and others. Most patients with uncomplicated, in the community acquired UTI are treated safely and effectively as out-patients. The available data support a short-course therapy with 3 days as the current standard therapy for lower UTI, but with a 7-14 days treatment for upper and complicated UTI. Recurrent UTI is best managed by low-dose antimicrobial prophylaxis for 3-6 (12 ore more) months. Besides that, new approaches to preventive strategies must prove their value in specific patient groups.

[Invasive candidiasis in the critically ill, patient non-neutropenic]

Invasive candidiasis can occur in immunosuppressed patients as well as in critically ill, non-immunocompromised patients and is associated with high mortality (20-40 %). Intestinal Candida colonisation is an important source for invasive candidiasis. Risk factors for the development of invasive candidiasis include presence of an intravascular device, organ dysfunction, impaired mucosal or skin barrier function, therapy with antacids or corticosteroids, prolonged stay at the ICU, total parenteral nutrition and prolonged antibiotic therapy. Among patients with invasive candidiasis, antifungal treatment should be started without delay. Antifungal prophylaxis is currently not recommended in critically ill, non-immunocompromised patients.

Voriconazole therapeutic drug monitoring in patients with invasive mycoses improves efficacy and safety outcomes

BACKGROUND

Voriconazole is the therapy of choice for aspergillosis and a new treatment option for candidiasis. Liver disease, age, genetic polymorphism of the cytochrome CYP2C19, and comedications influence voriconazole metabolism. Large variations in voriconazole pharmacokinetics may be associated with decreased efficacy or with toxicity.

METHODS

This study was conducted to assess the utility of measuring voriconazole blood levels with individualized dose adjustments.

RESULTS

A total of 181 measurements with high-pressure liquid chromatography were performed during 2388 treatment days in 52 patients. A large variability in voriconazole trough blood levels was observed, ranging from <or=1 mg/L (the minimum inhibitory concentration at which, for most fungal pathogens, 90% of isolates are susceptible) in 25% of cases to >5.5 mg/L (a level possibly associated with toxicity) in 31% of cases. Lack of response to therapy was more frequent in patients with voriconazole levels <or=1 mg/L (6 [46%] of 13 patients, including 5 patients with aspergillosis, 4 of whom were treated orally with a median dosage of 6 mg/kg per day) than in those with voriconazole levels >1 mg/L (15 [12%] of 39 patients; P=.02). Blood levels >1 mg/L were reached after increasing the voriconazole dosage, with complete resolution of infection in all 6 cases. Among 16 patients with voriconazole trough blood levels >5.5 mg/L, 5 patients (31%) presented with an encephalopathy, including 4 patients who were treated intravenously with a median voriconazole dosage of 8 mg/kg per day, whereas none of the patients with levels <or=5.5 mg/L presented with neurological toxicity (P=.002). Comedication with omeprazole possibly contributed to voriconazole accumulation in 4 patients. In all cases, discontinuation of therapy resulted in prompt and complete neurological recovery.

CONCLUSIONS

Voriconazole therapeutic drug monitoring improves the efficacy and safety of therapy in severely ill patients with invasive mycoses.

Comparison of the efficacy and safety of miconazole 50-mg mucoadhesive buccal tablets with miconazole 500-mg gel in the treatment of oropharyngeal candidiasis: a prospective, randomized, single-blind, multicenter, comparative, phase III trial in patients treated with radiotherapy for head and neck cancer

BACKGROUND

Topical antifungal treatments are recommended but rarely used as first-line therapy for oropharyngeal candidiasis (OPC) in patients with cancer. Miconazole Lauriad 50-mg mucoadhesive buccal tablet (MBT) Loramyc reportedly delivered rapid and prolonged, effective concentrations of miconazole in the mouth. The objective of the current study was to compare MBT with miconazole 500-mg oral gel (MOG) in patients with head and neck cancer.

METHODS

Two hundred eighty-two patients with head and neck cancer received a 14-day treatment of either single-dose MBT or MOG administered in 4 divided doses. The primary endpoint was clinical success at Day 14, and secondary endpoints included clinical success at Day 7, clinical cure, improvement in clinical symptoms, mycologic cure, recurrence rate, and safety.

RESULTS

The success rate was statistically not inferior (P < .0001) in the MBT population to the rate observed in the MOG group (56% vs 49%, respectively; P < .0001). After adjustment for the extent of lesions and salivary secretions, a trend toward superiority was observed in favor of MBT (P = .13), particularly among patients with multiple lesions (P = .013). Results for secondary endpoints were comparable to those observed for the primary endpoint. Compliance with MBT was excellent, and >80% of patients completed treatment. Both treatments were safe.

CONCLUSIONS

The success rate of MBT Loramyc was significantly not inferior to that of MOG in the treatment of cancer patients with OPC; and, after adjusting for prognostic variables, it was more effective than MOG. MBT was well tolerated and, thus, may be recommended as first-line treatment in cancer patients who have OPC as an alternative to systemic antifungal agents. Society.

Neonatal Candida spp. infections: an update

Candida-related morbidity and mortality have increased in neonatal intensive care units (NICUs) in the last 20 years. Invasive fungal infections (IFIs) in preterm infants are associated with high severity, high attributable mortality, substantial morbidity and poor outcomes owing to the frequent association with late neurodevelopmental impairment and retinopathy of prematurity in the survivors. Preterm very-low birth weight infants in NICUs have a specific, increased risk for IFIs, mainly because up to 60% of them may become colonized during their first month of life. Prevention of Candida colonization and infection is the key in these settings of unique patients, and solid data have recently been added to the very first promising results obtained in the early 2000’s with administation of fluconazole. In a multicenter randomized trial, this azole caused a striking reduction in the incidences of Candida spp. colonization (from 33 to 9%) and infection (from 13.2 to 3.2%), with no occurrence of significant side-effects and no signs of selective resistance during the 15-month study period. New guidelines incorporating the recent multicenter results are urgently needed.

Reavaliação da suscetibilidade de Candida à anfotericina B: estudo comparativo com isolados de três hospitais do estado do Rio Grande do Sul

Comparou-se a suscetibilidade à anfotericina B de Candida spp isoladas de candidemias, sendo: 41 do Hospital Universitário de Santa Maria, 56 do Hospital de Clínicas de Porto Alegre e 47 da Santa Casa, Complexo Hospitalar de Porto Alegre. Os testes foram baseados no documento M27-A2 do Clinical Laboratory Standards Institute. Todavia, foram empregadas 20 concentrações de anfotericina B, variáveis entre 0,1 e 2µg/ml. Os testes foram realizados nos meios RPMI 1640 com glicose, antibiotic medium 3 e yeast nitrogen base dextrosado. O caldo antibiotic medium 3 gerou amplas faixas de concentrações inibitórias mínimas e concentrações fungicidas mínimas quando comparado aos demais. As variações de suscetibilidade entre os hospitais foram melhor detectadas no antibiotic médium 3; os isolados do Hospital Universitário de Santa Maria evidenciaram menor sensibilidade do que os da Santa Casa, Complexo Hospitalar de Porto Alegre (p < 0,05). As causas das variações de suscetibilidade não foram avaliadas mas apontam para a necessidade de vigilância da suscetibilidade a anfotericina B.

Bench-to-bedside review: Candida infections in the intensive care unit

Invasive mycoses are life-threatening opportunistic infections and have emerged as a major cause of morbidity and mortality in critically ill patients. This review focuses on recent advances in our understanding of the epidemiology, diagnosis and management of invasive candidiasis, which is the predominant fungal infection in the intensive care unit setting. Candida spp. are the fourth most common cause of bloodstream infections in the USA, but they are a much less common cause of bloodstream infections in Europe. About one-third of episodes of candidaemia occur in the intensive care unit. Until recently, Candida albicans was by far the predominant species, causing up to two-thirds of all cases of invasive candidiasis. However, a shift toward non-albicans Candida spp., such as C. glabrata and C. krusei, with reduced susceptibility to commonly used antifungal agents, was recently observed. Unfortunately, risk factors and clinical manifestations of candidiasis are not specific, and conventional culture methods such as blood culture systems lack sensitivity. Recent studies have shown that detection of circulating β-glucan, mannan and antimannan antibodies may contribute to diagnosis of invasive candidiasis. Early initiation of appropriate antifungal therapy is essential for reducing the morbidity and mortality of invasive fungal infections. For decades, amphotericin B deoxycholate has been the standard therapy, but it is often poorly tolerated and associated with infusion-related acute reactions and nephrotoxicity. Azoles such as fluconazole and itraconazole provided the first treatment alternatives to amphotericin B for candidiasis. In recent years, several new antifungal agents have become available, offering additional therapeutic options for the management of Candida infections. These include lipid formulations of amphotericin B, new azoles (voriconazole and posaconazole) and echinocandins (caspofungin, micafungin and anidulafungin).

Geographic and temporal trends in isolation and antifungal susceptibility of Candida parapsilosis: a global assessment from the ARTEMIS DISK Antifungal Surveillance Program, 2001 to 2005

We examined data from the ARTEMIS DISK Antifungal Surveillance Program to describe geographic and temporal trends in the isolation of Candida parapsilosis from clinical specimens and the in vitro susceptibilities of 9,371 isolates to fluconazole and voriconazole. We also report the in vitro susceptibility of bloodstream infection (BSI) isolates of C. parapsilosis to the echinocandins, anidulafungin, caspofungin, and micafungin. C. parapsilosis represented 6.6% of the 141,383 isolates of Candida collected from 2001 to 2005 and was most common among isolates from North America (14.3%) and Latin America (9.9%). High levels of susceptibility to both fluconazole (90.8 to 95.8%) and voriconazole (95.3 to 98.1%) were observed in all geographic regions with the exception of the Africa and Middle East region (79.3 and 85.8% susceptible to fluconazole and voriconazole, respectively). C. parapsilosis was most often isolated from blood and skin and/or soft tissue specimens and from patients hospitalized in the medical, surgical, intensive care unit (ICU) and dermatology services. Notably, isolates from the surgical ICU were the least susceptible to fluconazole (86.3%). There was no evidence of increasing azole resistance over time among C. parapsilosis isolates tested from 2001 to 2005. Of BSI isolates tested against the three echinocandins, 92, 99, and 100% were inhibited by concentrations of < or = 2 microg/ml of anidulafungin (621 isolates tested), caspofungin (1,447 isolates tested), and micafungin (539 isolates tested), respectively. C. parapsilosis is a ubiquitous pathogen that remains susceptible to the azoles and echinocandins; however, both the frequency of isolation and the resistance of C. parapsilosis to fluconazole and voriconazole may vary by geographic region and clinical service.

Antifungal agents in neonates: issues and recommendations

Fungal infections are responsible for considerable morbidity and mortality in the neonatal period, particularly among premature neonates. Four classes of antifungal agents are commonly used in the treatment of fungal infections in pediatric patients: polyene macrolides, fluorinated pyrimidines, triazoles, and echinocandins. Due to the paucity of pediatric data, many recommendations for the use of antifungal agents in this population are derived from the experience in adults. The purpose of this article was to review the published data on fungal infections and antifungal agents, with a focus on neonatal patients, and to provide an overview of the differences in antifungal pharmacology in neonates compared with adults. Pharmacokinetic data suggest dosing differences in children versus adult patients with some antifungals, but not all agents have been fully evaluated. The available pharmacokinetic data on the amphotericin B deoxycholate formulation in neonates exhibit considerable variability; nevertheless, the dosage regimen suggested in the neonatal population is similar to that used in adults. More pharmacokinetic information is available on the liposomal and lipid complex preparations of amphotericin B and fluconazole, and it supports their use in neonates; however, the optimal dosage and duration of therapy is difficult to establish. All amphotericin-B formulations, frequently used in combination with flucytosine, are useful for treating disseminated fungal infections and Candida meningitis in neonates. Fluconazole, with potent in vitro activity against Cryptococcus neoformans and almost all Candida spp., has been used in neonates with invasive candidiasis at dosages of 6 mg/kg/day, and for antifungal prophylaxis in high-risk neonates. There are limited data on itraconazole, voriconazole, and posaconazole use in neonates. Caspofungin, which is active against Candida spp. and Aspergillus spp., requires higher doses in children relative to adults, and dosing is best accomplished based on body surface area. Micafungin shows a clear trend toward lower levels in the smallest patients. There are no data on the use of other new antifungal drugs (ravuconazole and anidulafungin) in neonates. In summary, the initial data suggest dosage differences in neonates for some antifungal agents, although the newer agents have not been fully tested for optimal administration in these patients.

Candida lusitaniae septic arthritis: case report and review of the literature

Candida lusitaniae is an infrequently encountered Candida species that has been associated with resistance to amphotericin B. We present a case of septic arthritis with C. lusitaniae and provide a brief review of the organism, especially in regard to current information about its pattern of resistance to antifungal agents.

Efficacy of caspofungin in invasive candidiasis and candidemia--de-escalation strategy

Candida species constitute the majority of nosocomial fungal pathogens in non-neutropenic patients. Candida infections are still connected with substantial mortality. Recent epidemiological observations indicate a shift to non-albicans species, especially because of a rise of infections caused by C. glabrata, which frequently shows fluconazole-resistance. New therapeutic options like caspofungin, as the first licensed echinocandin, new broad-spectrum azoles, and lipid preparations of amphotericin B emerged in the last decade as efficient alternatives to fluconazole and amphotercin B deoxycholate. In invasive candidiasis, a delayed treatment initiation is associated with an increased mortality, thus risk stratification and empirical therapy strategies become vitally important. This review reflects the efficacy of caspofungin in the treatment of Candida infections, especially in the setting of empirical therapy in critically ill patients, and considers the option of de-escalation to fluconazole.

Pulmonary infections after lung transplantation

A tüdőtranszplantáció napjainkban már rutinszerűen végzett beavatkozássá vált a végstádiumú parenchymás és vascularis tüdőbetegségekben. Az elmúlt két évtized során több mint 20 ezer tüdőtranszplantációt végeztek a világon. Az immunszuppresszív szerek fejlődésének eredményeként az életet veszélyeztető akut rejekciók száma jelentősen csökkent, az első éven belüli halálozás csupán 2%-át okozza. A legnagyobb arányban az infekciók felelősek a korai és a késői morbiditásért és mortalitásért. A posztoperatív első 30 napon belüli halálozás 21,2%-a, az első éven belüli halálozás 40%-a infekciós eredetű. Az első hónapban a betegek 35–70%-ánál bakteriális pneumónia alakul ki, amelynek kb. felét Gram-negatív pálcák okozzák, dominálóan Pseudomonas-törzsek. A betegek a műtétet követően antibiotikus profilaxisban részesülnek, amit aztán a donortüdőből kimutatott törzs rezisztenciatesztje alapján módosíthatunk. A korai posztoperatív időszakban az invazív gomba- (Aspergillus-, Candida-) és CMV-infekciók a 100 napig tartó inhalatív amphotericin és szisztémás valganciklovir-profilaxis hatására kevesebb mint 10–10%-ban lépnek fel. Számuk a profilaxis befejezte után emelkedik. A későbbiekben kialakuló bronchiolitis obliterans szindróma (BOS) szintén hajlamosít a fertőzésekre. Ennek jelentőségét az adja, hogy 5 évvel a műtét után a betegek kb. 50%-ánál detektálható a BOS. Az infekciók sikeres leküzdésének alapja a rutinszerűen, illetve a tünetek fellépte után minél hamarabb elvégzett kontroll (laboratóriumi, radiológiai, légzésfunkciós, köpet- és bronchoszkópos vizsgálatok), majd a célzott terápia bevezetése. A munka célja a tüdőtranszplantáltaknál jelentkező leggyakoribb infekciók klinikai manifesztációjának, diagnosztikájának és kezelésének áttekintése.

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008

OBJECTIVE

To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," published in 2004.

DESIGN

Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding.

METHODS

We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations.

RESULTS

Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose < 150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B).

CONCLUSIONS

There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

The importance of genus Candida in human samples

Microbiology is a rapidly changing field. As new researches and experiences broaden our knowledge, changes in the approach to diagnosis and therapy have become necessary and appropriate. Recommended dosage of drugs, method and duration of administration, as well as contraindications to use, evolve over time all drugs. Over the last 2 decades, Candida species have emerged as causes of substantial morbidity and mortality in hospitalized individuals. Isolation of Candida from blood or other sterile sites, excluding the urinary tract, defines invasive candidiasis. Candida species are currently the fourth most common cause of bloodstream infections (that is, candidemia) in U.S. hospitals and occur primarily in the intensive care unit (ICU), where candidemia is recognized in up to 1% of patients and where deep-seated Candida infections are recognized in an additional 1 to 2% of patients. Despite the introduction of newer anti-Candida agents, invasive candidiasis continues to have an attributable mortality rate of 40 to 49%; excess ICU and hospital stays of 12.7 days and 15.5 days, respectively, and increased care costs. Postmortem studies suggest that death rates related to invasive candidiasis might, in fact, be higher than those described because of undiagnosed and therefore untreated infection. The diagnosis of invasive candidiasis remains challenging for both clinicians and microbiologists. Reasons for missed diagnoses include nonspecific risk factors and clinical manifestations, low sensitivity of microbiological culture techniques, and unavailability of deep tissue cultures because of risks associated with the invasive procedures used to obtain them. Thus, a substantial proportion of invasive candidiasis in patients in the ICU is assumed to be undiagnosed and untreated. Yet even when invasive candidiasis is diagnosed, culture diagnosis delays treatment for 2 to 3 days, which contributes to mortality. Interventions that do not rely on a specific diagnosis and are implemented early in the course of Candida infection (that is, empirical therapy) or before Candida infection occurs (that is, prophylaxis) might improve patient survival and may be warranted. Selective and nonselective administration of anti-Candida prophylaxis is practiced in some ICUs. Several trials have tested this, but results were limited by low statistical power and choice of outcomes. Thus, the role of anti-Candida prophylaxis for patients in the ICU remains controversial. Initiating anti-Candida therapy for patients in the ICU who have suspected infection but have not responded to antibacterial therapy (empirical therapy) is practiced in some hospitals. This practice, however, remains a subject of considerable debate. These patients are perceived to be at higher risk from invasive candidiasis and therefore are likely to benefit from empirical therapy. Nonetheless, empirical anti-Candida therapies have not been evaluated in a randomized trial and would share shortcomings that are similar to those described for prophylactic strategies. Current treatment guidelines by the Infectious Diseases Society of America (IDSA) do not specify whether empirical anti-Candida therapy should be provided to immunocompetent patients. If such therapy is given, IDSA recommends that its use should be limited to patients with Candida colonization in multiple sites, patients with several other risk factors, and patients with no uncorrected causes of fever. Without data from clinical trials, determining an optimal anti-Candida strategy for patients in the ICU is challenging. Identifying such a strategy can help guide clinicians in choosing adequate therapy and may improve patient outcomes. In our study, we developed a decision analytic model to evaluate the cost-effectiveness of empirical anti-Candida therapy given to high-risk patients in the ICU, defined as those with altered temperature (fever or hypothermia) or unexplained hypotension despite 3 days of antibacterial therapy in the ICU.

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008

OBJECTIVE

To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock," published in 2004.

DESIGN

Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding.

METHODS

We used the GRADE system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost), or clearly do not. Weak recommendations indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations.

RESULTS

Key recommendations, listed by category, include: early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures prior to antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for post-operative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B) targeting a blood glucose < 150 mg/dL after initial stabilization ( 2C ); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper GI bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include: greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); a recommendation against the use of recombinant activated protein C in children (1B).

CONCLUSION

There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Successfully treatedCandida kruseiinfection of the lumbar spine with combined caspofungin/posaconazole therapy

Candidal vertebral osteomyelitis represents an extremely rare invasive mycosis and can be difficult to treat due to poor drug penetration into bony tissue. We report on a case of vertebral osteomyelitis caused by Candida krusei in a patient who had neutropenia as a result of chemotherapy for acute myelogenous leukaemia. The patient received prophylactic liposomal amphotericin B during chemotherapy but became febrile and experienced severe lumbar pain. Magnetic resonance imaging revealed vertebral osteochondrosis. C. krusei was recovered from blood cultures and voriconazole monotherapy was initiated but proved unsuccessful. The patient was then started on caspofungin monotherapy, which was discontinued after Candida krusei was no longer recoverable from blood cultures. However, as lumbar pain increased and spinal biopsy confirmed the presence of Candida krusei, caspofungin therapy was resumed. Oral posaconazole was added to the regimen when the patient did not improve after 30 days of caspofungin therapy. Combined antimycotic therapy resulted in a successful outcome.

[Candiduria: a clinical and therapeutic approach]

Candiduria remains a controversial issue for clinicians once that it may represent a broad variety of possibilities including colonization, local or systemic infection. We will discuss the epidemiology, diagnosis and treatment of candiduria in different settings of patients, including renal transplant recipients. Definitions on therapy are mostly based on epidemiological and clinical data. Once antifungal therapy is required the following antifungal treatment may be used: intravenous amphotericin B, bladder irrigation with amphotericin B or fluconazole. Blood cultures may be required in patients with candiduria and high risk for developing hematogenous infection. Removal of the urinary catheter must be considered in order to avoid persistent candiduria and recurrence.

Candida krusei, a multidrug-resistant opportunistic fungal pathogen: geographic and temporal trends from the ARTEMIS DISK Antifungal Surveillance Program, 2001 to 2005

Candida krusei is well known as a fungal pathogen for patients with hematologic malignancies and for transplant recipients. Using the ARTEMIS Antifungal Surveillance Program database, we describe geographic and temporal trends in the isolation of C. krusei from clinical specimens and the in vitro susceptibilities of 3,448 isolates to voriconazole as determined by CLSI (formerly NCCLS) disk diffusion testing. In addition, we report the in vitro susceptibilities of bloodstream infection isolates of C. krusei to amphotericin B (304 isolates), flucytosine (254 isolates), anidulafungin (121 isolates), caspofungin (300 isolates), and micafungin (102 isolates) as determined by CLSI broth microdilution methods. Geographic differences in isolation were apparent; the highest frequency of isolation was seen for the Czech Republic (7.6%) and the lowest for Indonesia, South Korea, and Thailand (0 to 0.3%). Overall, 83% of isolates were susceptible to voriconazole, ranging from 74.8% in Latin America to 92.3% in North America. C. krusei was most commonly isolated from hematology-oncology services, where only 76.7% of isolates were susceptible to voriconazole. There was no evidence of increasing resistance of C. krusei to voriconazole from 2001 to 2005. Decreased susceptibilities to amphotericin B (MIC at which 90% of isolates were inhibited [MIC(90)], 4 microg/ml) and flucytosine (MIC(90), 16 microg/ml) were noted, whereas 100% of isolates were inhibited by < or =2 microg/ml of anidulafungin (MIC(90), 0.06 microg/ml), micafungin (MIC(90), 0.12 microg/ml) or caspofungin (MIC(90), 0.25 microg/ml). C. krusei is an uncommon but multidrug-resistant fungal pathogen. Among the systemically active antifungal agents, the echinocandins appear to be the most active against this important pathogen.

Candida bracarensis detected among isolates of Candida glabrata by peptide nucleic acid fluorescence in situ hybridization: susceptibility data and documentation of presumed infection

Molecular taxonomic studies have revealed new Candida species among phenotypically delineated species, the best example being Candida dubliniensis. This study was designed to determine the occurrence of two new molecularly defined species, Candida bracarensis and Candida nivariensis, which are closely related to and identified as Candida glabrata by phenotypic assays. A total of 137 recent clinical isolates of C. glabrata identified by phenotypic characteristics was tested with C. bracarensis and C. nivariensis species-specific peptide nucleic acid fluorescence in situ hybridization probes. Three of 137 (2.2%) isolates were positive with the C. bracarensis probe, whereas the control strain, but none of the clinical isolates, was positive with the C. nivariensis probe. D1/D2 sequencing confirmed the identification of the three isolates as representing C. bracarensis. Clinically, one C. bracarensis isolate was recovered from a presumed infection, a polymicrobial pelvic abscess in a patient with perforated diverticulitis. The other two isolates were recovered from two adult oncology patients who were only colonized. C. bracarensis was white on CHROMagar Candida, had variable API-20C patterns that overlapped with C. nivariensis and some C. glabrata isolates, and had variable results with a rapid trehalose assay. Interestingly, an isolate from one of the colonized oncology patients was resistant to fluconazole, itraconazole, voriconazole, and posaconazole in vitro. In summary, C. bracarensis was detected among clinical isolates of C. glabrata, while C. nivariensis was not. One C. bracarensis isolate causing a presumed deep infection was recovered, and another isolate was azole resistant. Whether clinical laboratories should identify C. bracarensis will require more data.

Posaconazole for the management of mucosal candidiasis

Mucocutaneous candidiasis (MC) is one of the first signs of HIV infection. In the pre-highly active antiretroviral therapy (HAART) era, more than 90% of patients with HIV infection eventually developed some form of oral candidiasis during their illness, and an additional 10% developed esophageal candidiasis (EC). Although several antifungal agents are available, systemic azoles (e.g., fluconazole and itraconazole) have replaced older topical antifungals (e.g., gentian violet and nystatin) in the management of MC in these patients. Overall, the azoles are safe and effective agents in HIV-infected patients with MC. However, clinical relapses are extremely common in HIV patients not on HAART or who are noncompliant. The relapses are dependent on the degree of immunosuppression and are more common following treatment with clotrimazole or ketoconazole than with fluconazole or itraconazole. Posaconazole is a new extended-spectrum triazole recently approved for the management of oropharyngeal candidiasis (OPC). In vitro, posaconazole possesses potent activity against Candida species, including strains that are resistant to fluconazole. Recent clinical trials demonstrate that posaconazole is as efficacious as fluconazole in producing a successful clinical response in HIV-infected patients with OPC/EC. In addition, posaconazole has been demonstrated to be well tolerated and more effective in sustaining clinical success after treatment was discontinued. Posaconazole appears to be an effective alternative in the management of MC in these difficult-to-treat infections.

Nursing guidelines for managing infections in patients with chronic lymphocytic leukemia

Infections are a primary cause of death in patients with chronic lymphocytic leukemia (CLL). Such individuals are particularly susceptible to infectious complications stemming from immune deficits associated with the primary disease process and with immunosuppression secondary to treatment. Although the recent availability of new treatment modalities and more aggressive therapies are improving outcomes for patients with CLL, standardized approaches are needed so that nurses can monitor for and manage infections. The aim is overall reduction in morbidity and mortality, as well as improvement in quality of life. The current pharmacologic therapies for CLL are alkylating agents, purine nucleoside analogs, monoclonal antibodies, and combinations of those therapies, which may present their own unique risks for and different spectra of infectious events. This article provides an overview of the known risks for developing infections in CLL, as well as nursing guidelines for monitoring and managing patients with CLL.