Guidelines for Treatment of Candidiasis

Caspofungin: a review of its use in the treatment of fungal infections

Caspofungin (Cancidas) is the first of a new class of antifungal agents, the echinocandins, that inhibit the synthesis of the fungal cell wall component beta-(1,3)-D-glucan. Caspofungin is administered once daily by slow intravenous infusion and is used to treat infections caused by Candida spp. and Aspergillus spp. Caspofungin is a valuable new antifungal agent with a novel mechanism of action. In comparative clinical trials, caspofungin was no less effective than liposomal amphotericin B in the empirical treatment of neutropenic patients with persistent fever, amphotericin B deoxycholate in the treatment of invasive candidiasis or fluconazole in the treatment of oesophageal candidiasis. Caspofungin also displayed broadly similar efficacy to amphotericin B deoxycholate in oesophageal or oropharyngeal candidiasis and was effective as salvage therapy in patients with invasive aspergillosis who were refractory to or intolerant of standard therapy. The tolerability profile of caspofungin was similar to that of fluconazole and superior to that of amphotericin B deoxycholate and liposomal amphotericin B. Therefore, in the appropriate indications, caspofungin is a viable alternative to amphotericin B deoxycholate, liposomal amphotericin B or fluconazole.

Activities of flucytosine, fluconazole, amphotericin B, and micafungin in a murine model of disseminated infection by Candida glabrata

We compared the efficacies of amphotericin B, fluconazole, flucytosine, and micafungin in a systemic murine infection by three isolates of Candida glabrata. Amphotericin B showed the best results, although none of the drugs dramatically reduced mortality or tissue burden in liver or spleen.

Management of the febrile neutropenic cancer patient: lessons from 40 years of study

Almost forty years ago the relationship between the circulating neutrophil count and the risk of pyogenic infection was established. Since that time, through the vehicle of clinical trials, much has been learnt about the etiologies, risk factors, pathogenesis, and natural history of first and subsequent febrile neutropenic episodes. Refinements to the empirical antibacterial management has reduced infection-related mortality to less than 10 percent. Algorithmic approaches to persistent fever in the setting of severe neutropenia have been developed. Circumstances wherein preventative strategies are most efficacious have been defined. Clinicians have learned that neutropenic patients comprise a heterogeneous population that does not encounter the same risks for infection-related morbidity and mortality. Tailored stratified approaches to management of the febrile neutropenic patient have been developed that are safe and cost-effective.

Emergence of disseminated candidiasis caused by Candida krusei during treatment with caspofungin: case report and review of literature

Current data indicate that caspofungin has in vitro activity against virtually all Candida species. However, we report herein a case of disseminated candidiasis due to Candida krusei which emerged during caspofungin treatment. Lung and brain secondary sites were then successfully treated using a combination of amphotericin B plus flucytosine, amphotericin B lipid complex, and voriconazole, sequentially. Among the total of four well documented cases of refractory invasive candidiasis during caspofungin therapy, the common risk factors appear to involve prior abdominal surgery, persistent foreign body, and anatomical sites where drug concentrations may be sub-optimal for Candida species with increased MICs. Caspofungin failure should be suspected in patients with persistent or emergent signs and symptoms of deep-seated invasive candidiasis.

Treatment of Candida infection: a view from the trenches!

PURPOSE OF REVIEW

To provide an overview of the treatment of Candida infections from the perspective of the infectious disease clinician in the community. An insight is given into relevant issues as they apply to clinical practice. As community hospitals strive to provide state-of-the-art medical care to critically ill patients, effective infection control programs and the infectious disease consultation availability become indispensable.

RECENT FINDINGS

Candida infections rank as the fourth most common cause of nosocomial bloodstream infections. Although C. albicans remains the most common pathogen, emerging trends in invasive candidiasis are notable for a dramatic increase in infections due to non-albicans Candida species, reflecting changes in clinical practice. These trends affect our practice because infections with non-albicans species raise concerns for inherent decreased antifungal susceptibility, ultimately impacting our preventive, empirical and therapeutic approaches. It seems inevitable for most acutely ill patients today to be admitted to the intensive care unit, thus increasing their risk for nosocomial infections. In addition, cost containment efforts may force patients receiving intravenous therapy into less supervised environments, potentially increasing their risk for candidemia.

SUMMARY

Potentially fatal Candida infections are commonplace in seriously ill hospitalized patients. The infectious disease physician is challenged to develop expertise in using the newly introduced antifungal agents, applying evidence-based guidelines developed from quality randomized clinical trials. The infectious disease specialist is called to play a multidisciplinary role formulating infection control policies, developing drug formularies, educating the staff and treating the sickest patients. Infection surveillance in local communities coupled with available antifungal agents may improve our management of Candida infections.

Bloodstream infections due to Candida species in the intensive care unit: identifying especially high-risk patients to determine prevention strategies

Nosocomial bloodstream infections due to Candida species are associated with a 40% crude (total) mortality rate in the United States. The attributable mortality rate defines the number of deaths due directly to the infection and represents the proportion of the total number of deaths influenced by the use of anti-infectives. We used 4 defined risk factors to create a conditional logistic regression model of individual patients' risk of candidemia and then examined the possibility of using a calculated risk threshold to begin treatment with anti-Candida antibiotics. We subsequently examined the number needed to treat (NNT) to prevent a single death related to bloodstream infection due to Candida species. By use of our model and assuming a 33% threshold for treating with an antibiotic, which is assumed to prevent 65% of candidal bloodstream infections, we show that the NNT would be 7 patients. Use of defined risk factors to select patients who are at high risk for candidemia and treatment with effective antibiotics would be an efficient way to reduce infection-related deaths.

Presumptive identification of Candida species other than C. albicans, C. krusei, and C. tropicalis with the chromogenic medium CHROMagar Candida

Background

CHROMagar Candida (CaC) is increasingly being reported as a medium used to differentiate Candida albicans from non-albicans Candida (NAC) species. Rapid identification of NAC can assist the clinician in selecting appropriate antifungal therapy. CaC is a differential chromogenic medium designed to identify C. albicans, C. krusei, and C. tropicalis based on colony color and morphology. Some reports have proposed that CaC can also reliably identify C. dubliniensis and C. glabrata.

Methods

We evaluated the usefulness of CaC in the identification of C. dubliniensis, C. famata, C. firmetaria, C. glabrata, C. guilliermondii, C. inconspicua, C. kefyr, C. lipolytica, C. lusitaniae, C. norvegensis, C. parapsilosis, and C. rugosa.

Results

Most NAC produced colonies that were shades of pink, lavender, or ivory. Several isolates of C. firmetaria and all C. inconspicua produced colonies difficult to differentiate from C. krusei. Most C. rugosa isolates produced unique colonies with morphology like C. krusei except in a light blue-green color. C. glabrata isolates produced small dark violet colonies that could be differentiated from the pink and lavender colors produced by other species. All seventeen isolates of C. dubliniensis produced green colonies similar to those produced by C. albicans.

Conclusion

C. glabrata and C. rugosa appear distinguishable from other species using CaC. Some NAC, including C. firmetaria and C. inconspicua, could be confused with C. krusei using this medium.

The usefulness of the PlateliaCandidaantigen in a patient with acute lymphocytic leukemia and chronic disseminated candidiasis

We report a protracted course of disseminated candidiasis due to Candida tropicalis in a 17-year-old man with acute lymphocytic leukemia. Despite adequate antifungal therapy (amphotericin B), C. tropicalis was recovered from biopsy specimens 25 days (skin) and 109 days (kidney) after the first positive blood cultures. While blood cultures became negative for C. tropicalis 11 days after the initiation of treatment, mannanemia persisted and became negative only after 130 days of antifungal therapy. Thus, antigen assays provided indicators of antifungal response. Differential diagnosis was difficult for this patient with the observation of persistent lesions in image studies. With positive results of antigen assays, an invasive procedure might be avoided and preemptive antifungal treatment could be initiated in a timely manner. Anti-mannan antibody remained undetectable up to 164 days after first positive blood culture despite the patient's recovery from neutropenia and recruitment of neutrophils in the tissue (skin).

Anidulafungin: a novel echinocandin

We evaluated the safety and efficacy of primary systemic chemotherapy (PSC) with docetaxel (DOC), epirubicin (EPI) and capecitabine (Xeloda:XLD) in 10 patients with advanced breast cancer. Their mean age was 54.7 years,and preoperative stages were IIB, seven cases; IIIA, two; and IV, one,respectively. The regimen consisted of XLD (2,400 or 3,000 mg/day) orally for 14 consecutive days, and DOC (60 or 70 mg/m2) and EPI (50 or 60 mg/m2) intravenously on day 8. This was repeated 4 times every 3 weeks. One patient discontinued this regimen after one course at her own request. Although the results revealed leucopenia and neutropenia of more than grade 3 in 8 and 10 patients,they could be treated on an outpatient basis with the use of G-CSF to maintain this regimen. Alopecia of grade 2 was found in all patients,neutropenic fever of more than 38.5 degrees C in 5,and hand-foot syndrome in 3. Downstaging after PSC was demonstrated in 7 cases (Stage IIB to I, three cases; IIB to IIA, three; and III A to I, one), with a response rate of 77.8%. Breast conserving therapy was performed in 8/10 patients. Pathological findings on cytological degeneration showed grade 0, one; grade 1a,seven; grade 2, one; and grade 3, one, respectively. Axillary lymph node metastasis was revealed in 7 cases. This regimen would be an alternative to PSC on an outpatient basis while taking great care of myelosuppression and hand-foot syndrome.

Two Approaches to Treatment of Complicated Candida Glabrata Urinary Tract Infection in Renal Failure

Objective:

To report the treatment of 2 cases of Candida glabrata urinary tract infection (UTI) in the setting of renal failure.

Case Summaries:

A 37-year-old female in acute renal failure developed a complicated UTI due to C. glabrata. The organism was eradicated after treatment with caspofungin. The second patient, a 58-year-old woman also in acute renal failure, developed a complicated UTI due to C. glabrata. This patient failed to eradicate the organism after repeated courses of voriconazole.

Discussion:

UTI caused by non-albicans Candida in the setting of renal failure presents few therapeutic options for management. Caspofungin and voriconazole have excellent activity against Candida spp., but have poor elimination as active drug in the urine. Amphotericin B is less feasible in the setting of acute renal failure, in which return of renal function is expected. Lipid-associated amphotericin products poorly penetrate the kidney. Despite these facts, one patient cleared the organism after treatment with caspofungin and one patient had persistent positive cultures after receiving voriconazole.

Conclusions:

Despite poor penetration into the urine, caspofungin may be an option in the management of UTI when other modalities are not feasible or desired.

Infectious Complications of Cancer Therapy

Advances in the management of cancer, particularly the development of new chemotherapeutic agents, have greatly improved the survival and outcome of patients with hematologic malignancies and solid tumors; overall 5-year survival rates in cancer patients have improved from 39% in the 1960s to 60% in the 1990s.1 However, infection, caused by both the underlying malignancy and cancer chemotherapy, particularly myelosuppressive chemotherapy, remains a persistent challenge.

Prophylactic fluconazole is effective in preventing fungal colonization and fungal systemic infections in preterm neonates: a single-center, 6-year, retrospective cohort study

OBJECTIVE

Despite the promising preliminary results observed in extremely low birth weight (ELBW) populations, the use of fluconazole to prevent fungal colonization and infection in preterm neonates in the NICU is still an open question and not yet recommended as a standard of care. We have reviewed our 6-year series to assess the effectiveness and safety of this form of prophylaxis.

METHODS

This retrospective study consisted of 465 neonates who weighed < 1500 g at birth and were admitted to our NICU in the period 1998-2003. Those who were born between 1998 and 2000 and did not receive fluconazole prophylaxis (group A, n = 240) were compared with those who were born between 2001 and 2003 and treated with fluconazole until the 30th day of life (45th for neonates < 1000 g at birth; group B, n = 225). Weekly surveillance cultures were obtained from all patients. Incidence of fungal colonization, incidence of systemic fungal infection (SFI), rate of progression from colonization to infection, and mortality rates attributable to fungi were calculated for both groups and separately for neonates who were < 1000 g (ELBW) and were 1001 to 1500 g (NE-VLBW) at birth.

RESULTS

Overall fungal colonization was significantly lower in group B (24.0%) than in group A (43.8%; relative risk [RR]: 0.406; 95% confidence interval [CI]: 0.273-0.605). The same was true of neonates with colonization in multiple sites (2.6% vs 5.8%) and of those with colonization from high-risk sites (5.8% vs 19.2%). SFI incidence was significantly lower in group B (10 of 225 cases; 4.4%) than in group A (40 of 240 cases; 16.7%; RR: 0.233; 95% CI: 0.113-0.447). Reduction of both colonization and SFI in group B was greater in the ELBW neonates and also significant in the NE-VLBW neonates. Rate of progression from colonization to infection was significantly lower in group B (0.17 vs 0.38; RR: 0.369; 95% CI: 0.159-0.815). Crude mortality rate attributable to Candida species was 1.7% (4 of 240) in group A vs 0% (0 of 225) in group B. Overall mortality rate (any cause before hospital discharge) was similar in the two groups (11.2% vs 10.6%), but in colonized infants (n = 159), it was significantly lower in group B (3.7% vs 18.1%; RR: 0.174; 95% CI: 0.039-0.778). The incidence of natively fluconazole-resistant fungal species did not increase over the years, and patterns of sensitivity to fluconazole remained the same. No adverse reaction related to fluconazole occurred.

CONCLUSIONS

Prophylactic fluconazole significantly reduces the incidence of colonization and systemic infection by Candida species in both ELBW and NE-VLBW neonates and decreases the rates of progression from initial colonization to massive colonization and to systemic infection. All VLBW neonates may benefit from fluconazole prophylaxis.

Candidaendocarditis in neonates: report of five cases and review of the literature

Candidal endocarditis is an uncommon and serious complication of invasive Candida infection in neonates. The aim of this study was to further characterise candidal endocarditis in neonates. Between 1995 and 2000, 56 patients were diagnosed with Candida bloodstream infections (CBSI) in the Neonatal Intensive Care Unit of Schneider Children's Medical Center of Israel. Five of them (9%) developed mycetoma of the right atrium. None of the patients had congenital heart disease or a central venous catheter in the right heart at the time of diagnosis. All were treated with amphotericin B alone or in combination with other antifungals, without surgical intervention. One patient died of the disease and one died later of polymicrobial sepsis and necrotizing enterocolitis. A review of the literature since 1980 yielded an additional 25 cases of candidal endocarditis. For the whole sample (n = 30) survival rate was 73.1%. Six of the 10 patients treated with antifungal agents and surgery survived (60%), compared with 13 of the 20 patients treated only medically (65%) (P = 1.0). Candida endocarditis in neonates differs from fungal endocarditis in adults in risk factors, clinical presentation and outcome. As the outcome of surgical and medical treatment are comparable, antifungal therapy alone may be a valid therapeutic option in high-risk cases.

Successful treatment of fungus balls due to fluconazole-resistant Candida sake obstructing ureter stents in a renal transplant patient

Reported here is the case of a 72-year-old renal transplant recipient with stenosis of the neo-ureter requiring stents, who was admitted to hospital with pyonephrosis caused by fungus balls. Fluconazole-resistant Candida sake was grown. Treatment with external drainage of the renal pelvis and intravenous and local administration of caspofungin resulted in relief of the obstruction. Eradication of the infection was achieved by surgical removal of the ureter with all stents and construction of a cysto-pyelostomy.

Current treatment strategies for disseminated candidiasis

The incidence of disseminated candidiasis has increased dramatically over the past several decades. Fortunately, in recent years, a variety of new antifungal agents have become available to treat these infections. On the basis of efficacy, safety, and cost considerations, fluconazole is the agent of choice for the empirical treatment of disseminated candidiasis in nonneutropenic, hemodynamically stable patients, unless a patient is suspected to be infected with an azole-resistant species (i.e., Candida glabrata or Candida krusei). For hemodynamically unstable or neutropenic patients, agents with broader species coverage, such as polyenes, echinocandins, or, possibly, voriconazole, are preferred for empirical treatment of candidemia. Modification of the initial, empirical regimen depends on the response to therapy and the subsequent identification of the species of the offending pathogen. Echinocandins or high-dose polyenes are preferred for the treatment of infections with C. glabrata or C. krusei. Central venous catheters should be removed from all patients who have disseminated candidiasis, if feasible, and antifungal therapy should be administered to all patients who have candidemia or proven candidiasis.

Experience with caspofungin in the treatment of persistent fungemia in neonates

OBJECTIVE

To review our experience of caspofungin in the treatment of persistent candidemia in the neonatal intensive care unit.

STUDY DESIGN

This was a retrospective chart review on 13 infants in whom caspofungin was added to conventional antifungals (amphotericin B and/or fluconazole or flucytosine) for the treatment of refractory candidemia.

RESULTS

A total of 12 infants were preterm (gestational age, 24 to 28 weeks) and one was term; the median birth weight was 800 g (range, 530 to 5600 g). Candidemia (Candida albicans in five, C. parapsilosis in six, C. albicans and C. parapsilosis in one and C. tropicalis in one) persisted despite 6 to 30 days of conventional antifungal therapy. After the addition of caspofungin, sterilization of blood cultures was achieved in 11 infants at the median time of 3 days (range, 1 to 21 days). Adverse events included thrombophlebitis (one patient), hypokalemia (two patients) and elevation of liver enzymes (four patients). Three infants had a second episode of candidemia and seven patients died.

CONCLUSION

Caspofungin may be an efficacious addition for treatment of candidemia refractory to conventional antifungal therapy. This drug should be further investigated in neonates.

Epidemiología de las infecciones en el paciente neutropénico

Epidemiological data are useful to determine changes in forms of clinical expression and in the microbial agents causing infections. This allows empirical or preemptive treatments to be designed and can guide diagnostic tests. Empirical data also allow patients to be classified by risk group in order to decide on the need for hospitalization. The incidence of neutropenia is increasing as a result of the more aggressive antineoplastic treatments used and the broader age range of patients who receive them. It has been calculated that in the USA neutropenia causes approximately 60,000 hospitalizations per year and that a third of these occur in hematological patients. The most frequent foci of infection are: pneumonia (38%), bacteremia (35%) and urinary (11%). Of the bacteria causing infection, two thirds are Gram-positive and the remaining bacilli are Gram-negative. In the last few years, an increase of Gram-negative bacteria seems to have reemerged. The incidence of fungal isolates represents 2-10%, depending on the type of neutropenic patient analyzed. Fungal isolates are found preferentially in patients with prolonged neutropenia and/or other associated immunodeficiencies, as occurs in allogenic bone marrow transplantation or in patients who have received purine analogs. Viruses are very frequent. Respiratory viruses seem to be emerging pathogens in this group of patients.

Pharmacoeconomics of antifungal pharmacotherapy – challenges and future directions

The frequency and severity of invasive fungal infections have been increasingly recognised and new antifungal therapies have expanded the therapeutic armamentarium available to manage such infections. Antifungal agents comprise a significant portion of antibiotic expenditures at major medical centres, prompting adoption of cost-containment measures and treatment guidelines. This paper reviews available data regarding the costs associated with managing fungal infections, including pharmacoeconomic analyses that have been performed in the setting of documented fungal infections, as well as prophylactic and empiric use of antifungal agents. The challenges of performing such studies are discussed, as well as the limitations of published investigations. Finally, recommendations are made regarding the design and implementation of future pharmacoeconomic analyses that can help establish the true costs of managing invasive fungal infections in at-risk patient populations.

The Changing Face of Fungal Infections in Health Care Settings

As strategies to prevent invasive fungal infections among both hospitalized and nonhospitalized patients have evolved, the epidemiology of these infections has changed. Several unique features of select Candida species and molds have facilitated the emergence of these pathogens as more-common causes of infection than in previous years. In this context, the changing pathogen profiles, unique antifungal susceptibilities, and approaches to treatment are outlined.

Candida glabrata prosthetic valve endocarditis treated successfully with fluconazole plus caspofungin without surgery: a case report and literature review

Reported here is the case of a 72-year-old man who was diagnosed with Candida glabrata prosthetic mitral valve endocarditis and treated successfully with fluconazole plus caspofungin after he refused and was determined unfit for surgery. Initial treatment with intravenous amphotericin B resulted in acute renal impairment. Despite 8 days of intravenous fluconazole therapy, he remained fungemic. Caspofungin was added to the treatment regimen with subsequent sterilisation of blood culture. The patient was treated for 34 days with caspofungin and 41 days with fluconazole. He continued oral fluconazole after hospital discharge and remained well at follow-up 11 months later. The role of fluconazole and caspofungin in the treatment of Candida endocarditis is discussed.

International, open-label, noncomparative, clinical trial of micafungin alone and in combination for treatment of newly diagnosed and refractory candidemia

Candida spp. are the fourth leading cause of bloodstream infections, and non-albicans species are increasing in importance. Micafungin is a new echinocandin antifungal agent with excellent in vitro activity against Candida spp. Pediatric, neonatal, and adult patients with new or refractory candidemia were enrolled into this open-label, noncomparative, international study. The initial dose of micafungin was 50 mg/d (1 mg/kg for patients <40 kg) for infections due to C. albicans and 100 mg/d (2 mg/kg for patients <40 kg) for infections due to other species. Dose escalation was allowed. Maximum length of therapy was 42 days. A total of 126 patients were evaluable (received at least five doses of micafungin). Success (complete or partial response) was seen in 83.3% patients overall. Success rates for treatment of infections caused by the most common Candida spp. were as follows: C. albicans 85.1%, C. glabrata 93.8%, C. parapsilosis 86.4%, and C. tropicalis 83.3%. Serious adverse events related to micafungin were uncommon. Micafungin shows promise as a safe and effective agent for the treatment of newly diagnosed and refractory cases of candidemia. Large-scale, randomized, controlled trials are warranted.

A probable case of aspiration pneumonia caused by Candida glabrata in a non-neutropenic patient with candidemia

Primary Candida pneumonia is rare, and detailed reports of Candida glabrata pneumonia have not been described. A 71-year-old woman had been treated for heart failure and developed aspiration pneumonia, which was refractory to antibacterial treatment. Antifungal treatment against C. glabrata resulted in resolution of pneumonia and candidemia. We report a probable case of C. glabrata pneumonia.

Management of intracranial fungal infections in patients with haematological malignancies

The incidence of, and mortality associated with, invasive fungal infections remains far higher than hoped. As a consequence of the overall increase in the incidence of such infections over time, the incidence of central nervous system (CNS) fungal infections is also increasing and, despite improvements in diagnostic techniques and the introduction of novel antifungal agents, therapy for CNS infections is still associated with discouragingly poor results. In patients with haematological malignancies, opportunistic infections with Candida or Aspergillus remain the most common infections affecting the CNS; however, opportunistic infections with less well-known fungi are becoming more common and must be considered in the differential diagnosis. New techniques for the early diagnosis of invasive fungal infections are emerging. Pharmacologic options for treating invasive fungal infections have also improved during the past few years, with new drugs becoming available that have broader antifungal spectra and better safety profiles. Other novel treatment approaches, such as combination therapy, are also being explored. Early investigations have produced encouraging results; however, large, prospective studies involving many patients are necessary to validate the widespread use of these approaches. This review analyses the existing guidelines for treatment of CNS fungal infections and the literature available on the use of new drugs to generate sets of recommendations for treatment of these life-threatening infections in patients with haematological malignancies.

Invasive Candidiasis in Immunocompromised Hospitalized Patients

The frequency of infections by Candida species is increasing worldwide, with candidemia representing the fourth most common bloodstream infection in the U.S. The risk of infection is especially high in the immunocompromised, hospitalized patient. The treatment of and prophylaxis for Candida infection have led to the emergence of resistant species and the acquisition of resistance in previously susceptible species. Current therapeutic options include amphotericin B and its lipid compounds, fluconazole, itraconazole, voriconazole, and caspofungin. Research is focusing on better diagnostics and the evaluation of strategies such as prophylaxis in high-risk hosts and pre-emptive therapy.

Voriconazole versus a regimen of amphotericin B followed by fluconazole for candidaemia in non-neutropenic patients: a randomised non-inferiority trial

BACKGROUND

Voriconazole has proven efficacy against invasive aspergillosis and oesophageal candidiasis. This multicentre, randomised, non-inferiority study compared voriconazole with a regimen of amphotericin B followed by fluconazole for the treatment of candidaemia in non-neutropenic patients.

METHODS

Non-neutropenic patients with a positive blood culture for a species of candida and clinical evidence of infection were enrolled. Patients were randomly assigned, in a 2:1 ratio, either voriconazole (n=283) or amphotericin B followed by fluconazole (n=139). The primary efficacy analysis was based on clinical and mycological response 12 weeks after the end of treatment, assessed by an independent data-review committee unaware of treatment assignment.

FINDINGS

Of 422 patients randomised, 370 were included in the modified intention-to-treat population. Voriconazole was non-inferior to amphotericin B/fluconazole in the primary efficacy analysis, with successful outcomes in 41% of patients in both treatment groups (95% CI for difference -10.6% to 10.6%). At the last evaluable assessment, outcome was successful in 162 (65%) patients assigned voriconazole and 87 (71%) assigned amphotericin B/fluconazole (p=0.25). Voriconazole cleared blood cultures as quickly as amphotericin B/fluconazole (median time to negative blood culture, 2.0 days). Treatment discontinuations due to all-cause adverse events were more frequent in the voriconazole group, although most discontinuations were due to non-drug-related events and there were significantly fewer serious adverse events and cases of renal toxicity than in the amphotericin B/fluconazole group.

INTERPRETATION

Voriconazole was as effective as the regimen of amphotericin B followed by fluconazole in the treatment of candidaemia in non-neutropenic patients, and with fewer toxic effects.

RELEVANCE TO PRACTICE

There are several options for treatment of candidaemia in non-neutropenic patients, including amphotericin B, fluconazole, voriconazole, and echinocandins. Voriconazole can be given both as initial intravenous treatment and as an oral stepdown agent.

Antibiotic Dosing in Critically Ill Adult Patients Receiving Continuous Renal Replacement Therapy

Continuous renal replacement therapy (CRRT) is now commonly used as a means of support for critically ill patients with renal failure. No recent comprehensive guidelines exist that provide antibiotic dosing recommendations for adult patients receiving CRRT. Doses used in intermittent hemodialysis cannot be directly applied to these patients, and antibiotic pharmacokinetics are different than those in patients with normal renal function. We reviewed the literature for studies involving the following antibiotics frequently used to treat critically ill adult patients receiving CRRT: vancomycin, linezolid, daptomycin, meropenem, imipenem-cilastatin, nafcillin, ampicillin-sulbactam, piperacillin-tazobactam, ticarcillin-clavulanic acid, cefazolin, cefotaxime, ceftriaxone, ceftazidime, cefepime, aztreonam, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, colistin, amikacin, gentamicin, tobramycin, fluconazole, itraconazole, voriconazole, amphotericin B (deoxycholate and lipid formulations), and acyclovir. We used these data, as well as clinical experience, to make recommendations for antibiotic dosing in critically ill patients receiving CRRT.

Tratamiento antifúngico empírico en pacientes seleccionados con fiebre persistente y neutropenia

Empirical antifungal treatment (EAT) in neutropenia is mainly aimed at improving the poor prognosis of patients with invasive fungal infection through early treatment. The Infectious Diseases Society of America recommends initiating EAT in patients with persistent fever after 5-7 days of antibacterial treatment, and in those in whom remission of neutropenia is not imminent. Nevertheless, EAT has not been shown to be more effective than a placebo, it does not show better results than directed antifungal treatment, its effectiveness is minimal, it is not innocuous, and it is not very efficient with the use of most antifungal agents. All considered, we believe that the aforementioned recommendation for EAT treatment is unjustified. In its place we propose the application of EAT in patients selected on the basis of clinical criteria and risk factors.

Candida glabrata Fungemia: Experience in a Tertiary Care Center

BACKGROUND

During the past decade, Candida glabrata has emerged as an important cause of fungemia. We reviewed demographic data, risk factors, treatment, and outcomes associated with C. glabrata fungemia from 1995-2002 and performed susceptibility testing of isolates.

METHODS

Data on all episodes of fungemia were prospectively recorded, and the associated isolates were saved. Medical records were reviewed retrospectively. Susceptibility testing was performed for fluconazole, itraconazole, and voriconazole.

RESULTS

C. glabrata caused 103 (17%) of 609 fungemic episodes during the 8-year period that we studied. Medical records and isolates were available for 94 episodes that occurred in 91 patients. The patients included 42 men and 49 women. The mean age was 51 years. Thirty-four episodes (36%) occurred in patients >60 years old; only 3 episodes occurred in patients <1 year old. The most common predisposing factors were use of broad-spectrum antibiotics (in 86% of episodes), use of central venous catheters (77%), stay in an intensive care unit (48%), renal failure (46%), and receipt of parenteral nutrition (45%). Of the 94 episodes, 83 were treated with antifungal agents. The overall mortality rate at day 30 was 29%. For the 11 episodes that were not treated, the mortality rate was 64% (7 of 11 episodes). Outcome appeared to be unrelated to whether fluconazole or amphotericin B was administered. In vitro, 60% of isolates were resistant to fluconazole, 83% to itraconazole, and 44% to voriconazole. Susceptibility to these azoles did not change over the 8 years of the study.

CONCLUSION

C. glabrata fungemia was most often seen in older adults and was associated with a mortality rate of 29%. Outcomes appeared to be unrelated to in vitro susceptibility results and to the antifungal agent used.

The epidemiology and attributable outcomes of candidemia in adults and children hospitalized in the United States: a propensity analysis

BACKGROUND

Candida species are the fourth most common cause of bloodstream infection and are the leading cause of invasive fungal infection among hospitalized patients in the United States. However, the frequency and outcomes attributable to the infection are uncertain. This retrospective study set out to estimate the incidence of candidemia in hospitalized adults and children in the United States and to determine attributable mortality, length of hospital stay, and hospital charges related to candidemia.

METHODS

We used the Nationwide Inpatient Sample 2000 for adult patients and the Kids' Inpatient Database 2000 for pediatric patients. We matched candidemia-exposed and candidemia-unexposed patients by the propensity scores for the probability of candidemia exposure, which were derived from patient characteristics. Attributable outcomes were calculated as the differences in estimates of outcomes between propensity score-matched patients with and without candidemia.

RESULTS

In the United States in 2000, candidemia was diagnosed in an estimated 1118 hospital admissions of pediatric patients and 8949 hospital admissions of adult patients, yielding a frequency of 43 cases per 100,000 pediatric admissions (95% confidence interval [CI], 35-52 cases per 100,000 pediatric admissions) and 30 cases per 100,000 adult admissions (95% CI, 26-34 cases per 100,000 adult admissions). In pediatric patients, candidemia was associated with a 10.0% increase in mortality (95% CI, 6.2%-13.8%), a mean 21.1-day increase in length of stay (95% CI, 14.4-27.8 days), and a mean increase in total per-patient hospital charges of 92,266 dollars (95% CI, 65,058 dollars-119,474 dollars). In adult patients, candidemia was associated with a 14.5% increase in mortality (95% CI, 12.1%-16.9%), a mean 10.1-day increase in length of stay (95% CI, 8.9-11.3 days), and a mean increase in hospital charges of 39,331 dollars (95% CI, 33,604 dollars-45,602 dollars).

CONCLUSION

The impact of candidemia on excess mortality, increased length of stay, and the burden of cost of hospitalization underscores the need for improved means of prevention and treatment of candidemia in adults and children.

In vitro interaction of posaconazole and caspofungin against clinical isolates of Candida glabrata

Combinations of caspofungin and posaconazole were evaluated by fractional inhibitory concentration index against 119 Candida glabrata isolates. Synergy was seen in 18% of all isolates and in 4% of fluconazole-resistant isolates at 48 h without evidence of antagonism. This antifungal combination may have utility against this organism.

Advances and challenges in management of invasive mycoses

Invasive mycoses pose a major diagnostic and therapeutic challenge. Advances in antifungal agents and diagnostic methods offer the potential for improved outcomes in patients with these infections, which are often lethal. Many fungal pathogens occur almost exclusively in opportunistic settings--in the immunocompromised host--and these infections are the focus of this review. Several areas of ongoing challenge remain, including the emergence of resistant organisms and the absence of reliable markers for early identification of patients at risk of developing invasive fungal disease. This Seminar reviews the changing epidemiology of invasive mycoses, new diagnostic methods, and recent therapeutic options and current management strategies for these opportunistic pathogens.

Candiduria

Candiduria is a common finding. Yeasts can be detected in urine that is contaminated during collection, in patients who have bladder colonization, and in patients who have upper urinary tract infection that developed either from retrograde spread from the bladder or hematogenous spread from a distant source. Most patients with candiduria are asymptomatic. The rate of development of complications is not known but appears to be low; candidemia rarely results from asymptomatic candiduria unless obstruction is present or instrumentation of the urinary tract is done. Unfortunately, there are no established diagnostic tests that reliably distinguish infection from colonization. Guidelines for the treatment of candiduria, based almost entirely on anecdotal reports and expert opinions, rather than controlled clinical trials, have been suggested by the Infectious Diseases Society of America. Until reliable methods to distinguish infection from colonization are developed, further treatment trials are unlikely to provide information to guide the clinician in the treatment of candiduria.

In vitro susceptibilities of clinical isolates of Candida species, Cryptococcus neoformans, and Aspergillus species to itraconazole: global survey of 9,359 isolates tested by clinical and laboratory standards institute broth microdilution methods

The in vitro activity of itraconazole was determined against 7,299 isolates of Candida spp., 1,615 isolates of Cryptococcus neoformans, and 445 isolates of Aspergillus spp. obtained from over 200 medical centers worldwide. Itraconazole was active against all Candida spp. (96% of MICs were < or =1 microg/ml) with the exception of C. glabrata (77% of MICs were < or =1 microg/ml). Itraconazole inhibited 94% of C. krusei and 84% of other fluconazole-resistant Candida species, exclusive of C. glabrata, at a MIC of < or =1 microg/ml. Itraconazole was not active against fluconazole-resistant isolates of C. glabrata. Only modest activity was seen against C. neoformans (80% of MICs were < or =1 microg/ml); however, itraconazole showed excellent activity against Aspergillus spp. (94% of MICs were < or =1 microg/ml). These results provide an update on the antifungal activity of itraconazole against major opportunistic fungal pathogens. In light of the new intravenous formulation of itraconazole these data suggest that this agent remains a viable systemically active antifungal agent.

Invasive fungal infections at The Norwegian Radium Hospital 1998-2003

The study evaluates the clinical and microbiological data from patients with documented invasive fungal infections at a comprehensive cancer centre in Norway. Relevant microbiology and pathology databases were screened and medical records were reviewed. 17 yeast infections, including 1 case of cryptococcal meningitis, and no mould infections were found. Diagnostically, in 30% of the positive blood cultures Candida only grew in the Mycosis IC/F bottle. Half of the patients had febrile neutropenia, and 30% had undergone complicated abdominal or pelvic surgery. 12 out of 13 positive blood cultures were Candida albicans. 30% of the patients died of acute septic candidiasis. Within 14 months 90% of the patients were dead from their underlying diseases. A diagnosis of invasive fungal infection is an ominous sign for the patient's overall prognosis.

A 9-year study comparing risk factors and the outcome of paediatric and adults with nosocomial candidaemia

Although there are numerous studies of candidaemia in adults, data on paediatrics are still limited. The aim of this study was to compare risk factors, aetiology, therapy, and the outcome of nosocomial candidaemia among paediatric and adult patients in a large Brazilian tertiary hospital (1995-2003). During this period, 78 paediatrics and 113 adults were studied. Species other than Candida albicans caused 78.2% of episodes of candidaemia in paediatrics. Compared to adults, paediatrics received more frequently broad-spectrum antibiotics, vasopressors, blood transfusions, arterial catheter, chest tube, cardiothoracic surgery, mechanical ventilation, and parenteral nutrition. Candidaemia caused by Candida parapsilosis was more common in paediatrics, as was the isolation of Candida spp. from catheters. Amphotericin B treatment was more common in paediatrics. Mortality rate was higher in adults than in paediatrics with nosocomial candidaemia. We reinforce the necessity of continuous epidemiologic surveillance to follow the dynamics of candidaemia.

Actividad in vitro de las equinocandinas ¿Cómo debe evaluarse?

Echinocandins are a novel class of antifungal drugs. They have good activity against Candida spp and Aspergillus spp. Their low selective toxicity allows their administration at high doses with few secondary side effects. We have reviewed the available data on the endpoints for these drugs in their in vitro susceptibility testing on yeasts and moulds. The microdilution broth method is the most commonly used technique and MIC-1 (80% of growth inhibition) seems to be the most reliable endpoint when yeasts are tested. This endpoint also seems to be the most appropriate for the different drugs when they are combined with echinocandins using the checkerboard method for testing yeasts. By contrast, in the case of moulds, the minimum effective concentration (MEC) correlates better with the in vivo activity than the MIC when echinocandins are tested, and when these drugs are combined with other antifungals, MIC-2 (50% of growth inhibition) seems the most appropriate endpoint. Criteria based on drug pharmacodynamics is the most useful to define the echinocandin endpoints that best correlate with their in vivo efficacy.

Emerging Fungal Diseases

The epidemiology of invasive fungal infection is evolving. Yeasts other than Candida albicans and molds other than Aspergillus fumigatus have emerged as significant causes of invasive mycoses in severely immunocompromised patients. Although, in some instances, these changes may be related to medical interventions, such as the use of antifungal agents in prophylaxis, in the majority of cases, they seem to be a consequence of changes in the host, such as more-severe immunosuppression or different types of immunosuppression impacting both risk periods and the infections that occur. These factors have altered the epidemiology of infection in organ transplant recipients, premature newborns, and critically ill patients. This review discusses the epidemiology of some fungal infections that have emerged in the past few years, with an emphasis on the potential factors associated with their emergence and on practical implications of these epidemiological changes.

Management of invasive candidiasis in critically ill patients

Candida species have become predominant pathogens in critically ill patients. In this population, invasive candidiasis is associated with a poor prognosis but adequate management can limit the attributable mortality. Adequate management, however, is hampered by a problematic diagnosis as the clinical picture of invasive disease is non-specific and blood cultures have a low sensitivity. Moreover, it is often hard to differentiate colonisation from infection and many critically ill patients are heavily colonised with Candida species, especially when receiving broad-spectrum antibacterials. The question of which antifungal agent to choose has become more complex as the development of new drugs raises promising expectations. Until the 1980s therapy for invasive candidiasis was limited to amphotericin B, but with the advent of new antifungal agents, such as azoles and echinocandins, less toxic therapeutic options are possible and doors have opened towards prevention and optimised therapy in the case of documented candidiasis. Through the arrival of these new antifungal agents, a range of therapeutic strategies for the management of invasive candidiasis has been developed: antifungal prophylaxis, pre-emptive therapy, and empirical and definitive antifungal therapy. Each of these strategies has a specific target population, as defined by specific underlying conditions and/or individual risk factors. Antifungal prophylaxis, in order to prevent candidal infection, is based on the type of underlying diseases with a high risk for invasive candidiasis. Individual risk factors are not taken into account. Potential indications are bone marrow transplantation, liver transplantation, recurrent gastrointestinal perforations or leakages, and surgery for acute necrotising pancreatitis. Pre-emptive therapy is also a preventive strategy. It can be recommended on the basis of an individual risk profile including overt candidal colonisation. Empirical therapy is started in patients with a risk profile for invasive candidiasis. It is recommended in the presence of clinical signs of infection, deteriorating clinical parameters, or a clinical picture of infection not responding to antibacterials but in the absence of a clear causative pathogen. Definitive antifungal therapy is defined as therapy in patients with documented invasive infection. The main goal is to maintain a balance between optimal prevention and timely initiation of therapy on one hand, and to minimise selection pressure in order to avoid a shift towards less susceptible Candida species on the other hand.

First reported case of endocarditis caused by Candida dubliniensis

Candida dubliniensis is an uncommon cause of bloodstream infection. We describe the first reported case of endocarditis caused by C. dubliniensis and the use of a rapid and novel real-time PCR assay based on the internal transcribed spacer 2 variable region of the rRNA operon that was used to identify this organism.