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Impact of Invasive Fungal Diseases on Survival under Veno-Venous Extracorporeal Membrane Oxygenation for ARDS. J Clin Med 2022; 11:jcm11071940. [PMID: 35407548 PMCID: PMC8999842 DOI: 10.3390/jcm11071940] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To assess the incidence and significance of invasive fungal diseases (IFD) during veno-venous (VV) ECMO support for acute respiratory distress syndrome (ARDS). METHODS Retrospective analysis from January 2013 to April 2021 of all ECMO cases for ARDS at a German University Hospital. In patients with IFD (IFD patients), type of IFD, time of IFD, choice of antifungal agent, duration, and success of therapy were investigated. For comparison, patients without IFD (non-IFD patients) were selected by propensity score matching using treatment-independent variables (age, gender, height, weight, and the Sequential Organ Failure Assessment (SOFA) score at ICU admission). Demographics, hospital and ICU length of stay, duration of ECMO therapy, days on mechanical ventilation, prognostic scores (Charlson Comorbidity Index (CCI), Therapeutic Intervention Scoring System (TISS), and length of survival were assessed. RESULTS A total of 646 patients received ECMO, 368 patients received VV ECMO. The incidence of IFD on VV ECMO was 5.98%, with 5.43% for Candida bloodstream infections (CBSI) and 0.54% for invasive aspergillosis (IA). In IFD patients, in-hospital mortality was 81.8% versus 40.9% in non-IFD patients. The hazard ratio for death was 2.5 (CI 1.1-5.4; p: 0.023) with IFD. CONCLUSIONS In patients on VV ECMO for ARDS, about one in 17 contracts an IFD, with a detrimental impact on prognosis. Further studies are needed to address challenges in the diagnosis and treatment of IFD in this population.
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Dudakova A, Blei C, Groß U, Schulze MH. Impact of routine bedside infectious diseases service on clinical management and prognosis of patients with Candida fungemia - an example for Antifungal Stewardship at university level in Germany. Int J Infect Dis 2022; 119:150-159. [PMID: 35367354 DOI: 10.1016/j.ijid.2022.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Candidemia is rare and has a high mortality rate. This study analyses the impact of bedside antifungal stewardship (AFS) on clinical management and prognosis of patients with candidemia at a university hospital in Germany. METHODS All patients with at least one positive blood culture with Candida species between 2014 and 2016 received bedside AFS with standardized recommendations. Medical records were retrospectively analyzed. Results from the intervention period from 2014-2016 (n=109), with focus on 2016 (n=39), were compared with those from the pre-intervention period in 2013 (n=30). RESULTS Bedside AFS was performed in 24/35 (69%) surviving patients in 2016 within the first 3 days after diagnosis of candidemia. All surviving patients (n=35) in 2016 received antifungal treatment compared with 24/28 (86%) in 2013 (p=0.0344). Follow-up blood cultures were performed in 25/35 (71%) in 2016 compared with 10/25 (40%) in 2013 (p=0.0046). Survival in the intervention compared with the pre-intervention group did not differ significantly (p=0.58) one year after the diagnosis of candidemia was made. However, patients with candidemia often have multiple serious comorbidities. CONCLUSIONS Individualized bedside AFS significantly improves adherence to recommendations for patients with Candida fungemia, especially guideline-oriented diagnostics and therapy. Improving the prognosis of patients with candidemia remains a huge challenge for AFS.
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Affiliation(s)
- Anna Dudakova
- Institute for Medical Microbiology and Virology, University Medical Center Göttingen, Kreuzbergring 57, 37075 Göttingen, Germany.
| | - Claudia Blei
- Hospital Pharmacy, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany
| | - Uwe Groß
- Institute for Medical Microbiology and Virology, University Medical Center Göttingen, Kreuzbergring 57, 37075 Göttingen, Germany.
| | - Marco H Schulze
- Institute for Medical Microbiology and Virology, University Medical Center Göttingen, Kreuzbergring 57, 37075 Göttingen, Germany; Institute of Infection Control and Infectious Diseases, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany.
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Combined Use of Presepsin and (1,3)-β-D-glucan as Biomarkers for Diagnosing Candida Sepsis and Monitoring the Effectiveness of Treatment in Critically Ill Patients. J Fungi (Basel) 2022; 8:jof8030308. [PMID: 35330311 PMCID: PMC8954802 DOI: 10.3390/jof8030308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 11/17/2022] Open
Abstract
New biomarker panel was developed and validated on 165 critically ill adult patients to enable a more accurate invasive candidiasis (IC) diagnosis. Serum levels of the panfungal biomarker (1,3)-β-D-glucan (BDG) and the inflammatory biomarkers C-reactive protein, presepsin (PSEP), and procalcitonin (PCT) were correlated with culture-confirmed candidemia or bacteremia in 58 and 107 patients, respectively. The diagnostic utility was evaluated in sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). BDG was the best marker for IC, achieving 96.6% sensitivity, 97.2% specificity, 94.9% PPV, and 98.1% NPV at a cut-off of 200 pg/mL (p ≤ 0.001). PSEP exhibited 100% sensitivity and 100% NPV at a cut-off of 700 pg/mL but had a lower PPV (36.5%) and low specificity (5.6%). Combined use of PSEP and BDG, thus, seems to be the most powerful laboratory approach for diagnosing IC. Furthermore, PSEP was more accurate for 28-day mortality prediction the area under the receiver operating characteristic curve (AUC = 0.74) than PCT (AUC = 0.31; PCT cut-off = 0.5 ng/mL). Finally, serum PSEP levels decreased significantly after only 14 days of echinocandin therapy (p = 0.0012). The probability of IC is almost 100% in critically ill adults with serum BDG and PSEP concentrations > 200 pg/mL and >700 pg/mL, respectively, defining a borderline between non-invasive superficial Candida colonization and IC.
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Tabah A, Lipman J, Barbier F, Buetti N, Timsit JF. Use of Antimicrobials for Bloodstream Infections in the Intensive Care Unit, a Clinically Oriented Review. Antibiotics (Basel) 2022; 11:antibiotics11030362. [PMID: 35326825 PMCID: PMC8944491 DOI: 10.3390/antibiotics11030362] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/22/2022] [Accepted: 02/26/2022] [Indexed: 01/06/2023] Open
Abstract
Bloodstream infections (BSIs) in critically ill patients are associated with significant mortality. For patients with septic shock, antibiotics should be administered within the hour. Probabilistic treatment should be targeted to the most likely pathogens, considering the source and risk factors for bacterial resistance including local epidemiology. Source control is a critical component of the management. Sending blood cultures (BCs) and other specimens before antibiotic administration, without delaying them, is key to microbiological diagnosis and subsequent opportunities for antimicrobial stewardship. Molecular rapid diagnostic testing may provide faster identification of pathogens and specific resistance patterns from the initial positive BC. Results allow for antibiotic optimisation, targeting the causative pathogen with escalation or de-escalation as required. Through this clinically oriented narrative review, we provide expert commentary for empirical and targeted antibiotic choice, including a review of the evidence and recommendations for the treatments of extended-spectrum β-lactamase-producing, AmpC-hyperproducing and carbapenem-resistant Enterobacterales; carbapenem-resistant Acinetobacter baumannii; and Staphylococcus aureus. In order to improve clinical outcomes, dosing recommendations and pharmacokinetics/pharmacodynamics specific to ICU patients must be followed, alongside therapeutic drug monitoring.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Metro North Hospital and Health Services, Redcliffe, QLD 4020, Australia
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Antimicrobial Optimisation Group, UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia;
- Correspondence: ; Tel.: +61-(0)-7-3883-7777
| | - Jeffrey Lipman
- Antimicrobial Optimisation Group, UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia;
- Jamieson Trauma Institute and Intensive Care Services, Royal Brisbane and Women’s Hospital, Metro North Hospital and Health Services, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30029 Nîmes, France
| | - François Barbier
- Medical Intensive Care Unit, CHR Orléans, 45100 Orléans, France;
| | - Niccolò Buetti
- IAME, INSERM, Université de Paris, 75018 Paris, France; (N.B.); (J.-F.T.)
- Infection Control Program and WHO Collaborating Centre on Patient Safety, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - Jean-François Timsit
- IAME, INSERM, Université de Paris, 75018 Paris, France; (N.B.); (J.-F.T.)
- APHP Medical and Infectious Diseases Intensive Care Unit (MI), Bichat-Claude Bernard Hospital, 75018 Paris, France
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Boussen I, Lisan Q, Raffoux E, Di Blasi R, Boissel N, Oksenhendler E, Adès L, Xhaard A, Bretagne S, Alanio A, Molina JM, Denis B. Hepatosplenic candidiasis in patients with hematological malignancies: a 13-year retrospective cohort study. Open Forum Infect Dis 2022; 9:ofac088. [PMID: 35355897 PMCID: PMC8962726 DOI: 10.1093/ofid/ofac088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/18/2022] [Indexed: 11/14/2022] Open
Abstract
Background Hepatosplenic candidiasis (HSC) used to be reported in patients with acute myeloid leukemia (AML) without antifungal prophylaxis. The aim was to describe the clinical features and outcomes of HSC over the last 13 years in a single French hematology center. Methods All patients diagnosed with HSC between 2008 and 2020 were included in a single-center retrospective cohort study. Data were collected from patient charts, and HSC was classified according to the 2020 European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions. Results Sixty patients were included, with 18.3% proven, 3.3% probable, and 78.3% possible HSC according to the 2020 European Organization for Research and Treatment of Cancer Mycoses Study Group classification. Among them, 19 patients were treated for acute myeloid leukemia (AML), 21 for lymphomas, and 14 for acute lymphoblastic leukemia. HSC occurred in 13 patients after autologous stem cell transplantation for lymphoma. At HSC diagnosis, 13 patients were receiving antifungal prophylaxis. Candida colonization was present in 84.2%, with prior candidemia in 36.7% of cases. β-D-glucans was positive in 55.8%, and 45.8% of tissue biopsies were contributive. First-line antifungal therapy was azoles in 61.7%, and steroids were associated in 45% of cases. At 3 months of follow-up, partial response to antifungal therapy was 94.2%. At last follow-up (mean, 22.6 months), 41 patients (68.3%) presented a complete hematological remission and 22 patients were deceased, none because of HSC. Conclusions The epidemiology of HSC has changed in the last decade, with fewer cases occurring in the AML setting. A better identification of patients at risk could lead to specific prophylaxis and improved diagnosis.
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Affiliation(s)
- I Boussen
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France
- Université de Paris, Paris, France
| | - Q Lisan
- Department of Otolaryngology-Head and Neck Surgery, Foch Hospital, School of Medicine, University Paris Saclay, Paris, France
| | - E Raffoux
- Department of adult hematology, Saint Louis Hospital, APHP, Paris, France
| | - R Di Blasi
- Department of hemato-oncology, Saint Louis Hospital, APHP, Paris, France
| | - N Boissel
- Department of teenagers and young adult hematology, Saint Louis Hospital, APHP, Paris, France
| | - E Oksenhendler
- Department of clinical immunology, Saint Louis Hospital, APHP, Paris, France
| | - L Adès
- Department of senior adult hematology, Saint Louis Hospital, APHP, Paris, France
| | - A Xhaard
- Department of hematology - transplantation, Saint Louis Hospital, APHP, Paris, France
| | - S Bretagne
- Université de Paris, Paris, France
- Molecular Mycology Unit, Institut Pasteur, CNRS UMR2000, Paris, France
- Department of mycology, Saint Louis Hospital, APHP, Paris, France
| | - A Alanio
- Université de Paris, Paris, France
- Molecular Mycology Unit, Institut Pasteur, CNRS UMR2000, Paris, France
- Department of mycology, Saint Louis Hospital, APHP, Paris, France
| | - J M Molina
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France
- Université de Paris, Paris, France
| | - B Denis
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France
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Zakhem AE, Istambouli R, Jabbour JF, Hindy JR, Gharamti A, Kanj SS. Diagnosis and Management of Invasive Candida Infections in Critically Ill Patients. Semin Respir Crit Care Med 2022; 43:46-59. [PMID: 35172358 DOI: 10.1055/s-0041-1741009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Invasive candidiasis (IC) has become a serious problem in the intensive care unit patients with an attributable mortality rate that can reach up to 51%. Multiple global surveillance studies have shown an increasing incidence of candidemia. Despite their limited sensitivity (21-71%), cultures remain the gold standard for the diagnosis of IC associated with candidemia. Many adjunct laboratory tests exist to support or rule out the diagnosis, each with its indications and limitations, including procalcitonin, 1,3-β-D-glucan, mannan and anti-mannan antibodies, and Candida albicans germ tube antibody. In addition, polymerase chain reaction-based methods could expedite species identification in positive blood cultures, helping in guiding early empirical antifungal therapy. The management of IC in critically ill patients can be classified into prophylactic, preemptive, empiric, and directed/targeted therapy of a documented infection. There is no consensus concerning the benefit of prophylactic therapy in critically ill patients. While early initiation of appropriate therapy in confirmed IC is an important determinant of survival, the selection of candidates and drug of choice for empirical systemic antifungal therapy is more controversial. The choice of antifungal agents is determined by many factors, including the host, the site of infection, the species of the isolated Candida, and its susceptibility profile. Echinocandins are considered initial first-line therapy agents. Due to the conflicting results of the various studies on the benefit of preemptive therapy for critically ill patients and the lack of robust evidence, the Infectious Diseases Society of America (IDSA) omitted this category from its updated guidelines and the European Society of Intensive Care Medicine (ESICM) and the Critically Ill Patients Study Group of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) do not recommend it.
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Affiliation(s)
- Aline El Zakhem
- Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rachid Istambouli
- Leeds and York Partnership NHS Foundation Trust, Leeds, United Kingdom
| | - Jean-Francois Jabbour
- Department of Internal Medicine, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
| | - Joya-Rita Hindy
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Amal Gharamti
- Department of Internal Medicine, Yale School of Medicine, Waterbury Hospital, Waterbury, Connecticut
| | - Souha S Kanj
- Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
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White PL, Alanio A, Brown L, Cruciani M, Hagen F, Gorton R, Lackner M, Millon L, Morton CO, Rautemaa-Richardson R, Barnes RA, Donnelly JP, Loffler J. An overview of using fungal DNA for the diagnosis of invasive mycoses. Expert Rev Mol Diagn 2022; 22:169-184. [PMID: 35130460 DOI: 10.1080/14737159.2022.2037423] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Fungal PCR has undergone considerable standardization and together with the availability of commercial assays, external quality assessment schemes and extensive performance validation data, is ready for widespread use for the screening and diagnosis of invasive fungal disease (IFD). AREAS COVERED Drawing on the experience and knowledge of the leads of the various working parties of the Fungal PCR initiative, this review will address general considerations concerning the use of molecular tests for the diagnosis of IFD, before focussing specifically on the technical and clinical aspects of molecular testing for the main causes of IFD and recent technological developments. EXPERT OPINION For infections caused by Aspergillus, Candida and Pneumocystis jirovecii, PCR testing is recommended, combination with serological testing will likely enhance the diagnosis of these diseases. For other IFD (e.g. Mucormycosis) molecular diagnostics, represent the only non-classical mycological approach towards diagnoses and continued performance validation and standardization has improved confidence in such testing. The emergence of antifungal resistance can be diagnosed, in part, through molecular testing. Next-generation sequencing has the potential to significantly improve our understanding of fungal phylogeny, epidemiology, pathogenesis, mycobiome/microbiome and interactions with the host, while identifying novel and existing mechanisms of antifungal resistance and novel diagnostic/therapeutic targets.
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Affiliation(s)
- P Lewis White
- Public Health Wales Microbiology Cardiff, UHW, Cardiff, UK CF14 4XW
| | - Alexandre Alanio
- Laboratoire de Parasitologie-Mycologie, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Université de Paris, Paris, France.,Institut Pasteur, CNRS UMR2000, Unité de Mycologie Moléculaire, Centre National de Reference Mycoses invasives et Antifongiques, Paris, France
| | - Lottie Brown
- NHS Mycology Reference Centre Manchester, ECMM Centre of Excellence, Manchester University NHS Foundation Trust, Wythenshawe Hospital; and Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | | | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands & Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rebecca Gorton
- Dept. of Infection Sciences, Health Services Laboratories (HSL) LLP, London, UK
| | - Michaela Lackner
- Institute of Hygiene and Medical Microbiology, Department of Hygiene, Medical Microbiology and Publics Health, Medical University Innsbruck, Innsbruck, Austria
| | - Laurence Millon
- Parasitology-Mycology Department, University Hospital of Besançon, 25000 Besançon, France.,UMR 6249 CNRS Chrono-Environnement, University of Bourgogne Franche-Comté, 25000 Besançon, France
| | - C Oliver Morton
- Western Sydney University, School of Science, Campbelltown, NSW 2560, Australia
| | - Riina Rautemaa-Richardson
- NHS Mycology Reference Centre Manchester, ECMM Centre of Excellence, Manchester University NHS Foundation Trust, Wythenshawe Hospital; and Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | | | | | - Juergen Loffler
- Department of Internal Medicine II, WÜ4i, University Hospital Wuerzburg, Wuerzburg, Germany
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Recent advances in neutropenic enterocolitis: Insights into the role of gut microbiota. Blood Rev 2022; 54:100944. [DOI: 10.1016/j.blre.2022.100944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 11/24/2022]
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OUP accepted manuscript. Med Mycol 2022; 60:6526320. [PMID: 35142862 PMCID: PMC8929677 DOI: 10.1093/mmy/myac008] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/13/2021] [Accepted: 02/01/2022] [Indexed: 11/23/2022] Open
Abstract
Candida auris is an emerging, multi drug resistant fungal pathogen that has caused infectious outbreaks in over 45 countries since its first isolation over a decade ago, leading to in-hospital crude mortality rates as high as 72%. The fungus is also acclimated to disinfection procedures and persists for weeks in nosocomial ecosystems. Alarmingly, the outbreaks of C. auris infections in Coronavirus Disease-2019 (COVID-19) patients have also been reported. The pathogenicity, drug resistance and global spread of C. auris have led to an urgent exploration of novel, candidate antifungal agents for C. auris therapeutics. This narrative review codifies the emerging data on the following new/emerging antifungal compounds and strategies: antimicrobial peptides, combinational therapy, immunotherapy, metals and nano particles, natural compounds, and repurposed drugs. Encouragingly, a vast majority of these exhibit excellent anti- C. auris properties, with promising drugs now in the pipeline in various stages of development. Nevertheless, further research on the modes of action, toxicity, and the dosage of the new formulations are warranted. Studies are needed with representation from all five C. auris clades, so as to produce data of grater relevance, and broader significance and validity.
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Keighley C, Cooley L, Morris AJ, Ritchie D, Clark JE, Boan P, Worth LJ. Consensus guidelines for the diagnosis and management of invasive candidiasis in haematology, oncology and intensive care settings, 2021. Intern Med J 2021; 51 Suppl 7:89-117. [DOI: 10.1111/imj.15589] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Caitlin Keighley
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney Camperdown New South Wales Australia
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, New South Wales Health Pathology Westmead New South Wales Australia
- Southern IML Pathology, Sonic Healthcare Coniston New South Wales Australia
| | - Louise Cooley
- Department of Microbiology and Infectious Diseases Royal Hobart Hospital Hobart Tasmania Australia
- University of Tasmania Hobart Tasmania Australia
| | - Arthur J. Morris
- LabPLUS, Clinical Microbiology Laboratory Auckland City Hospital Auckland New Zealand
| | - David Ritchie
- Department of Clinical Haematology Peter MacCallum Cancer Centre and Royal Melbourne Hospital Melbourne Victoria Australia
| | - Julia E. Clark
- Department of Infection Management Queensland Children's Hospital, Children's Health Queensland Brisbane Queensland Australia
- Child Health Research Centre The University of Queensland Brisbane Queensland Australia
| | - Peter Boan
- PathWest Laboratory Medicine WA, Department of Microbiology Fiona Stanley Fremantle Hospitals Group Murdoch Western Australia Australia
- Department of Infectious Diseases Fiona Stanley Fremantle Hospitals Group Murdoch Western Australia Australia
| | - Leon J. Worth
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
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Abstract
PURPOSE OF REVIEW This review will comment on the current knowledge for the diagnosis of the main causes of COVID-19-associated invasive fungal disease (IFD); it will discuss the optimal strategies and limitations and wherever available, will describe international recommendations. RECENT FINDINGS A range of secondary IFDs complicating COVID-19 infection have been described and while COVID-19-associated pulmonary aspergillosis was predicted, the presentation of significant numbers of COVID-19-associated candidosis and COVID-19-associated mucormycosis was somewhat unexpected. Given the range of IFDs and prolonged duration of risk, diagnostic strategies need to involve multiple tests for detecting and differentiating various causes of IFD. Although performance data for a range of tests to diagnose COVID-19-associated pulmonary aspergillosis is emerging, the performance of tests to diagnose other IFD is unknown or based on pre-COVID performance data. SUMMARY Because of the vast numbers of COVID-19 infections, IFD in COVID-19 critical-care patients represents a significant burden of disease, even if incidences are less than 5%. Optimal diagnosis of COVID-19-associated IFD requires a strategic approach. The pandemic has highlighted the potential impact of IFD outside of the typical high-risk clinical cohorts, given the ever-increasing population at risk of IFD and enhanced surveillance of fungal infections is required.
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Affiliation(s)
- P Lewis White
- Public Health Wales, Microbiology Cardiff, UHW, Heath Park, Cardiff, UK
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Ghasemiyeh P, Mohammadi-Samani S, Firouzabadi N, Vazin A, Zand F. A brief ICU residents’ guide: Pharmacotherapy, pharmacokinetic aspects and dose adjustments in critically ill adult patients admitted to ICU. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Esposito A, Migliaccio A, Iula VD, Zarrilli R, Guaragna A, De Gregorio E. The Glucocorticoid PYED-1 Disrupts Mature Biofilms of Candida spp. and Inhibits Hyphal Development in Candida albicans. Antibiotics (Basel) 2021; 10:1396. [PMID: 34827334 PMCID: PMC8614962 DOI: 10.3390/antibiotics10111396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/05/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Invasive Candida infections have become a global public health problem due to the increase of Candida species resistant against antifungal therapeutics. The glucocorticoid PYED-1 (pregnadiene-11-hydroxy-16α,17α-epoxy-3,20-dione-1) has antimicrobial activity against various bacterial taxa. Consequently, it might be considered for the treatment of Candida infections. The antifungal activity of PYED-1 was evaluated against several fungal strains that were representative of the five species that causes the majority of Candida infections-namely, Candida albicans, Candida glabrata, Candida tropicalis, Candida parapsilosis and Candida krusei. PYED-1 exhibited a weak antifungal activity and a fungistatic effect on all five Candida species. On the other hand, PYED-1 exhibited a good anti-biofilm activity, and was able to eradicate the preformed biofilms of all Candida species analyzed. Moreover, PYED-1 inhibited germ tube and hyphae formation of C. albicans and reduced adhesion of C. albicans to abiotic surfaces by up to 30%.
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Affiliation(s)
- Anna Esposito
- Department of Chemical, Materials and Production Engineering, University of Naples Federico II, 80126 Naples, Italy; (A.E.); (A.G.)
| | - Antonella Migliaccio
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (A.M.); (R.Z.)
| | - Vita Dora Iula
- Complex Operative Unit of Clinical Pathology, Ospedale del Mare-ASL NA1 Centro, 80145 Naples, Italy;
| | - Raffaele Zarrilli
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (A.M.); (R.Z.)
| | - Annalisa Guaragna
- Department of Chemical, Materials and Production Engineering, University of Naples Federico II, 80126 Naples, Italy; (A.E.); (A.G.)
| | - Eliana De Gregorio
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy
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Kurland S, Löwdin E, Furebring M, Shams A, Chryssanthou E, Lagerbäck P, Tängden T, Breuer O, Sjölin J. Human plasma protein levels alter the in vitro antifungal activity of caspofungin: An explanation to the effect in critically ill? Mycoses 2021; 65:79-87. [PMID: 34709674 DOI: 10.1111/myc.13386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recent studies have shown low caspofungin concentrations in critically ill patients. In some patients, the therapeutic target, area under the total plasma concentration curve in relation to the minimal inhibition concentration (AUCtot /MIC), seems not to be achieved and therapeutic drug monitoring (TDM) has been proposed. Caspofungin is highly protein-bound and the effect of reduced plasma protein levels on pharmacodynamics has not been investigated. OBJECTIVES Fungal killing activity of caspofungin in vitro was investigated under varying levels of human plasma protein. METHODS Time-kill studies were performed with clinically relevant caspofungin concentrations of 1-9 mg/L on four blood isolates of C. glabrata, three susceptible and one strain with reduced susceptibility, in human plasma and plasma diluted to 50% and 25% using Ringer's acetate. RESULTS Enhanced fungal killing of the three susceptible strains was observed in plasma with lower protein content (p < .001). AUCtot /MIC required for a 1 log10 CFU/ml kill at 24 h in 50% and 25% plasma was reduced with 36 + 12 and 80 + 9%, respectively. The maximum effect was seen at total caspofungin concentrations of 4-9 × MIC. For the strain with reduced susceptibility, growth was significantly decreased at lower protein levels. CONCLUSIONS Reduced human plasma protein levels increase the antifungal activity of caspofungin in vitro, most likely by increasing the free concentration. Low plasma protein levels in critically ill patients with candidemia might explain a better response to caspofungin than expected from generally accepted target attainment and should be taken into consideration when assessing TDM based on total plasma concentrations.
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Affiliation(s)
- Siri Kurland
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Elisabeth Löwdin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Mia Furebring
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Ayda Shams
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Erja Chryssanthou
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Thomas Tängden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Olof Breuer
- Department of Laboratory Medicine, Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Sjölin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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65
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Nakada-Motokawa N, Miyazaki T, Ueda T, Yamagishi Y, Yamada K, Kawamura H, Kakeya H, Mukae H, Mikamo H, Takesue Y, Kohno S. Modified Pitt bacteremia score for predicting mortality in patients with candidaemia: A multicentre seven-year retrospective study conducted in Japan. Mycoses 2021; 64:1498-1507. [PMID: 34655487 PMCID: PMC9297953 DOI: 10.1111/myc.13380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/11/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several severity indexes have been reported for critically ill patients. The Pitt bacteremia score (PBS) is commonly used to predict the risk of mortality in patients with bacteraemia. OBJECTIVES To develop a scoring system for predicting mortality in candidaemia patients. METHODS Medical records at five Japanese tertiary hospitals were reviewed. Factors associated with mortality were analysed using logistic regression modelling. The discriminatory power of scoring models was evaluated by assessing the area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS In total, 422 candidaemia patients were included. Higher PBS, dialysis and retainment of central venous catheter were independent risk factors for all-cause 30-day mortality. However, among the five PBS components, fever was not associated with mortality; therefore, we developed a modified version of the PBS (mPBS) by replacing fever with dialysis. AUC for PBS and mPBS were 0.74 (95% confidence interval [CI]: 0.68-0.80) and 0.76 (95% CI: 0.71-0.82), respectively. The increase in predictive ability of mPBS for 30-day mortality was statistically significant as assessed by NRI (0.24, 95% CI: 0.01-0.46, p = .04) and IRI (0.04, 95% CI: 0.02-0.06, p = .0008). When patients were stratified by mPBS into low (scores 0-3), moderate (4-7) and high risk (≥8), there were significant differences among the survival curves (p < .0001, log-rank test), and 30-day mortality rates were 13.8% (40/290), 36.8% (28/76) and 69.4% (34/49), respectively. CONCLUSIONS mPBS can be a useful tool for predicting mortality in candidaemia patients.
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Affiliation(s)
| | - Taiga Miyazaki
- Department of Respiratory Medicine, Nagasaki University, Nagasaki, Japan.,Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Takashi Ueda
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Japan
| | - Koichi Yamada
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hideki Kawamura
- Division of Medical and Environmental Safety, Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - Hiroshi Kakeya
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University, Nagasaki, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Japan
| | - Yoshio Takesue
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shigeru Kohno
- Department of Respiratory Medicine, Nagasaki University, Nagasaki, Japan
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66
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Kollef MH, Shorr AF, Bassetti M, Timsit JF, Micek ST, Michelson AP, Garnacho-Montero J. Timing of antibiotic therapy in the ICU. Crit Care 2021; 25:360. [PMID: 34654462 PMCID: PMC8518273 DOI: 10.1186/s13054-021-03787-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 12/15/2022] Open
Abstract
Severe or life threatening infections are common among patients in the intensive care unit (ICU). Most infections in the ICU are bacterial or fungal in origin and require antimicrobial therapy for clinical resolution. Antibiotics are the cornerstone of therapy for infected critically ill patients. However, antibiotics are often not optimally administered resulting in less favorable patient outcomes including greater mortality. The timing of antibiotics in patients with life threatening infections including sepsis and septic shock is now recognized as one of the most important determinants of survival for this population. Individuals who have a delay in the administration of antibiotic therapy for serious infections can have a doubling or more in their mortality. Additionally, the timing of an appropriate antibiotic regimen, one that is active against the offending pathogens based on in vitro susceptibility, also influences survival. Thus not only is early empiric antibiotic administration important but the selection of those agents is crucial as well. The duration of antibiotic infusions, especially for β-lactams, can also influence antibiotic efficacy by increasing antimicrobial drug exposure for the offending pathogen. However, due to mounting antibiotic resistance, aggressive antimicrobial de-escalation based on microbiology results is necessary to counterbalance the pressures of early broad-spectrum antibiotic therapy. In this review, we examine time related variables impacting antibiotic optimization as it relates to the treatment of life threatening infections in the ICU. In addition to highlighting the importance of antibiotic timing in the ICU we hope to provide an approach to antimicrobials that also minimizes the unnecessary use of these agents. Such approaches will increasingly be linked to advances in molecular microbiology testing and artificial intelligence/machine learning. Such advances should help identify patients needing empiric antibiotic therapy at an earlier time point as well as the specific antibiotics required in order to avoid unnecessary administration of broad-spectrum antibiotics.
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Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Avenue, MSC 8052-43-14, St. Louis, MO, 63110, USA.
| | - Andrew F Shorr
- Pulmonary and Critical Care Medicine, Medstar Washington Hospital, Washington, DC, USA
| | - Matteo Bassetti
- Infectious Diseases Unit, Department of Health Sciences, San Martino Policlinico Hospital - IRCCS, University of Genoa, Genoa, Italy
| | - Jean-Francois Timsit
- AP-HP, Bichat Claude Bernard Hospital, Medical and Infectious Diseases ICU (MI2), IAME, INSERM, Université de Paris, Paris, France
| | - Scott T Micek
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Avenue, MSC 8052-43-14, St. Louis, MO, 63110, USA
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67
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Pharmacokinetic Variability and Target Attainment of Fluconazole in Critically Ill Patients. Microorganisms 2021; 9:microorganisms9102068. [PMID: 34683388 PMCID: PMC8538061 DOI: 10.3390/microorganisms9102068] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/09/2021] [Accepted: 09/22/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Fluconazole is one of the oldest antifungal drugs. Previous studies have raised concerns considering variability in exposure and inadequate target attainment in critically ill patients. The current study aims to define variability and target attainment for fluconazole exposure in a large group of critically ill patients. Methods: In this pharmacokinetic study, daily plasma trough samples and, if possible, 24 h urine samples were collected to determine fluconazole concentration. A minimum target trough concentration of 10-15 mg/L was selected, corresponding to a free area under the concentration-time curve above the minimum inhibitory concentration (fAUC/MIC) of at least 100 for an MIC of 4 mg/L. Covariates that significantly influenced fluconazole exposure were identified. Results: In total, 288 plasma samples from 43 patients, with a median age of 66 years, were included. The median fluconazole trough concentration was 22.9 mg/L. A notable component of the measured concentrations was below the target trough concentrations (13% <10 mg/L and 27% <15 mg/L). The intra- and intersubject variability were 28.3% and 50.5%, respectively. The main covariates determining fluconazole exposure were the administered dose (mg/kg), augmented renal clearance, and renal replacement therapy. Conclusions: Fluconazole trough concentrations are variable in critically ill patients and a considerable number of these concentrations was below the predefined target trough concentrations.
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68
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Li Z, Li Y, Chen Y, Li J, Li S, Li C, Lin Y, Jian W, Shi J, Zhan Y, Cheng J, Zheng J, Zhong N, Ye F. Trends of pulmonary fungal infections from 2013 to 2019: an AI-based real-world observational study in Guangzhou, China. Emerg Microbes Infect 2021; 10:450-460. [PMID: 33620282 PMCID: PMC7971272 DOI: 10.1080/22221751.2021.1894902] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recently, the prevalence trend of pulmonary fungal infection (PFI) has rapidly increased. Changes in the risk factors for, distributions of underlying diseases associated with and clinical characteristics of some individual PFIs have been reported in the past decade. However, data regarding PFIs remain uncertain. This study reports the epidemiological characteristics and trends of PFIs over time in recent years. We applied an automated natural language processing (NLP) system to extract clinically relevant information from the electronic health records (EHRs) of PFI patients at the First Affiliated Hospital of Guangzhou Medical University. Then, a trend analysis was performed. From January 1, 2013, to December 31, 2019, 40,504 inpatients and 219,414 outpatients with respiratory diseases were screened, in which 1368 inpatients and 1313 outpatients with PFI were identified. These patients were from throughout the country, but most patients were from southern China. Upward trends in PFIs were observed in both hospitalized patients and outpatients (P<0.05). The stratification by age showed that the incidence of hospitalized patients aged 14–30 years exhibited the most obvious upward trend, increasing from 9.5 per 1000 patients in 2013 to 88.3 per 1000 patients in 2019. Aspergillosis (56.69%) was the most common PFI, but notably, the incidence rates of Talaromyces marneffei, which used to be considered uncommon, exhibited the most rapid increases. In younger PFI patients, the incidence and trend of PFIs have increased. Infection by previously uncommon pathogens has also gradually increased. Increased attention should be paid to young PFI patients and uncommon PFI pathogen infections.
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Affiliation(s)
- Zhengtu Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yongming Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yijun Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Jing Li
- Guangzhou Tianpeng Technology Co., Ltd., Guangzhou, People's Republic of China
| | - Shaoqiang Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Chenglong Li
- Guangzhou Tianpeng Technology Co., Ltd., Guangzhou, People's Republic of China
| | - Ye Lin
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Wenhua Jian
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Jingrong Shi
- Guangzhou Tianpeng Technology Co., Ltd., Guangzhou, People's Republic of China
| | - Yangqing Zhan
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Jing Cheng
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Jingping Zheng
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Nanshan Zhong
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Feng Ye
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
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Niederman MS, Baron RM, Bouadma L, Calandra T, Daneman N, DeWaele J, Kollef MH, Lipman J, Nair GB. Initial antimicrobial management of sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:307. [PMID: 34446092 PMCID: PMC8390082 DOI: 10.1186/s13054-021-03736-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 02/08/2023]
Abstract
Sepsis is a common consequence of infection, associated with a mortality rate > 25%. Although community-acquired sepsis is more common, hospital-acquired infection is more lethal. The most common site of infection is the lung, followed by abdominal infection, catheter-associated blood steam infection and urinary tract infection. Gram-negative sepsis is more common than gram-positive infection, but sepsis can also be due to fungal and viral pathogens. To reduce mortality, it is necessary to give immediate, empiric, broad-spectrum therapy to those with severe sepsis and/or shock, but this approach can drive antimicrobial overuse and resistance and should be accompanied by a commitment to de-escalation and antimicrobial stewardship. Biomarkers such a procalcitonin can provide decision support for antibiotic use, and may identify patients with a low likelihood of infection, and in some settings, can guide duration of antibiotic therapy. Sepsis can involve drug-resistant pathogens, and this often necessitates consideration of newer antimicrobial agents.
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Affiliation(s)
- Michael S Niederman
- Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, 425 East 61st St, New York, NY, 10065, USA.
| | - Rebecca M Baron
- Harvard Medical School; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Lila Bouadma
- AP-HP, Bichat Claude Bernard, Medical and Infectious Diseas ICU, University of Paris, Paris, France
| | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lusanne University Hospital, University of Lusanne, Lusanne, Switzerland
| | - Nick Daneman
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jan DeWaele
- Department of Critical Care Medicine, Surgical Intensive Care Unit, Ghent University, Ghent, Belgium
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffrey Lipman
- Royal Brisbane and Women's Hospital and Jamieson Trauma Institute, The University of Queensland, Brisbane, Australia.,Nimes University Hospital, University of Montpelier, Nimes, France
| | - Girish B Nair
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
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70
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Dynamics and Predictors of Mortality Due to Candidemia Caused by Different Candida Species: Comparison of Intensive Care Unit-Associated Candidemia (ICUAC) and Non-ICUAC. J Fungi (Basel) 2021; 7:jof7080597. [PMID: 34436136 PMCID: PMC8397010 DOI: 10.3390/jof7080597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/23/2021] [Accepted: 07/23/2021] [Indexed: 01/05/2023] Open
Abstract
We investigated mortality and predictors of mortality due to intensive care unit-associated candidemia (ICUAC) versus non-ICUAC by Candida species. This study included all candidemia cases in 11 hospitals from 2017 to 2018 in South Korea. The all-cause mortality rates in all 370 patients with ICUAC were approximately twofold higher than those in all 437 patients with non-ICUAC at 7 days (2.3-fold, 31.1%/13.3%), 30 days (1.9-fold, 49.5%/25.4%), and 90 days (1.9-fold, 57.8%/30.9%). Significant species-specific associations with 7- and 30-day ICUAC-associated mortality were not observed. Multivariate analysis revealed that ICU admission was an independent predictor of Candida glabrata (OR, 2.07–2.48) and Candida parapsilosis-associated mortality (OR, 6.06–11.54). Fluconazole resistance was a predictor of C. glabrata-associated mortality (OR, 2.80–5.14). Lack (less than 3 days) of antifungal therapy was the strongest predictor of 7-day mortality due to ICUAC caused by Candida albicans (OR, 18.33), Candida tropicalis (OR, 10.52), and C. glabrata (OR, 21.30) compared with 30- and 90-day mortality (OR, 2.72–6.90). C. glabrata ICUAC had a stronger association with lack of antifungal therapy (55.2%) than ICUAC caused by other species (30.6–36.7%, all p < 0.05). Most predictors of mortality associated with ICUAC were distinct from those associated with non-ICUAC and were mediated by Candida species.
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71
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Zaragoza R, Maseda E, Pemán J. [Individualized antifungal therapy in critically ill patients with invasive fungal infection]. Rev Iberoam Micol 2021; 38:68-74. [PMID: 34301466 DOI: 10.1016/j.riam.2021.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/16/2021] [Accepted: 04/28/2021] [Indexed: 12/12/2022] Open
Abstract
Invasive candidiasis (IC) is the most common invasive fungal infection (IFI) affecting critically ill patients, followed by invasive pulmonary aspergillosis (IPA). International guidelines provide different recommendations for a first-line antifungal therapy and, in most of them, echinocandins are considered the first-line treatment for IC, and triazoles are so for the treatment of IPA. However, liposomal amphotericinB (L-AmB) is still considered a second-line therapy for both clinical entities. Although in the last decade the management of IFI has improved, several controversies persist. The antifungal drugs currently available may have a suboptimal activity, or be wrongly used in certain IFI involving critically ill patients. The aim of this review is to analyze when to provide individualized antifungal therapy to critically ill patients suffering from IFI, emphasizing the role of L-AmB. Drug-drug interactions, the clinical status, infectious foci (peritoneal candidiasis is discussed), the fungal species involved, and the need of monitoring the concentration of the antifungal drug in the patient are considered.
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Affiliation(s)
- Rafael Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, España.
| | - Emilio Maseda
- Unidad de Críticos Quirúrgicos, Servicio de Anestesia y Reanimación, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Javier Pemán
- Servicio de Microbiología, Hospital Universitario y Politécnico la Fe, Valencia, España
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Ruiz-Azcona L, Santibañez M, Roig FJ, Vanaclocha H, Ventero MP, Boix V, Portilla-Sogorb J, Sánchez-Paya J, Merino E, Rodriguez JC. Isolation of Candida auris in large hospitals in the Autonomous Community of Valencia; population-based study (2013-2017). Rev Iberoam Micol 2021; 38:141-144. [PMID: 34266756 DOI: 10.1016/j.riam.2021.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 11/30/2020] [Accepted: 01/18/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Candida auris is an emerging multidrug-resistant and highly virulent yeast that spreads easily among patients. AIMS To describe the characteristics of candidemia caused by C. auris in the southeast of Spain (Autonomous Community of Valencia - ACV) through a 5-year population-based study. METHODS An analysis of all the episodes of candidemia diagnosed in the ACV, with approximately 4,500,000 inhabitants, during 2013-2017, was done. Data were obtained from the Epidemiological Surveillance Valencian Network, a network that collects all the microbiological data from the hospitals in the study region. RESULTS Based on the records, 1.9% of the isolates recovered from the positive blood cultures (corresponding to 1789 patients) were yeasts. This implies an annual rate of 7.09 cases/100,000 inhabitants. Of the 23 yeast species isolated, Candida albicans was the most frequent (37.3%), showing a higher frequency than Candida parapsilosis (28.4%) and Candida glabrata (15.6%) (p<0.0001). It is remarkable the emergence of C. auris during 2016 and 2017, as this species became the fourth more prevalent in 2016 (9.2%), and the third in 2017 (15.7%). Fungemia was more common in hospitals with >500 beds (63.3% versus 36.7% in small hospitals) (p<0.0001), and C. auris was mostly isolated in large hospitals (8.5% versus 0.3%); its incidence was higher in autumn and among the age group of 65-84 years. CONCLUSIONS The information about the local epidemiology of candidemia is essential in order to decide the best empirical treatment approach. This study reports the novel presence of C. auris in large hospitals. This pathogen has usually resistance to several antifungals and causes severe fungemia, so the results of this work reveal the need to monitor the presence of this species systematically.
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Affiliation(s)
- Laura Ruiz-Azcona
- Global Health Research Group, University of Cantabria-IDIVAL, Santander, Spain; Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), Spain
| | - Miguel Santibañez
- Global Health Research Group, University of Cantabria-IDIVAL, Santander, Spain
| | - Francisco Javier Roig
- Dirección General de Salud Pública, Conselleria de Sanitat Universal y Salud Pública, Comunidad Valenciana, Valencia, Spain
| | - Hermelinda Vanaclocha
- Dirección General de Salud Pública, Conselleria de Sanitat Universal y Salud Pública, Comunidad Valenciana, Valencia, Spain
| | - Maria Paz Ventero
- Servicio de Microbiología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain.
| | - Vicente Boix
- Unidad de Enfermedades Infecciosas, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain; Universidad Miguel Hernández, Elche, Alicante, Spain
| | - Joaquín Portilla-Sogorb
- Unidad de Enfermedades Infecciosas, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain; Universidad Miguel Hernández, Elche, Alicante, Spain
| | - José Sánchez-Paya
- Universidad Miguel Hernández, Elche, Alicante, Spain; Servicio Medicina Preventiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Esperanza Merino
- Unidad de Enfermedades Infecciosas, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Juan Carlos Rodriguez
- Servicio de Microbiología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain; Universidad Miguel Hernández, Elche, Alicante, Spain
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Abstract
Concentrations of anidulafungin and micafungin were determined in eight different tissues obtained during autopsy of four deceased individuals who had been treated with anidulafungin and of seven who had received micafungin. The largest amounts were recovered from liver, with anidulafungin concentrations of 11.01 to 66.50 μg/g and micafungin levels of 0.36 to 5.53 μg/g (0.65 μg/g 30 days after the last administration). The lowest anidulafungin levels were measured in skeletal muscle, and the lowest micafungin concentrations were in kidneys.
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Mazzanti S, Brescini L, Morroni G, Orsetti E, Pocognoli A, Donati A, Cerutti E, Munch C, Montalti R, Barchiesi F. Candidemia in intensive care units over nine years at a large Italian university hospital: Comparison with other wards. PLoS One 2021; 16:e0252165. [PMID: 34038468 PMCID: PMC8153423 DOI: 10.1371/journal.pone.0252165] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/11/2021] [Indexed: 12/14/2022] Open
Abstract
Purpose Candidemia is an alarming problem in critically ill patients including those admitted in intensive care units (ICUs). We aimed to describe the clinical and microbiological characteristics of bloodstream infections (BSIs) due to Candida spp. in patients admitted to ICUs of an italian tertiary referral university hospital over nine years. Methods A retrospective observational study of all cases of candidemia in adult patients was carried out from January 1, 2010 to December 31, 2018 at a 980-bedded University Hospital in Ancona, Italy, counting five ICUs. The incidence, demographics, clinical and microbiologic characteristics, therapeutic approaches and outcomes of ICU-patients with candidemia were collected. Non-ICU patients with candidemia hospitalized during the same time period were considered for comparison purposes. Early (7 days from the occurrence of the episode of Candida BSI) and late (30 days) mortality rates were calculated. Results During the study period, 188/505 (36%) episodes of candidemia occurred in ICU patients. Cumulative incidence was 9.9/1000 ICU admission and it showed to be stable over time. Candida albicans accounted for 52% of the cases, followed by C. parapsilosis (24%), and C. glabrata (14%). There was not a significant difference in species distribution between ICU and non-ICU patients. With the exception of isolates of C. tropicalis which showed to be fluconazole resistant in 25% of the cases, resistance to antifungals was not of concern in our patients. Early and late mortality rates, were 19% and 41% respectively, the latter being significantly higher than that observed in non-ICU patients. At multivariate analysis, factors associated with increased risk of death were septic shock, acute kidney failure, pulmonary embolism and lack of antifungal therapy. The type of antifungal therapy did not influence the outcome. Mortality did not increased significantly over time. Conclusion Neither cumulative incidence nor crude mortality of candidemia in ICU patients increased over time at our institution. However, mortality rate remained high and significantly associated with specific host-related factors in the majority of cases.
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Affiliation(s)
- Sara Mazzanti
- Dipartimento di Scienze Biomediche e Sanità Pubblica Università Politecnica delle Marche, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I°- Lancisi-Salesi, Ancona, Italy
- Clinica Malattie Infettive, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I°- Lancisi-Salesi, Ancona, Italy
| | - Lucia Brescini
- Dipartimento di Scienze Biomediche e Sanità Pubblica Università Politecnica delle Marche, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I°- Lancisi-Salesi, Ancona, Italy
- Clinica Malattie Infettive, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I°- Lancisi-Salesi, Ancona, Italy
| | - Gianluca Morroni
- Dipartimento di Scienze Biomediche e Sanità Pubblica Università Politecnica delle Marche, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I°- Lancisi-Salesi, Ancona, Italy
| | | | - Antonella Pocognoli
- Laboratorio di Microbiologia, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I°- Lancisi-Salesi, Ancona, Italy
| | - Abele Donati
- Dipartimento di Scienze Biomediche e Sanità Pubblica Università Politecnica delle Marche, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I°- Lancisi-Salesi, Ancona, Italy
- Clinica di Anestesia e Rianimazione, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I°- Lancisi-Salesi, Ancona, Italy
| | - Elisabetta Cerutti
- Anestesia e Rianimazione, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I°- Lancisi-Salesi, Ancona, Italy
| | - Christopher Munch
- Anestesia e Rianimazione Cardiochirurgica, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I°- Lancisi-Salesi, Ancona, Italy
| | - Roberto Montalti
- Unità di Chirurgia Epato-Bilio-Pancreatica, Mininvasiva e Robotica, Dipartimento di Sanità Pubblica, Università Federico II, Napoli, Italy
| | - Francesco Barchiesi
- Dipartimento di Scienze Biomediche e Sanità Pubblica Università Politecnica delle Marche, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I°- Lancisi-Salesi, Ancona, Italy
- Malattie Infettive, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy
- * E-mail:
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Macera M, Calò F, Onorato L, Di Caprio G, Monari C, Russo A, Galdieri A, Giordano A, Cuccaro P, Coppola N. Inappropriateness of Antibiotic Prescribing in Medical, Surgical and Intensive Care Units: Results of a Multicentre Observational Study. Life (Basel) 2021; 11:475. [PMID: 34073866 PMCID: PMC8225033 DOI: 10.3390/life11060475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022] Open
Abstract
The objectives of the present study were to provide a snapshot analysis of antibiotic appropriateness in two hospitals in Southern Italy in three specific areas, surgical, medical and intensive care, and to evaluate the risk factors associated with inappropriateness in antimicrobial prescriptions. We conducted a multicentre observational study in two hospitals in the Campania region. We collected data of all patients admitted on the day of evaluation to antibiotic therapy or prophylaxis through a case report form. The primary outcome was to assess the inappropriateness of antibiotic prescribing, related to the spectrum, dose, route of administration and duration of treatment-in particular, to assess whether there was a difference in the adequacy of the prescriptive practice in the medical, surgical and intensive sectors. Prescriptive inappropriateness was more frequently observed in surgical units (79.8% of the 104 antimicrobial prescriptions) than in medical units (53.8% of the 65 prescriptions, p = 0.0003) or in intensive care units (64.1% of the 39 prescriptions, p = 0.052). The reasons for the inappropriate antimicrobial prescriptions were similar in the three areas evaluated: antimicrobial unnecessary and antimicrobial not recommended were the most frequent reasons for inappropriateness. Not participating in an antimicrobial stewardship program (ASP) was identified as a factor associated with inappropriate antimicrobial prescriptions in medical and surgical units, but not in Intensive Care Units (ICUs). ASPs may enhance the appropriateness of antimicrobial prescriptions especially in medical and surgical units. In ICUs, specific programs able to limit empirical therapies and encourage the collection of microbiological samples may be useful to set up targeted therapies and to design antimicrobial protocols.
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Affiliation(s)
- Margherita Macera
- Department of Mental Health and Public Medicine. University of Campania Luigi Vanvitelli, 81100 Caserta, Italy; (M.M.); (F.C.); (L.O.); (C.M.); (A.R.)
| | - Federica Calò
- Department of Mental Health and Public Medicine. University of Campania Luigi Vanvitelli, 81100 Caserta, Italy; (M.M.); (F.C.); (L.O.); (C.M.); (A.R.)
| | - Lorenzo Onorato
- Department of Mental Health and Public Medicine. University of Campania Luigi Vanvitelli, 81100 Caserta, Italy; (M.M.); (F.C.); (L.O.); (C.M.); (A.R.)
- Infectious Diseases Unit, AORN Sant’Anna and San Sebastiano, Caserta Hospital, 81100 Caserta, Italy;
| | - Giovanni Di Caprio
- Infectious Diseases Unit, AORN Sant’Anna and San Sebastiano, Caserta Hospital, 81100 Caserta, Italy;
| | - Caterina Monari
- Department of Mental Health and Public Medicine. University of Campania Luigi Vanvitelli, 81100 Caserta, Italy; (M.M.); (F.C.); (L.O.); (C.M.); (A.R.)
| | - Antonio Russo
- Department of Mental Health and Public Medicine. University of Campania Luigi Vanvitelli, 81100 Caserta, Italy; (M.M.); (F.C.); (L.O.); (C.M.); (A.R.)
| | - Anna Galdieri
- Direzione Sanitaria, AOU Vanvitell, University of Campania, 80138 Naples, Italy;
| | - Antonio Giordano
- Direzione Generale, AOU Vanvitell, University of Campania, 80138 Naples, Italy;
| | - Patrizia Cuccaro
- Direzione Sanitaria, AORN Sant’Anna and San Sebastiano, Caserta Hospital, 81100 Caserta, Italy;
| | - Nicola Coppola
- Department of Mental Health and Public Medicine. University of Campania Luigi Vanvitelli, 81100 Caserta, Italy; (M.M.); (F.C.); (L.O.); (C.M.); (A.R.)
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Fluconazole Underexposure in Critically Ill Patients: a Matter of Using the Right Targets? Antimicrob Agents Chemother 2021; 65:AAC.00430-21. [PMID: 33782011 DOI: 10.1128/aac.00430-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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77
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Bassetti M, Azoulay E, Kullberg BJ, Ruhnke M, Shoham S, Vazquez J, Giacobbe DR, Calandra T. EORTC/MSGERC Definitions of Invasive Fungal Diseases: Summary of Activities of the Intensive Care Unit Working Group. Clin Infect Dis 2021; 72:S121-S127. [PMID: 33709127 DOI: 10.1093/cid/ciaa1751] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The EORTC/MSGERC recently revised and updated the consensus definitions of invasive fungal disease (IFD). These definitions primarily focus on patients with cancer and stem cell or solid-organ transplant patients. They may therefore not be suitable for intensive care unit (ICU) patients. More in detail, while the definition of proven IFD applies to a broad range of hosts, the categories of probable and possible IFD were primarily designed for classical immunocompromised hosts and may therefore not be ideal for other populations. Moreover, the scope of the possible category of IFD has been diminished in the recently revised definitions for classically immunocompromised hosts. Diagnosis of IFD in the ICU presents many challenges, which are different for invasive candidiasis and for invasive aspergillosis. The aim of this article is to review progresses made in recent years and difficulties remaining in the development of definitions applicable in the ICU setting.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Elie Azoulay
- Medical ICU, APHP, Saint-Louis Hospital, Paris, France.,Université de Paris, Paris, France
| | - Bart-Jan Kullberg
- Department of Medicine and Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Markus Ruhnke
- Division of Hematology, Oncology and Palliative Care, Department of Internal Medicine, Helios Klinikum Aue, Aue, Germany
| | - Shmuel Shoham
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jose Vazquez
- Department of Medicine, Division of Infectious Diseases, Medical College of Georgia/Augusta University, Augusta, Georgia, USA
| | | | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Abstract
PURPOSE OF REVIEW Timely and adequate management are the key priorities in the care of peritonitis. This review focuses on the cornerstones of the medical support: source control and antiinfective therapies. RECENT FINDINGS Peritonitis from community-acquired or healthcare-associated origins remains a frequent cause of admission to the ICU. Each minute counts for initiating the proper management. Late diagnosis and delayed medical care are associated to dramatically increased mortality rates. The diagnosis of peritonitis can be difficult in these ICU cases. The signs of organ failures are more relevant than biological surrogates. A delayed source control and a late anti-infective therapy are of critical importance. The quality of source control and medical management are other key elements of the prognosis. The conventional rules applied for sepsis are applicable for peritonitis, including hemodynamic support and anti-infective therapy. Growing proportions of multidrug resistant pathogens are reported from surgical samples, mainly related to Gram-negative bacteria. The increasing complexity in the care of these critically ill patients is a strong incentive for a multidisciplinary approach. SUMMARY Early clinical diagnosis, timely and adequate source control and antiinfective therapy are the essential pillars of the management of peritonitis in ICU patients.
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Impact of mTOR signaling pathway on CD8+ T cell immunity through Eomesodermin in response to invasive candidiasis. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:370-378. [PMID: 33972181 DOI: 10.1016/j.jmii.2021.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/16/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND We investigated the effect of the mammalian target of rapamycin (mTOR) pathway on CD8+ T cell immunity through Eomesodermin (Eomes) in intensive care unit (ICU) patients with invasive candidiasis (IC) and in a mouse model. METHODS We evaluated quantitative changes in parameters of the mTOR/phosphorylated ribosomal S6 kinase (pS6K) pathway and immune system at the onset of infection in ICU patients. The study was registered on 28 February 2017 at chictr.org.cn (ChiCTR-ROC-17010750). We also used a mouse model of Candida infection and constructed T-cell-specific mTOR and T-cell-specific tuberous sclerosis complex (TSC) 1 conditional knockout mice to elucidate the molecular mechanisms. RESULTS We enrolled 88 patients, including 8 with IC. The IC group had lower CD8+ T cell counts, higher serum levels of mTOR, pS6K, Eomes and interleukin (IL)-6. The mouse model with IC showed results consistent in the clinical study. The CD8+ T cell immune response to IC seemed to be weakened in TSC1 knockout mice compared with wild-type IC mice, demonstrating that mTOR activation resulted in the impaired CD8+ T cell immunity in IC. CONCLUSIONS In IC, the mTOR activation may play a vital role in impaired CD8+ T cell immunity through enhancing expression of Eomes. The study was registered on 28 February 2017 at chictr.org.cn (identifier ChiCTR-ROC-17010750).
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80
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Li F, Zhou M, Jiao Z, Zou Z, Yu E, He Z. Caspofungin pharmacokinetics and probability of target attainment in ICU patients in China. J Glob Antimicrob Resist 2021; 25:238-263. [PMID: 33845162 DOI: 10.1016/j.jgar.2021.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/18/2021] [Accepted: 03/06/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Effective antifungal therapy is important to reduce mortality in patients with invasive fungal infections (IFIs). Numerous factors affect pharmacokinetic/pharmacodynamic (PK/PD) parameters in critically-ill patients. To guide individualised administration in critically-ill patients, it is of great significance to determine the population pharmacokinetics of caspofungin. METHODS A prospective study in 42 ICU patients with IFIs was conducted in China. A population pharmacokinetic model of caspofungin was established using a non-linear mixed-effects model, which was utilised to investigate the effects of demographic indices, liver function and kidney function on pharmacokinetics. Additionally, appropriate dosages of caspofungin under various scenarios were determined based on MICs and probability of target attainment (PTA) at specific dosages. RESULTS In critically-ill Chinese patients, clearance (CL), volume of distribution (V) and area under the curve at steady-state (AUCss) of caspofungin were 0.32 L/h, 6.77 L and 135.47 mg•h/L, respectively. Blood albumin and total bilirubin levels were factors affecting CL, while body weight was the only factor affecting V among Chinese people with relatively low weight compared with other populations. A maintenance dose of 50 mg caspofungin achieved a high PTA for treating IFIs caused by Candida albicans (MIC ≤ 0.06 mg/L) and Candida glabrata (MIC ≤ 0.125 mg/L). The maintenance dose of caspofungin should be adjusted to 70-200 mg for IFIs caused by C. albicans (MIC, 0.06-0.125 mg/L). For IFIs caused by Candida parapsilosis, an MIC > 0.03 mg/L is associated with a very low PTA, but higher doses of caspofungin or alternative antifungals need to be further studied. CONCLUSION The population pharmacokinetic model established here described well the PK/PD characteristics of caspofungin in critically-ill Chinese patients. These results could guide the formulation of individualised caspofungin dosing regimens for critically-ill patients.
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Affiliation(s)
- Fangyi Li
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou 510120, Guangdong, China
| | - Minggen Zhou
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou 510120, Guangdong, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China; Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China.
| | - Zijun Zou
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou 510120, Guangdong, China
| | - Erqian Yu
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China; The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhijie He
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou 510120, Guangdong, China.
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81
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Mareković I, Pleško S, Rezo Vranješ V, Herljević Z, Kuliš T, Jandrlić M. Epidemiology of Candidemia: Three-Year Results from a Croatian Tertiary Care Hospital. J Fungi (Basel) 2021; 7:jof7040267. [PMID: 33807486 PMCID: PMC8065499 DOI: 10.3390/jof7040267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/24/2021] [Accepted: 03/29/2021] [Indexed: 12/15/2022] Open
Abstract
Invasive candidosis is the most common invasive fungal infection in hospitalized patients and is associated with a high mortality rate. This is the first study from a Croatian tertiary care hospital describing epidemiology, risk factors and species distribution in patients with candidemia. A three-year retrospective observational study, from 2018 to 2020, was performed at the University Hospital Centre Zagreb, Zagreb, Croatia. A total of 160 patients with candidemia (n = 170 isolates) were enrolled. Candidemia incidence increased from 0.47 to 0.69 per 1000 admissions in 2018 and 2020, respectively. Ninety-five patients (58.38%) were in the intensive care unit. The main risk factors for candidemia were central venous catheter (CVC) (84.38%), previous surgical procedure (56.88%) and invasive mechanical ventilation (42.50%). Candida albicans was identified in 43.53% of isolates, followed by C. parapsilosis (31.76%) and C. glabrata (12.36%), C. krusei (5.29%), C. tropicalis (2.35%) and C. lusitaniae (2.35%). The study discovered a shift to non-albicansCandida species, particularly C. parapsilosis, and made it possible to determine the main tasks we should focus on to prevent candidemia in the hospital, these being mainly infection control measures directed towards prevention of catheter-related bloodstream infections, specifically comprising hand hygiene and CVC bundles of care. The potential benefit of fluconazole prophylaxis in certain populations of surgical patients could also be considered.
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Affiliation(s)
- Ivana Mareković
- Department of Clinical and Molecular Microbiology, University Hospital Centre Zagreb, School of Medicine University of Zagreb, 10000 Zagreb, Croatia; (S.P.); (V.R.V.); (Z.H.); (M.J.)
- Correspondence: ; Tel.: +385-1-2367-318
| | - Sanja Pleško
- Department of Clinical and Molecular Microbiology, University Hospital Centre Zagreb, School of Medicine University of Zagreb, 10000 Zagreb, Croatia; (S.P.); (V.R.V.); (Z.H.); (M.J.)
| | - Violeta Rezo Vranješ
- Department of Clinical and Molecular Microbiology, University Hospital Centre Zagreb, School of Medicine University of Zagreb, 10000 Zagreb, Croatia; (S.P.); (V.R.V.); (Z.H.); (M.J.)
| | - Zoran Herljević
- Department of Clinical and Molecular Microbiology, University Hospital Centre Zagreb, School of Medicine University of Zagreb, 10000 Zagreb, Croatia; (S.P.); (V.R.V.); (Z.H.); (M.J.)
| | - Tomislav Kuliš
- Department of Urology, University Hospital Centre Zagreb, School of Medicine University of Zagreb, 10000 Zagreb, Croatia;
| | - Marija Jandrlić
- Department of Clinical and Molecular Microbiology, University Hospital Centre Zagreb, School of Medicine University of Zagreb, 10000 Zagreb, Croatia; (S.P.); (V.R.V.); (Z.H.); (M.J.)
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82
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Kochanek M, Köhler P. [Invasive fungal infections in ICU patients - What's New?]. Dtsch Med Wochenschr 2021; 146:455-460. [PMID: 33780991 DOI: 10.1055/a-1267-0763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Invasive fungal infections are gaining increasing importance in intensive care medicine. The aim of this article is to present an update on recent developments in the field of invasive fungal infection in critically ill patients. Particular emphasis is placed on the recently described invasive mold infections in patients with acute respiratory distress syndrome due to influenza or COVID-19. Detecting high-risk patients and the optimal diagnostic and therapeutic strategies play a decisive role to improve outcome.
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Affiliation(s)
- Matthias Kochanek
- Klinik I für Innere Medizin, Uniklinik Köln.,Zentrum für Integrierte Onkologie (CIO) Köln-Bonn, Uniklinik Köln.,Arbeitsgruppe Intensive Care in Hematologic and Oncologic Patients (iCHOP) der DGHO/DGIIN
| | - Philipp Köhler
- Klinik I für Innere Medizin, Uniklinik Köln.,Zentrum für Integrierte Onkologie (CIO) Köln-Bonn, Uniklinik Köln.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Universität zu Köln
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83
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Wang Y, Zhang Y, McGuire TM, Hollingworth SA, Van Driel ML, Cao L, Wang X, Dong Y. ICU Patients' Antibiotic Exposure and Triazole-Resistance in Invasive Candidiasis: Parallel Analysis of Aggregated and Individual Data. Front Pharmacol 2021; 12:586893. [PMID: 33828482 PMCID: PMC8019904 DOI: 10.3389/fphar.2021.586893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/10/2021] [Indexed: 11/23/2022] Open
Abstract
Background: The relationship between antibiotic use and the incidence of triazole-resistant phenotypes of invasive candidiasis (IC) in critically ill patients is unclear. Different methodologies on determining this relationship may yield different results. Methods: A retrospective multicenter observational analysis was conducted to investigate exposure to antibiotics and the incidence of non-duplicate clinical isolates of Candida spp. resistant to fluconazole, voriconazole, or both during November 2013 to April 2018, using two different methodologies: group-level (time-series analysis) and individual-patient-level (regression analysis and propensity-score adjusting). Results: Of 393 identified Candida spp. from 388 critically ill patients, there were three phenotypes of IC identified: fluconazole-resistance (FR, 63, 16.0%); voriconazole-resistance (VR, 46, 11.7%); and cross-resistance between fluconazole and voriconazole (CR, 32, 8.1%). Exposure to several antibacterial agents with activity against the anaerobic gastrointestinal flora, especially third-generation cefalosporins (mainly cefoperazone/sulbactam and ceftriaxone), but not triazoles, have an immediate effect (time lag = 0) on subsequent ICU-acquired triazole-resistant IC in the group-level (p < 0.05). When the same patient database was analyzed at the individual-patient-level, we found that exposure to many antifungal agents was significantly associated with triazole-resistance (fluconazole [adjusted odds ratio (aOR) = 2.73] or caspofungin [aOR = 11.32] on FR, voriconazole [aOR = 2.87] on CR). Compared to the mono-triazole-resistant phenotype, CR IC has worse clinical outcomes (14-days mortality) and a higher level of resistance. Conclusion: Group-level and individual-patient-level analyses of antibiotic-use-versus-resistance relations yielded distinct but valuable results. Antibacterials with antianaerobic activity and antifungals might have “indirect” and “direct” effect on triazole-resistant IC, respectively.
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Affiliation(s)
- Yan Wang
- Department of Pharmacy, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Pharmacy, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,School of Pharmacy, the University of Queensland, Woolloongabba, QLD, Australia
| | - Ying Zhang
- Department of Pharmacy, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Treasure M McGuire
- School of Pharmacy, the University of Queensland, Woolloongabba, QLD, Australia.,Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia.,Mater Pharmacy, Mater Health, Brisbane, QLD, Australia
| | | | - Mieke L Van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Lu Cao
- Department of Pharmacy, Beiguan Community Health Service Center, Xi'an, China
| | - Xue Wang
- Central Intensive Care Unit, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yalin Dong
- Department of Pharmacy, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Protocol for the pBDG2 Study: Prospective Evaluation of 1.3-β-D-Glucan in the Peritoneal Fluid for the Diagnosis of Intra-Abdominal Candidiasis in Critically Ill Patients. MICROBIOLOGY RESEARCH 2021. [DOI: 10.3390/microbiolres12010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The delayed diagnosis of the presence of Candida in severe intra-abdominal infections exposes patients to an increased risk of mortality. The prevalence of intra-abdominal candidiasis (IAC) varies with the type of intra-abdominal infection, the underlying conditions and the presence of risk factors for Candida infection. This study aims to evaluate the interest of the measure of 1.3-β-D-glucan (BDG) in the peritoneal fluid for the early diagnosis of IAC. Methods and analysis: This is a prospective multicenter (n = 5) non-interventional study, focusing on all critically ill patients with an intra-abdominal infection requiring intra-abdominal surgery. The primary objective is to assess the diagnostic performance of the BDG measured in the peritoneal fluid for the early detection of IAC using the Candida culture as the gold standard. The secondary objective is to report the prevalence of IAC in the selected population. This study aims to enroll 200 patients within 48 months. By estimating the prevalence of IAC in the selected population at 30%, 50 patients with IAC (cases) are expected. These 50 IAC cases will be matched with 50 non-IAC patients (as a control group). The peritoneal BDG will be measured a posteriori in all of these 100 selected patients. This article presents the protocol and the current status of the study. Only the prevalence of IAC is reported as preliminary result.
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85
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Wang D, An N, Yang Y, Yang X, Fan Y, Feng J. Candida tropicalis distribution and drug resistance is correlated with ERG11 and UPC2 expression. Antimicrob Resist Infect Control 2021; 10:54. [PMID: 33722286 PMCID: PMC7958445 DOI: 10.1186/s13756-021-00890-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 01/11/2021] [Indexed: 12/15/2022] Open
Abstract
Background Candida tropicalis (C. tropicalis) is an important opportunistic pathogenic Candida species that can cause nosocomial infection. In this study, we analyzed the distribution and drug susceptibility of C. tropicalis and the relationship between ERG11 and UPC2 expression and resistance to azole antifungal agents. Methods C. tropicalis was cultured and identified by Sabouraud Agar Medium, CHROM Agar Candida and ATB tests (Bio-Mérieux, France). Total RNA was extracted from the collected strains, and the ERG11 and UPC2 mRNA expression levels were analyzed by quantitative real-time PCR. Results In total, 2872 clinical isolates of Candida, including 319 strains of C. tropicalis, were analyzed herein; they were mainly obtained from the Departments of Respiratory Medicine and ICU. The strains were predominantly isolated from airway secretion samples, and the detection trend in four years was mainly related to the type of department and specimens. The resistance rates of C. tropicalis to fluconazole, itraconazole and voriconazole had been increasing year by year. The mRNA expression levels of ERG11 and UPC2 in the fluconazole-resistant group were significantly higher than they were in the susceptible group. In addition, there was a significant positive linear correlation between these two genes in the fluconazole-resistant group. Conclusions Overexpression of the ERG11 and UPC2 genes in C. tropicalis could increase resistance to azole antifungal drugs. The routine testing for ERG11 and UPC2 in high-risk patients in key departments would provide a theoretical basis for the rational application of azole antifungal drugs.
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Affiliation(s)
- Dan Wang
- Department of Laboratory Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, Sichuan Province, China
| | - Na An
- Department of Laboratory Medicine, Mianyang Central Hospital, Mianyang, 621000, Sichuan Province, China
| | - Yuwei Yang
- Department of Laboratory Medicine, Mianyang Central Hospital, Mianyang, 621000, Sichuan Province, China
| | - Xianggui Yang
- Department of Laboratory Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, Sichuan Province, China
| | - Yingzi Fan
- Department of Laboratory Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, Sichuan Province, China
| | - Jiafu Feng
- Department of Laboratory Medicine, Mianyang Central Hospital, Mianyang, 621000, Sichuan Province, China.
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86
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Dupuis C, Le Bihan C, Maubon D, Calvet L, Ruckly S, Schwebel C, Bouadma L, Azoulay E, Cornet M, Timsit JF. Performance of Repeated Measures of (1-3)-β-D-Glucan, Mannan Antigen, and Antimannan Antibodies for the Diagnosis of Invasive Candidiasis in ICU Patients: A Preplanned Ancillary Analysis of the EMPIRICUS Randomized Clinical Trial. Open Forum Infect Dis 2021; 8:ofab080. [PMID: 33816643 PMCID: PMC8002176 DOI: 10.1093/ofid/ofab080] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/26/2021] [Indexed: 12/13/2022] Open
Abstract
Background We aimed to assess the prognostic value of repeated measurements of serum (1–3)-β-D-glucan (BDG), mannan-antigen (mannan-Ag), and antimannan antibodies (antimannan-Ab) for the occurrence of invasive candidiasis (IC) in a high-risk nonimmunocompromised population. Methods This was a preplanned ancillary analysis of the EMPIRICUS Randomized Clinical Trial, including nonimmunocompromised critically ill patients with intensive care unit–acquired sepsis, multiple Candida colonization, and multiple organ failure who were exposed to broad-spectrum antibacterial agents. BDG (>80 and >250 pg/mL), mannan-Ag (>125 pg/mL), and antimannan-Ab (>10 AU) were collected repeatedly. We used cause-specific hazard models. Biomarkers were assessed at baseline in the whole cohort (cohort 1). Baseline covariates and/or repeated measurements and/or increased biomarkers were then studied in the subgroup of patients who were still alive at day 3 and free of IC (cohort 2). Results Two hundred thirty-four patients were included, and 215 were still alive and free of IC at day 3. IC developed in 27 patients (11.5%), and day 28 mortality was 29.1%. Finally, BDG >80 pg/mL at inclusion was associated with an increased risk of IC (CSHR[IC], 4.67; 95% CI, 1.61–13.5) but not death (CSHR[death], 1.20; 95% CI, 0.71–2.02). Conclusions Among high-risk patients, a first measurement of BDG >80 pg/mL was strongly associated with the occurrence of IC. Neither a cutoff of 250 pg/mL nor repeated measurements of fungal biomarkers seemed to be useful to predict the occurrence of IC. The cumulative risk of IC in the placebo group if BDG >80 pg/mL was 25.39%, which calls into question the efficacy of empirical therapy in this subgroup.
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Affiliation(s)
- Claire Dupuis
- Medical ICU, Gabriel Montpied University Hospital, Clermont-Ferrand, France.,UMR1137-IAME Inserm, Paris Diderot University, Paris, France
| | - Clément Le Bihan
- Saint Eloi Department of Anesthesiology and Critical Care Medicine, Montpellier University and Montpellier University Health Care Center, Montpellier, France
| | - Daniele Maubon
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, Grenoble, France
| | - Laure Calvet
- Medical ICU, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | | | - Carole Schwebel
- Medical ICU, Albert Michallon University Hospital, Grenoble, France
| | - Lila Bouadma
- UMR1137-IAME Inserm, Paris Diderot University, Paris, France.,Medical and Infectious Diseases ICU, Bichat-Claude Bernard University Hospital, Paris, France
| | - Elie Azoulay
- Saint-Louis University Hospital, Medical ICU, Paris, France
| | - Muriel Cornet
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, Grenoble, France
| | - Jean-Francois Timsit
- UMR1137-IAME Inserm, Paris Diderot University, Paris, France.,Medical and Infectious Diseases ICU, Bichat-Claude Bernard University Hospital, Paris, France
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87
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Kritikos A, Lamoth F. Letter on "(1,3)-β-D-Glucan-based empirical antifungal interruption in suspected invasive candidiasis: a randomized trial". Crit Care 2021; 25:55. [PMID: 33563306 PMCID: PMC7874441 DOI: 10.1186/s13054-020-03450-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 12/22/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Antonios Kritikos
- Microbiology Institute and Infectious Diseases Service, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Frederic Lamoth
- Microbiology Institute and Infectious Diseases Service, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
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88
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Liu J, Yu YT, Xu CH, Chen DC. Candida Colonization in the Respiratory Tract: What Is the Significance? Front Med (Lausanne) 2021; 7:598037. [PMID: 33614672 PMCID: PMC7889970 DOI: 10.3389/fmed.2020.598037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 12/18/2020] [Indexed: 02/05/2023] Open
Affiliation(s)
- Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue-Tian Yu
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chun-Hui Xu
- Clinical Laboratory Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - De-Chang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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89
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Adequate duration of therapy in severe fungal infections. Curr Opin Crit Care 2021; 26:466-472. [PMID: 32773617 DOI: 10.1097/mcc.0000000000000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To highlight recent findings on the adequate duration of antifungal therapy in patients with invasive fungal disease (IFD). RECENT FINDINGS Plenty of published data available suggest that there is no additional clinical benefit at a certain point after initiation of antifungal treatment in patients with confirmed IFD. Moreover, the prolonged antifungal exposure can be associated with an increased risk of side effects and toxicity as well as striking risk for developing antifungal resistance or rising unnecessary healthcare costs. Recent data suggest that, in the presence of an adequate initial antifungal therapy and adequate source control of the infection, new stratified approaches integrating clinical judgment, biomarkers and microbiological eradication, should be considered as an alternative to the 'one-size-fits-all' treatment duration currently used worldwide. SUMMARY The optimal duration of antifungal therapy is still an unresolved issue that depends by many key elements including the host; the pathogen and its microbiological eradication, the adequateness of initial antifungal therapy and the promptness of source control of the infection. In general, many patients with invasive candidiasis can be treated with a 2 weeks course of antifungal therapy. Longer antifungal course (6 weeks or more) is generally required for patients with invasive aspergilosis.
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90
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Sridharan S, Gopalakrishnan R, Nambi PS, Kumar S, Sethuraman N, Ramasubramanian V. Clinical Profile of Non-neutropenic Patients with Invasive Candidiasis: A Retrospective Study in a Tertiary Care Center. Indian J Crit Care Med 2021; 25:267-272. [PMID: 33790505 PMCID: PMC7991763 DOI: 10.5005/jp-journals-10071-23748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Introduction: Invasive candidiasis (IC) is a major cause of morbidity and mortality in critically ill patients in the intensive care unit (ICU). In this study, we aim to analyze the clinical profile, species distribution, and susceptibility pattern of patients with IC. Methods: Case records of non-neutropenic patients ≥18 years of age with IC between January 2016 and June 2019 at a tertiary care referral hospital were analyzed. IC was defined as either candidemia or isolation of Candida species from a sterile site (such as CSF; ascitic, pleural, or pericardial fluid; or pus or tissue from an intraoperative sample) in a patient with clinical signs and symptoms of infection. Results: A total of 114 patients were analyzed, out of which 105 (92.1%) patients had bloodstream infection (BSI) due to Candida and 9 (7.9%) had IC identified from a sterile site. Central line-associated blood stream infection (27 patients, 23.6%) and a gastrointestinal source (30 patients, 26.3%) were the most common presumed sources for candidemia. The commonest species was Candida tropicalis 42 (36.8%), followed by Candida glabrata 20 (17.5%). Serum beta-D-glucan (BDG) was done only in 32 patients of the 114 (35.3%); among those who were tested, 5 (15.6%) had a BDG value of less than 80 pg/mL despite having Candida BSI. Fluconazole sensitivity was 69.5% overall. At 14 days after diagnosis of IC, 49.1% had recovered, with the remainder having an unfavorable outcome (32.4% had died and 18.4% had left against medical advice). Clinical significance: IC is a major concern in Indian ICUs, with a satisfactory outcome in only half of our patients. Serum BDG is a valuable test to diagnose blood culture-negative IC, but more studies are needed to determine its role in the exclusion of IC, as we had a small minority of patients with negative tests despite proven IC. Conclusion: We recommend sending two sets of blood cultures and serum BDG assay for all suspected patients. Initiating empiric antifungal therapy with an echinocandin is advisable, in view of increasing azole resistance and the emergence of Candida auris, with de-escalation to fluconazole for sensitive isolates after clinical stability and blood culture clearance. How to cite this article: Sridharan S, Gopalakrishnan R, Nambi PS, Kumar S, Sethuraman N, Ramasubramanian V. Indian J Crit Care Med 2021;25(3):267-272.
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Affiliation(s)
- Sowmya Sridharan
- Department of Infectious Disease, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Ram Gopalakrishnan
- Department of Infectious Disease, Apollo Hospitals, Chennai, Tamil Nadu, India
| | | | - Suresh Kumar
- Department of Infectious Disease, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Nandini Sethuraman
- Department of Infectious Disease, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - V Ramasubramanian
- Department of Infectious Disease, Apollo Hospitals, Chennai, Tamil Nadu, India
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91
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Impact of Loading Dose of Caspofungin in Pharmacokinetic-Pharmacodynamic Target Attainment for Severe Candidiasis Infections in Patients in Intensive Care Units: the CASPOLOAD Study. Antimicrob Agents Chemother 2020; 64:AAC.01545-20. [PMID: 32958709 DOI: 10.1128/aac.01545-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/13/2020] [Indexed: 12/14/2022] Open
Abstract
This study evaluated the impact of a high loading dose of caspofungin (CAS) on the pharmacokinetics of CAS and the pharmacokinetic-pharmacodynamic (PK-PD) target attainment in patients in intensive care units (ICU). ICU patients requiring CAS treatment were prospectively included to receive a 140-mg loading dose of CAS. Plasma CAS concentrations (0, 2, 3, 5, 7, and 24 h postinfusion) were determined to develop a two-compartmental population PK model. A Monte Carlo simulation was performed and the probabilities of target attainment (PTAs) were computed using previously published MICs. PK-PD targets were ratios of area under the concentration-time curve from 0 to 24 h (AUC0-24h) divided by the MIC (AUC0-24h/MIC) of 250, 450, and 865 and maximal concentration (C max) divided by the MIC (C max/MIC) of 5, 10, 15, and 20. Among 13 included patients, CAS clearance was 0.98 ± 0.13 liters/h and distribution volumes were V1 = 9.0 ± 1.2 liters and V2 = 11.9 ± 2.9 liters. Observed and simulated CAS AUC0-24h were 79.1 (IQR 55.2; 108.4) and 81.3 (IQR 63.8; 102.3) mg · h/liter during the first 24 h of therapy, which is comparable to values usually observed in ICU patients at day 3 or later. PTAs were >90% for MICs of 0.19 and 0.5 mg/liter, considering AUC/MIC = 250 and C max/MIC = 10 as PK-PD targets, respectively. Thus, a high loading dose of CAS (140 mg) increased CAS exposure in the first 24 h of therapy, allowing early achievement of PK-PD targets for most Candida strains. Such a strategy seems to improve treatment efficacy, though further studies are needed to assess the impact on clinical outcomes. (This study has been registered at ClinicalTrials.gov under identifier NCT02413892.).
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92
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Torres A, Martin-Loeches I. Invasive Pulmonary Aspergillosis in Ventilator-associated Pneumonia: The Hidden Enemy? Am J Respir Crit Care Med 2020; 202:1071-1073. [PMID: 32730104 PMCID: PMC7560816 DOI: 10.1164/rccm.202006-2605ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Antoni Torres
- Hospital Clinic, IDIBAPS Universitat de Barcelona Barcelona, Spain.,Universitat de Barcelona Barcelona, Spain.,CIBERes, Barcelona Spain.,ICREA, Institución Catalana de Investigación y Estudios Avanzados Barcelona, Spain
| | - Ignacio Martin-Loeches
- Hospital Clinic, IDIBAPS Universitat de Barcelona Barcelona, Spain.,Universitat de Barcelona Barcelona, Spain.,CIBERes, Barcelona Spain.,Multidisciplinary Intensive Care Research Organization (MICRO) Department of Intensive Care Medicine, St. James's University Hospital Dublin, Ireland and.,Trinity Centre for Health Sciences Department of Intensive Care Medicine, Dublin, Ireland
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93
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Logan C, Martin-Loeches I, Bicanic T. Invasive candidiasis in critical care: challenges and future directions. Intensive Care Med 2020; 46:2001-2014. [PMID: 32990778 DOI: 10.1007/s00134-020-06240-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/01/2020] [Indexed: 12/19/2022]
Abstract
Invasive candidiasis is the most common critical care-associated fungal infection with a crude mortality of ~ 40-55%. Important factors contributing to risk of invasive candidiasis in ICU include use of broad-spectrum antimicrobials, immunosuppressive drugs, and total parenteral nutrition alongside iatrogenic interventions which breach natural barriers to infection [vascular catheters, renal replacement therapy, extracorporeal membrane oxygenation (ECMO), surgery]. This review discusses three key challenges in this field. The first is the shift in Candida epidemiology across the globe to more resistant non-albicans species, in particular, the emergence of multi-resistant Candida glabrata and Candida auris, which pose significant treatment and infection control challenges in critical care. The second challenge lies in the timely and appropriate initiation and discontinuation of antifungal therapy. Early antifungal strategies (prophylaxis, empirical and pre-emptive) using tools such as the Candida colonisation index, clinical prediction rules and fungal non-culture-based tests have been developed: we review the evidence on implementation of these tools in critical care to aid clinical decision-making around the prescribing and cessation of antifungal therapy. The third challenge is selection of the most appropriate antifungal to use in critical care patients. While guidelines exist to aid choice, this heterogenous and complex patient group require a more tailored approach, particularly in cases of acute kidney injury, liver impairment and for patients supported by extracorporeal membrane oxygenation. We highlight key research priorities to overcome these challenges in the future.
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Affiliation(s)
- C Logan
- Institute of Infection and Immunity, St George's University of London, London, UK
- Clinical Infection Unit, St George's University Hospital, London, UK
| | - I Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital/Trinity College, Dublin, Ireland.
- Hospital Clinic, Universidad de Barcelona, CIBERes, Barcelona, Spain.
| | - T Bicanic
- Institute of Infection and Immunity, St George's University of London, London, UK
- Clinical Infection Unit, St George's University Hospital, London, UK
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94
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Bal AM. European confederation of medical mycology quality of clinical candidaemia management score: A review of the points based best practice recommendations. Mycoses 2020; 64:123-131. [PMID: 33058251 DOI: 10.1111/myc.13196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 12/14/2022]
Abstract
Candidaemia is associated with high mortality. In the last few years, several guidelines have been published on the management of Candida bloodstream infection. However, adherence to the practice guidelines has been suboptimal. In order to facilitate and objectively measure the adherence to good practice recommendations, a scoring criterion was published by the European Confederation of Medical Mycology (ECMM). The ECMM Quality (EQUAL) of Clinical Candidaemia Management is an audit tool that comprises of 10 quality indicators. Each quality indicator is allotted between 1 and 3 points. The maximum achievable score is 22 or 19 in patients with or without a central venous catheter, respectively. This paper reviews each of the 10 quality indicators and provides the context for improving quality within the individual domains. The review also suggests areas that are in need of further clarity or areas which merit attention in the future updates of the EQUAL scoring system so that clinicians are able to derive maximum benefit from the audit tool. The EQUAL scoring tool is an important milestone in the quality improvement aspect of the management of candidaemia and contributes to the various components of clinical governance in the management of Candida infection of the bloodstream.
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Affiliation(s)
- Abhijit M Bal
- Department of Microbiology, University Hospital Crosshouse, Kilmarnock, UK
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95
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Schroeder M, Weber T, Denker T, Winterland S, Wichmann D, Rohde H, Ozga AK, Fischer M, Kluge S. Epidemiology, clinical characteristics, and outcome of candidemia in critically ill patients in Germany: a single-center retrospective 10-year analysis. Ann Intensive Care 2020; 10:142. [PMID: 33064220 PMCID: PMC7567770 DOI: 10.1186/s13613-020-00755-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/03/2020] [Indexed: 12/15/2022] Open
Abstract
Background Despite advances in the management of bloodstream infections (BSI) caused by Candida spp., the mortality still remains high in critically ill patients. The worldwide epidemiology of yeast-related BSI is subject to changing species distribution and resistance patterns, challenging antifungal treatment strategies. The aim of this single-center study was to identify predictors of mortality after 28 and 180 days in a cohort of mixed surgical and medical critically ill patients with candidemia. Methods Patients, who had been treated for laboratory-confirmed BSI caused by Candida spp. in one of 12 intensive care units (ICU) at a University hospital between 2008 and 2017, were retrospectively identified. We retrieved data including clinical characteristics, Candida species distribution, and antifungal management from electronic health records to identify risk factors for mortality at 28 and 180 days using a Cox regression model. Results A total of 391 patients had blood cultures positive for Candida spp. (incidence 4.8/1000 ICU admissions). The mortality rate after 28 days was 47% (n = 185) and increased to 60% (n = 234) after 180 days. Age (HR 1.02 [95% CI 1.01–1.03]), a history of liver cirrhosis (HR 1.54 [95% CI 1.07–2.20]), septic shock (HR 2.41 [95% CI 1.73–3.37]), the Sepsis-related Organ Failure Assessment score (HR 1.12 [95% CI 1.07–1.17]), Candida score (HR 1.25 [95% CI 1.11–1.40]), and the length of ICU stay at culture positivity (HR 1.01 [95% CI 1.00–1.01]) were significant risk factors for death at 180 days. Patients, who had abdominal surgery (HR 0.66 [95% CI 0.48–0.91]) and patients, who received adequate (HR 0.36 [95% CI 0.24–0.52]) or non-adequate (HR 0.31 [95% CI 0.16–0.62]) antifungal treatment, had a reduced mortality risk compared to medical admission and no antifungal treatment, respectively. Conclusions The mortality of critically ill patients with Candida BSI is high and is mainly determined by disease severity, multiorgan dysfunction, and antifungal management rather than species distribution and susceptibility. Our results underline the importance of timely treatment of candidemia. However, controversies remain on the optimal definition of adequate antifungal management.
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Affiliation(s)
- Maria Schroeder
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Theresa Weber
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Timme Denker
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Sarah Winterland
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Dominic Wichmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Holger Rohde
- Department of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ann-Kathrin Ozga
- Center for Experimental Medicine, Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Fischer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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96
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He ZX, Zhao HH, Wang FK. PCR-detectable Candida DNA exists a short period in the blood of systemic candidiasis murine model. Open Life Sci 2020; 15:677-682. [PMID: 33817256 PMCID: PMC7747513 DOI: 10.1515/biol-2020-0075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/21/2020] [Accepted: 07/11/2020] [Indexed: 12/15/2022] Open
Abstract
Invasive candidiasis is a major challenge to clinical medicine today. However, traditional fungal diagnostic techniques and empirical treatments have shown great limitations. Although efforts are necessarily needed in methodology standardization and multicenter validation, polymerase chain reaction (PCR) is a very promising assay in detecting fungal pathogens. Using a "heat-shock" DNA preparation method, a rapid and simple PCR protocol for quantification of the Candida albicans (C. albicans) ribosomal DNA was established. The PCR assay could detect Candida DNA as low as 10 CFU/mL in samples prepared by the heat-shock protocol, without any cross-reaction with DNA prepared from other Candida spp. and bacterial pathogens. For simulated blood samples, the PCR test sensitivity of whole blood samples was better than that of plasma and blood cells. In the systemic candidiasis murine model, detectable DNA was only observed within 24 h after C. albicans SC5314 injection, which is much shorter than that observed in the kidney.
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Affiliation(s)
- Zheng-Xin He
- Department of Clinical Laboratory, The 980th Hospital of PLA Joint Logistical Support Force (Bethune International Peace Hospital), 398 Zhongshan Road, Shijiazhuang, Hebei, 050082, People's Republic of China
| | - Hui-Hai Zhao
- Department of Clinical Laboratory, The 980th Hospital of PLA Joint Logistical Support Force (Bethune International Peace Hospital), 398 Zhongshan Road, Shijiazhuang, Hebei, 050082, People's Republic of China
| | - Fu-Kun Wang
- Department of Clinical Laboratory, The 980th Hospital of PLA Joint Logistical Support Force (Bethune International Peace Hospital), 398 Zhongshan Road, Shijiazhuang, Hebei, 050082, People's Republic of China
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97
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(1,3)-β-D-Glucan-based empirical antifungal interruption in suspected invasive candidiasis: a randomized trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:550. [PMID: 32891170 PMCID: PMC7487510 DOI: 10.1186/s13054-020-03265-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/26/2020] [Indexed: 12/15/2022]
Abstract
Background (1,3)-β-d-Glucan has been widely used in clinical practice for the diagnosis of invasive Candida infections. However, such serum biomarker showed potential to guide antimicrobial therapy in order to reduce the duration of empirical antifungal treatment in critically ill septic patients with suspected invasive candidiasis. Methods This was a single-centre, randomized, open-label clinical trial in which critically ill patients were enrolled during the admission to the intensive care unit (ICU). All septic patients who presented invasive Candida infection risk factors and for whom an empirical antifungal therapy was commenced were randomly assigned (1:1) in those stopping antifungal therapy if (1,3)-β-d-glucan was negative ((1,3)-β-d-glucan group) or those continuing the antifungal therapy based on clinical rules (control group). Serum 1,3-β-d-glucan was measured at the enrolment and every 48/72 h over 14 days afterwards. The primary endpoint was the duration of antifungal treatment in the first 30 days after enrolment. Results We randomized 108 patients into the (1,3)-β-d-glucan (n = 53) and control (n = 55) groups. Median [IQR] duration of antifungal treatment was 2 days [1–3] in the (1,3)-β-d-glucan group vs. 10 days [6–13] in the control group (between-group absolute difference in means, 6.29 days [95% CI 3.94–8.65], p < 0.001). Thirty-day mortality was similar (28.3% [(1,3)-β-d-glucan group] vs. 27.3% [control group], p = 0.92) as well as the overall rate of documented candidiasis (11.3% [(1,3)-β-d-glucan group] vs. 12.7% [control group], p = 0.94), the length of mechanical ventilation (p = 0.97) and ICU stay (p = 0.23). Conclusions In critically ill septic patients admitted to the ICU at risk of invasive candidiasis, a (1,3)-β-d-glucan-guided strategy could reduce the duration of empirical antifungal therapy. However, the safety of this algorithm needs to be confirmed in future, multicentre clinical trial with a larger population. Trial registration ClinicalTrials.gov, NCT03117439, retrospectively registered on 18 April 2017
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Caspofungin Weight-Based Dosing Supported by a Population Pharmacokinetic Model in Critically Ill Patients. Antimicrob Agents Chemother 2020; 64:AAC.00905-20. [PMID: 32660990 PMCID: PMC7449215 DOI: 10.1128/aac.00905-20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/02/2020] [Indexed: 12/14/2022] Open
Abstract
The objective of this study was to develop a population pharmacokinetic model and to determine a dosing regimen for caspofungin in critically ill patients. Nine blood samples were drawn per dosing occasion. Fifteen patients with (suspected) invasive candidiasis had one dosing occasion and five had two dosing occasions, measured on day 3 (±1) of treatment. Pmetrics was used for population pharmacokinetic modeling and probability of target attainment (PTA). A target 24-h area under the concentration-time curve (AUC) value of 98 mg·h/liter was used as an efficacy parameter. The objective of this study was to develop a population pharmacokinetic model and to determine a dosing regimen for caspofungin in critically ill patients. Nine blood samples were drawn per dosing occasion. Fifteen patients with (suspected) invasive candidiasis had one dosing occasion and five had two dosing occasions, measured on day 3 (±1) of treatment. Pmetrics was used for population pharmacokinetic modeling and probability of target attainment (PTA). A target 24-h area under the concentration-time curve (AUC) value of 98 mg·h/liter was used as an efficacy parameter. Secondarily, the AUC/MIC targets of 450, 865, and 1,185 were used to calculate PTAs for Candida glabrata, C. albicans, and C. parapsilosis, respectively. The final 2-compartment model included weight as a covariate on volume of distribution (V). The mean V of the central compartment was 7.71 (standard deviation [SD], 2.70) liters/kg of body weight, the mean elimination constant (Ke) was 0.09 (SD, 0.04) h−1, the rate constant for the caspofungin distribution from the central to the peripheral compartment was 0.44 (SD, 0.39) h−1, and the rate constant for the caspofungin distribution from the peripheral to the central compartment was 0.46 (SD, 0.35) h−1. A loading dose of 2 mg/kg on the first day, followed by 1.25 mg/kg as a maintenance dose, was chosen. With this dose, 98% of the patients were expected to reach the AUC target on the first day and 100% of the patients on the third day. The registered caspofungin dose might not be suitable for critically ill patients who were all overweight (≥120 kg), over 80% of median weight (78 kg), and around 25% of lower weight (≤50 kg). A weight-based dose regimen might be appropriate for achieving adequate exposure of caspofungin in intensive care unit patients.
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Bassetti M, Vena A, Pincino R, Briano F, Giacobbe DR. Role of Antifungal Therapy in Complicated Intra-abdominal Infections. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00731-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ohki S, Shime N, Kosaka T, Fujita N. Impact of host- and early treatment-related factors on mortality in ICU patients with candidemia: a bicentric retrospective observational study. J Intensive Care 2020; 8:30. [PMID: 32351697 PMCID: PMC7183603 DOI: 10.1186/s40560-020-00450-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/21/2020] [Indexed: 12/15/2022] Open
Abstract
Background Candidemia is one of the most life-threatening infections among critically ill patients in the intensive care unit. However, the number of studies on the impact of host- and early treatment-related factors on mortality in this cohort is limited. The aim of this study was to investigate the relationship between clinically relevant factors, including early treatment (appropriate antifungal therapy and/or central venous catheter removal) and mortality in intensive care unit patients with candidemia. Methods We performed a retrospective observational study in two Japanese University hospitals between January 2007 and December 2016. Adult intensive care unit patients with candidemia who met the following inclusion criteria: (1) ≥ 18 years old; (2) admitted in intensive care unit at the time of onset; and (3) central venous catheter in situ at the time of onset were included. We performed univariate and multivariate logistic regression analysis to identify factors associated with 30-day crude mortality. Results A total of 68 patients met the inclusion criteria, 47 (69%) of whom were males. The median age was 68.0 (interquartile range, 61.0-76.0) years. The most common causative Candida species was Candida albicans (40 [59%] patients). With respect to the source of infection, central venous catheter-related candidemia was the most frequent (30 [44%] patients). Thirty-day crude mortality was 54% (37 patients). In multivariate logistic regression analysis, Acute Physiology and Chronic Health Evaluation II score (1-point increments) was the only factor that was independently associated with higher 30-day crude mortality. Other variables, including appropriate antifungal therapy and/or central venous catheter removal ≤ 24 h and ≤ 48 h following onset, did not significantly influence mortality. Conclusions Candidemia in intensive care unit patients is still associated with high 30-day crude mortality rates. The only predictor of death was Acute Physiology and Chronic Health Evaluation II score ≤ 24 h following candidemia onset. Early empiric antifungal therapy and/or early CVC removal conferred no significant clinical benefit on survival in this patient population.
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Affiliation(s)
- Shingo Ohki
- 1Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Nobuaki Shime
- 1Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Tadashi Kosaka
- 2Department of Pharmacy, Kyoto Prefectural University of Medicine, Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan
| | - Naohisa Fujita
- 3Department of Infection Control and Laboratory Medicine, Kyoto Prefectural University of Medicine, Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan
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