Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America

Integrating ensemble machine learning and multi-omics approaches to identify Dp44mT as a novel anti-Candida albicans agent targeting cellular iron homeostasis

Introduction

Candidiasis, mainly caused by Candida albicans, poses a serious threat to human health. The escalating drug resistance in C. albicans and the limited antifungal options highlight the critical need for novel therapeutic strategies.

Methods

We evaluated 12 machine learning models on a self-constructed dataset with known anti-C. albicans activity. Based on their performance, the optimal model was selected to screen our separate in-house compound library with unknown anti-C. albicans activity for potential antifungal agents. The anti-C. albicans activity of the selected compounds was confirmed through in vitro drug susceptibility assays, hyphal growth assays, and biofilm formation assays. Through transcriptomics, proteomics, iron rescue experiments, CTC staining, JC-1 staining, DAPI staining, molecular docking, and molecular dynamics simulations, we elucidated the mechanism underlying the anti-C. albicans activity of the compound.

Result

Among the evaluated machine learning models, the best predictive model was an ensemble learning model constructed from Random Forests and Categorical Boosting using soft voting. It predicts that Dp44mT exhibits potent anti-C. albicans activity. The in vitro tests further verified this finding that Dp44mT can inhibit planktonic growth, hyphal formation, and biofilm formation of C. albicans. Mechanistically, Dp44mT exerts antifungal activity by disrupting cellular iron homeostasis, leading to a collapse of mitochondrial membrane potential and ultimately causing apoptosis.

Conclusion

This study presents a practical approach for predicting the antifungal activity of com-pounds using machine learning models and provides new insights into the development of antifungal compounds by disrupting iron homeostasis in C. albicans.

Vaginal mycobiome characteristics and therapeutic strategies in vulvovaginal candidiasis (VVC): differentiating pathogenic species and microecological features for stratified treatment

SUMMARYVulvovaginal candidiasis (VVC) is a prevalent global health burden, particularly among reproductive-aged women. Recurrent VVC affects a significant proportion of this population, presenting therapeutic challenges. The predominant pathogen, Candida albicans, opportunistically transitions from a commensal organism to a pathogen when microenvironmental conditions become dysregulated. Recently, non-albicans Candida species have gained attention for their reduced antifungal susceptibility and recurrence tendencies. Diagnosis is constrained by the limitations of conventional microbiological techniques, while emerging molecular assays offer enhanced pathogen detection yet lack established thresholds to differentiate between commensal and pathogenic states. Increasing resistance issues are encountered by traditional azole-based antifungals, necessitating innovative approaches that integrate microbiota modulation and precision medicine. Therefore, this review aims to systematically explore the pathogenic diversity, drug resistance mechanisms, and biofilm effects of Candida species. Vaginal microbiota (VMB) alterations associated with VVC were also examined, focusing on the interaction between Lactobacillus spp. and pathogenic fungi, emphasizing the role of microbial dysbiosis in disease progression. Finally, the potential therapeutic approaches for VVC were summarized, with a particular focus on the use of probiotics to modulate the VMB composition and restore a healthy microbial ecosystem as a promising treatment strategy. This review addresses antifungal resistance and adopts a microbiota-centric approach, proposing a comprehensive framework for personalized VVC management to reduce recurrence and improve patient outcomes.

Evaluation of shorter versus longer antifungal treatment durations for Candida spp. urinary tract infections among hospitalized adults

Infectious Diseases Society of America guidelines recommend 14 days of treatment for Candida spp. urinary tract infections (UTIs). To our knowledge, no data are available to compare <14 days for Candida spp. UTI. This was a single-center, retrospective cohort study between 01 January 2015 and 01 January 2024. Hospitalized adults with >1 urine culture with Candida spp. and symptoms who initiated >1 antifungal dose within 96 hours were included. Multiple exclusion criteria existed, including but not limited to if Candida spp. were isolated from another site, antifungals were received for another indication, or the participant was asymptomatic. The primary outcome was clinical treatment success. Binary logistic regression was performed to further assess the relationship between fluconazole duration and clinical treatment success. Among 2,400 patients with candiduria, 45 and 58 in the 14-day and <14-day cohorts were assessed after exclusion criteria were applied, respectively. Median (interquartile range) fluconazole duration was 14 (14-14) days in the 14-day cohort and 7 (5-7) in the <14-day cohort. There was no difference in clinical treatment success in patients treated for 14 days vs <14 days (14 days: 93.3% (42/45) vs <14 days: 93.1% (54/58), P = 1.000; between-group difference (95% CI: 0.02 [-9.6 to 10]). Fluconazole duration did not have a significant association with clinical treatment success on binary logistic regression (P = 0.503; odds ratio 0.917 [95% CI: 0.712-1.181]). There was no statistically significant difference in clinical treatment success in patients treated with fluconazole for a median of 14 days vs a median of 7 days for symptomatic Candida spp. UTI. These data support the potential utility of shorter antifungal durations for Candida spp. UTI.

A case of recurrent Candida glabrata fungemia and successful treatment with rezafungin

Antifungal resistance in Candida glabrata can develop to different classes of drugs, including the azoles and echinocandins. This organism is known to cause infective endocarditis with a particular predilection for prosthetic valves. Herein we present a case of recurrent fungemia with C. glabrata in a middle-aged woman with Tetralogy of Fallot who had a right ventricle to pulmonary artery conduit, and a transcatheter pulmonary valve replacement in the past. Her isolate showed increasing minimum inhibitory concentrations (MIC) to various antifungals with higher MICs to azoles, including resistance to fluconazole, resulting in limited treatment options. She had affliction of her prosthetic pulmonic valve with C. glabrata and was treated with the second-generation echinocandin, rezafungin, for six months. This case illustrates the tolerability profile of long-term treatment with rezafungin.

Phylogenetic and ecological drivers of the avian lung mycobiome and its potentially pathogenic component

Vertebrate lungs contain diverse microbial communities, but little is known about the drivers of community composition or consequences for health. Microbiome assembly by processes such as dispersal, coevolution, and host-switching can be probed with comparative surveys; however, few studies exist for lung microbiomes, particularly for the fungal component, the mycobiome. Distinguishing among fungal taxa that are generalist or specialist symbionts, potential pathogens, or incidentally inhaled spores is urgent because of potential for emerging diseases. Here, we characterize the avian lung mycobiome and test the relative influences of environment, phylogeny, and functional traits. We used metabarcoding and culturing from 195 lung samples representing 32 bird species across 20 families. We identified 526 fungal taxa as estimated by distinct sequence types (zOTUs) including many opportunistic pathogens. These were predominantly from the phylum Ascomycota (79%) followed by Basidiomycota (16%) and Mucoromycota (5%). Yeast and yeast-like taxa (Malassezia, Filobasidium, Saccharomyces, Meyerozyma, and Aureobasidium) and filamentous fungi (Cladosporium, Alternaria, Neurospora, Fusarium, and Aspergillus) were abundant. Lung mycobiomes were strongly shaped by environmental exposure, and further modulated by host identity, traits, and phylogenetic affinities. Our results implicate migratory bird species as potential vectors for long-distance dispersal of opportunistically pathogenic fungi.

Rezafungin for suppressive therapy of Candida auris in a patient with a left ventricular assist device (LVAD)

Introduction

Invasive candidiasis is a common healthcare-associated infection with significant morbidity and mortality. Candida auris in particular has emerged as a problematic and challenging healthcare-associated infection, especially with regards to infections involving left ventricular assist devices (LVADs). There is a paucity of evidence on the best management of these particular types of infections. Rezafungin is a newly-approved echinocandin and an important new tool in the management of invasive candidiasis. We report the novel use of rezafungin for suppressive therapy in a patient with an LVAD-associated C. auris infection.

Case

The patient is a 57-year-old male with a past medical history most notable for heart failure with ischemic cardiomyopathy. The patient underwent LVAD placement and his post-LVAD placement clinical course was notable for recurrent C. auris fungemia. The patient was originally on indefinite micafungin therapy, but was eventually switched to once-weekly rezafungin as this was felt to be safer, easier, and more convenient for the patient. He did well on weekly rezafungin for about 4 months but did eventually develop breakthrough C. auris fungemia.

Conclusions

Rezafungin is a promising new antifungal in the armamentarium of drugs for treatment of invasive candidiasis, notably C. auris. Though the patient did develop a breakthrough C. auris bloodstream infection while on rezafungin therapy, his infection was well-controlled for a little over 4 months, which prevented any C. auris-related hospital admissions during that time period. This case represents the first example of rezafungin being used for an LVAD-associated C. auris infection.

Hotspot gene conversion between FKS1 and FKS2 in echinocandin resistant Candida glabrata serial isolates

Candida glabrata (Nakaseomyces glabratus) is the most common cause of drug-resistant candidemia and is associated with a high mortality rate. Only a few mechanisms of drug resistance are known in C. glabrata, predominantly involving recurrent single nucleotide polymorphisms. The importance of structural variation in acquired drug resistance is not understood. We performed comparative phenotypic and genomic analyses of six serial bloodstream isolates of C. glabrata and identified novel mutations associated with resistance to echinocandins. Critically, we identified a novel gene conversion event between the hotspot 2 regions of FKS1 and FKS2 that was associated with increased resistance to micafungin. We further analyzed 621 publicly available C. glabrata genomes and found three additional examples of structural variation involving FKS1 and FKS2. Ultimately, drug resistance in C. glabrata involves structural variants that are missed with current diagnostic methods and need to be considered when designing and implementing more effective antifungal management strategies.

Candida Parapsilosis: a Rare Culprit of Shunt Infection in an Adult

Candida parapsilosis is an exceedingly rare cause of ventriculoperitoneal (VP) shunt infection, even in patients who have a history of long-term antibiotic use, immune-compromised newborns, and intensive care unit patients. We hereby report a case of a 53-year-old male who presented with subarachnoid hemorrhage and had a complicated postoperative course due to C. parapsilosis infection, and we discuss the pertinent clinical aspects.

Use of Intravaginal Cooling to Provide Symptom Relief in Women With Vulvovaginal Candidiasis and Reduce Immunopathology in an Accompanying Mouse Model

BACKGROUND

Vulvovaginal candidiasis (VVC), caused primarily by Candida albicans, is treated with anti-fungal drugs, often with variable efficacy and relapses. New therapeutic strategies, including drug-free alternatives, are needed. Upon overgrowth or environmental triggers, C. albicans commensal yeast transitions into hyphae resulting in an aberrant immunopathologic neutrophil response that contributes to the characteristic signs and symptoms of vaginitis. The purpose of this study was to evaluate the efficacy of an intravaginal cooling device (Vlisse) in women with VVC to provide symptom relief via putative reversal of C. albicans hyphae to yeast, with additional proof of principle in an animal model.

METHODS

Five women with VVC were instructed to use the device twice daily for 3 days. Vulvovaginal symptoms were monitored and scored for each use, followed by pelvic examination at 30 days. A mouse model of VVC employed cooled micro stir rods to evaluate the cooling effect on fungal morphology and vaginal immunopathology.

RESULTS

Clinical cure was achieved in all women. In the mouse model, the insertion of pre-cooled magnetic rods intravaginally for short periods over 3 days, reduced the immunopathogenic neutrophil infiltration and hyphae.

CONCLUSIONS

Intravaginal cooling provides clinical cure for VVC and proof of principle in an animal model.

Clinical characteristics and treatment response of chronic disseminated candidiasis in patients with hematological disorders

Chronic disseminated candidiasis (CDC) is an invasive fungal infection typically affecting patients with hematological diseases and severe neutropenia, associated with increased mortality. However, there is a global shortage of clinical evidence on CDC. We retrospectively analyzed clinical data from 49 CDC patients over the past decade. Clinical characteristics of primary hematological diseases, CDC diagnosis, treatment and response evaluations were included. Clinical factors associated with CDC remission and patients' survival were analyzed. The majority of patients had hematological malignancies (n = 43, 87.8%), and 27 patients (55.1%) had persistent severe neutropenia for more than 10 days prior to CDC. CT scans revealed liver lesions in 44 patients, spleen lesions in 34 patients, and kidney lesions in 9 patients. Proven, probable and possible CDC was diagnosed in 5 (10.2%), 3 (6.1%) and 41 patients (83.7%), respectively, and treatment outcomes at 3 months included 5 complete response (CR, 10.2%), 34 partial response (PR, 69.4%) and 10 treatment failure (20.4%). Caspofungin treatment showed a trend towards improving CR/PR rate, while severe neutropenia > 20 days and proven diagnosis were significantly associated with 3-month treatment failure. Kaplan-Meier curve showed achieving CR/PR within 3 months did not significantly prolong OS compared to treatment failure patients (1197.6 days vs. 564.8 days, P = 0.074). Additionally, no patient deaths were directly attributed to CDC infection. Age > 45 years old and malignancy non-remission were prognostic factors of overall survival (OS). Furthermore, a prediction model identified severe neutropenia > 20 days, proven/probable diagnosis and concomitant bacteremia as risk factors to effectively predict treatment failure. Also, patients with a risk score < 0.203 in the model exhibited more rapid treatment response. After CDC symptoms onset, lymphocyte levels remained consistently higher in treatment failure patients, while the neutrophil-to-lymphocyte ratio was persistently higher in CR/PR patients. Our findings recommend CT scans for diagnosis and caspofungin as first-line therapy while continuing scheduled chemotherapy or bone marrow transplantation. Notably, risk factors identified by the prediction model could be used to predict treatment response.

The unfolded protein response is a potential therapeutic target in pathogenic fungi

Pathogenic fungal infections cause significant morbidity and mortality, particularly in immunocompromised patients. The frequent emergence of multidrug-resistant strains challenges existing antifungal therapies, driving the need to investigate novel antifungal agents that target new molecular moieties. Pathogenic fungi are subjected to various environmental stressors, including pH, temperature, and pharmacological agents, both in natural habitats and the host body. These stressors elevate the risk of misfolded or unfolded protein production within the endoplasmic reticulum (ER) which, if not promptly mitigated, can lead to the accumulation of these proteins in the ER lumen. This accumulation triggers an ER stress response, potentially jeopardizing fungal survival. The unfolded protein response (UPR) is a critical cellular defense mechanism activated by ER stress to restore the homeostasis of protein folding. In recent years, the regulatory role of the UPR in pathogenic fungi has garnered significant attention, particularly for its involvement in fungal adaptation, regulation of virulence, and drug resistance. In this review, we comparatively analyze the UPRs of fungi and mammals and examine the potential utility of the UPR as a molecular antifungal target in pathogenic fungi. By clarifying the specificity and regulatory functions of the UPR in pathogenic fungi, we highlight new avenues for identifying potential therapeutic targets for antifungal treatments.

Concurrent invasive disseminated Nocardia farcinica and Candida infections in a patient undergoing long-term glucocorticoid therapy for autoimmune thrombocytopenia: a case report

BACKGROUND

Nocardia farcinica is a virulent organism known for its high resistance to many antibiotics and its ability to cause disseminated life-threatening infections, particularly in immunocompromised patients or those undergoing organ transplantation. Candida albicans can cause disseminated candidiasis with a mortality rate ranging from 30% to 60%. Cases involving concurrent disseminated N. farcinica and C. albicans, particularly in patients with autoimmune thrombocytopenia, are extremely rare. The presence of two disseminated pathogens complicates both diagnosis and treatment, creating substantial challenges for healthcare providers.

CASE PRESENTATION

A 50-year-old woman who had a history of autoimmune thrombocytopenia and was being treated with prednisone (60 mg qd). She presented with a 40-day history of high-grade fevers (40℃), cough, headache, and multiple abscesses in the skin structure. N. farcinica was found in her skin structure, cerebrospinal fluid, and blood, and C. albicans was cultured in cerebrospinal fluid, sputum, and urine. She was diagnosed with disseminated nocardiosis and disseminated candidiasis. The patient received a prolonged course of multiple anti-bacterial and anti-fungal medications and eventually recovered.

CONCLUSIONS

Due to the atypical clinical presentations, the diagnosis of concurrent invasive disseminated N. farcinica and C. albicans infections might be delayed. A variety of diagnostic testing, including metagenomics next-generation sequencing, can help to identify the pathogen rapidly. Drug susceptibility test can guide the selection and adjustment of antibiotics, which should be in companion with surgical interventions to save lives in affected patients.

Early fungal colonization and infection as an independent predictor of in-hospital mortality in mechanically ventilated COVID-19 patients: A nationwide target trial emulation study in Taiwan

PURPOSE

To evaluate the impact of fungal colonization and infection phenotypes and other prognostic factors on in-hospital mortality among mechanically ventilated COVID-19 patients (n = 376) admitted to ICUs during the first wave of the pandemic in Taiwan.

MATERIALS AND METHODS

A target trial emulation framework was used to minimize immortal time bias. Patients were matched 1:1:2 for age and gender and classified into three groups: 94 in the "Early" group (fungal colonization or infection within 10 days), 94 in the "Late" group (10-30 days), and 188 in the "No" group (no fungal colonization or infection within 30 days). In-hospital mortality and clinical outcomes were compared across groups.

RESULTS

Patients in the "Early" group received higher cumulative corticosteroid doses, had lower PaO2/FiO2 ratios, and exhibited higher rates of comorbidities, cytomegalovirus viremia, and lung, heart, and kidney complications. They also had a longer duration of ventilator use, ICU stay, and total hospitalization compared to the "Late" and "No" groups. Time-dependent multivariate Cox regression analysis identified the "Early" phenotype as a strong predictor of in-hospital mortality (adjusted hazard ratio [aHR]= 3.992, 95 % CI: 2.676-5.956, p < 0.001). Additional independent risk factors included Charlson Comorbidity Index (aHR = 1.213, 95 % CI: 1.113-1.323, p < 0.001) and APACHE II score (aHR = 1.028, 95 % CI: 1.011-1.045, p = 0.001). In contrast, higher PaO2/FiO2 ratios (aHR = 0.998, 95 % CI: 0.997-1.000, p = 0.021) and ganciclovir use (aHR = 0.419, 95 % CI: 0.245-0.717, p = 0.002) were associated with reduced mortality.

CONCLUSIONS

"Early" fungal colonization and infection within 10 days of corticosteroid initiation is an independent risk factor for in-hospital mortality in mechanically ventilated COVID-19 patients. Future research should explore early intervention strategies, including antifungal prophylaxis, optimized corticosteroid dosing, and immune modulation, to improve survival outcomes.

In Vitro Evaluation of Liposomal Amphotericin B Adsorption With Different Hemofilters for Continuous Hemofiltration

BACKGROUND

Fungemia is an infectious disease with a poor prognosis. Continuous hemofiltration (CHF) is widely used for the treatment of acute kidney injury associated with fungemia. However, the effect of hemofiltration membranes for CHF on antifungal drug concentrations remains poorly understood. Therefore, clarifying the adsorption of antifungal drugs onto these membranes is important. We investigated the adsorption properties of liposomal amphotericin B on different hemofiltration membranes using closed-circulation hemofiltration.

METHODS

We performed hemofiltration with each solution adjusted to liposomal amphotericin B as a closed circulatory circuit using polyacrylonitrile (AN69ST), polymethyl methacrylate (PMMA), and polysulfone (PS) membranes. Only this circuit was used as a control. Amphotericin B concentration at the inlet and in the effluent of the hemofiltration membrane was measured. The adsorption rate (Ra) of amphotericin B was then calculated.

RESULTS

The concentration of amphotericin B decreased in the PS membranes compared to that in the controls after 15 min (p = 0.03). The Ra of amphotericin B was higher in PS membranes than in the controls (p = 0.02). Amphotericin B was not adsorbed onto the PMMA or AN69ST membranes. The concentration of amphotericin B in these membranes showed no change compared with that in the control after 1440 min. Liposomal amphotericin B was temporarily absorbed on PS membranes, but at clinical doses, it did not appear to affect the antifungal doses.

CONCLUSIONS

Different blood purification membranes can be used to treat CHF without affecting the administration of antifungal drugs.

Clinical and Microbiologic Outcomes of Antifungal Lock-based Catheter Salvage in Pediatric Candidal CLABSI

We report a retrospective review of pediatric candidal central line-associated bloodstream infections (N = 145) with antifungal lock therapy-based catheter salvage. Rates of recurrence (6%) and mortality (5%) were low at 28 days. At 1 year, earlier catheter removal was associated with lower recurrence rates (21% vs. 45%, P = 0.005), but no significant difference in mortality (13% vs. 5%).

Acquired Amphotericin B Resistance Attributed to a Mutated ERG3 in Candidozyma auris

First identified in 2009, Candidozyma auris (formerly Candida auris ) is an emerging multidrug resistant fungus that can cause invasive infections with a crude mortality rate ranging from 30-60%. Currently, 30-50% of C. auris isolates are intrinsically resistant to amphotericin B. In this work, we characterized a clinical case of acquired amphotericin B resistance using whole genome sequencing, a large-scale phenotypic screen, comprehensive sterol profiling, and genotypic reversion using CRISPR. Data obtained in this work provides evidence that a deletion resulting in a frameshift in ERG3 contributes to the observed resistant phenotype. Characterization of this isolate also revealed a fitness cost is associated with the abrogation of ergosterol production and its replacement with other late-stage sterols. This article presents a clinical case description of amphotericin B resistance from a frameshift mutation in ERG3 in C. auris and marks an advancement in the understanding of antifungal resistance in this fungal pathogen.

Anti-Candida Activity of Cysteine-Modified Amidated Decoralin in the Presence of Engineered Nanomaterials

Background: Candidiasis remains a chief concern in global healthcare. Drug safety issues and increasing resistance make it urgent to develop alternative antifungal agents, namely antimicrobial peptides. Amidated decoralin (Dec-CONH2) possesses considerable anti-Candida activity, and its association with nanocarriers could help in enhancing efficacy while reducing intrinsic toxicity to the host. Methods: We studied an N-terminal cysteine-modified version of the peptide (Cys-Dec-CONH2) and screened the effects of different nanosystems (polymeric nanoparticles (NPs), liposomes and gold NPs) on its activity against azole-sensitive and azole-resistant Candida species using a clinically relevant in vitro assay. Results: The antifungal activity of Cys-Dec-CONH2 was maintained (minimum inhibitory concentration (MIC) = 16-64 µg/mL), but the presence of poly(d,l-lactic-co-glycolic acid) (PLGA)- and polycaprolactone-based NPs impaired the antifungal effect of the peptide (MIC > 256 µg/mL). This effect was milder for polystyrene-based NPs, liposomes, and gold NPs (MIC ≤ 128 µg/mL). Additionally, the covalent surface functionalization of PLGA-based NPs with Cys-Dec-CONH2 or the presence of relevant biomolecules (albumin and mucin) resulted in complete inhibition of antifungal activity. Conclusions: Our data suggest that Cys-Dec-CONH2 is able to establish strong interfacial interactions with different nanomaterials, which need to be considered when developing nanomedicines based on this peptide for the management of candidiasis.

Fluconazole step-down therapy versus echinocandins for the treatment of Candida glabrata invasive candidiasis with candidaemia

OBJECTIVES

Candida glabrata is the second most common species responsible for invasive candidiasis, including candidaemia. Echinocandins are typically the first-line therapy for C. glabrata candidaemia, with the option to transition to oral fluconazole. Studies are needed to evaluate clinical outcomes in patients initially treated with echinocandins then transitioned to fluconazole.

METHODS

This was a retrospective, single-centre cohort study of patients with C. glabrata candidaemia from November 2011 to August 2023. Inpatients aged 18-89 years who received an echinocandin within 24 h of the initial positive blood culture were included. Patients were excluded if they received antifungal treatment less than 48 h, combination therapy, or fluconazole as initial therapy. The primary composite outcome was 30-day clinical failure.

RESULTS

A total of 186 patients were included (n = 153 echinocandin only; n = 33 fluconazole step-down). The most common source of candidaemia was line-associated in both groups with the majority having source control (43% echinocandin versus 58% fluconazole; P = 0.32). Compared to fluconazole, patients in the echinocandin group had a higher rate of concomitant bacteraemia (45% versus 24%; P = 0.03) and endovascular complications (11% versus 0%; P = 0.05). There was no significant difference in treatment duration between echinocandin and fluconazole (16 versus 19 days; P = 0.46), incidence of persistent candidaemia (22% versus 24%; P = 0.7), or 30-day clinical failure (15% versus 9%; P = 0.58).

CONCLUSIONS

Fluconazole appears to be a safe and reasonable step-down therapy in the management of C. glabrata candidaemia.

Emergency medicine updates: Management of sepsis and septic shock

INTRODUCTION

Sepsis is a common condition associated with significant morbidity and mortality. Emergency physicians play a key role in the diagnosis and management of this condition.

OBJECTIVE

This paper evaluates key evidence-based updates concerning the management of sepsis and septic shock for the emergency clinician.

DISCUSSION

Sepsis is a life-threatening syndrome, and rapid diagnosis and management are essential. Antimicrobials should be administered as soon as possible, as delays are associated with increased mortality. Resuscitation targets include mean arterial pressure ≥ 65 mmHg, mental status, capillary refill time, lactate, and urine output. Intravenous fluid resuscitation plays an integral role in those who are fluid responsive. Balanced crystalloids and normal saline are both reasonable options for resuscitation. Early vasopressors should be initiated in those who are not fluid-responsive. Norepinephrine is the recommended first-line vasopressor, and if hypotension persists, vasopressin should be considered, followed by epinephrine. Administration of vasopressors through a peripheral 20-gauge or larger intravenous line is safe and effective. Steroids such as hydrocortisone and fludrocortisone should be considered in those with refractory septic shock.

CONCLUSION

An understanding of the recent updates in the literature concerning sepsis and septic shock can assist emergency clinicians and improve the care of these patients.

Central venous access Port-Related blood stream infection caused by Cyberlindnera fabianii: A case report and literature review

Cyberlindnera fabianii, an ascomycetous yeast, is a rare human pathogen. Here, we describe the first reported case of central venous (CV) access port-related blood-stream infection caused by C. fabianii. An 80-year-old Asian man presented to our department with a mass in the pancreas. A diagnosis of pancreatic cancer (cT4N0M0, cStage III) was made. A catheter with CV access port was inserted, and anticancer chemotherapy and radiotherapy was initiated. One year after the first visit, he was urgently admitted to our hospital due to recurrent hematemesis. On day 37, organism cultures of the blood and catheter tip were positive for Candida pelliculosa by the BD PHOENIX™ 100 system. On the basis of these findings, CV port-related blood-stream infection caused by C. pelliculosa was diagnosed, and treatment with micafungin (MCFG) was initiated. On day 51, the blood culture converted to negative. On day 65, MCFG was stopped. The cultured strain was sent to reference laboratory where Cyberlindnera fabianii was identified by MALDI-TOF mass spectrometry and direct sequencing of the internally transcribed spacer region. The present case report describes the first known case of CV access port-related blood-stream infection caused by C. fabianii. MCFG was successfully used to treat the fungemia caused by C. fabianii. Although the incidence of uncommon yeast species causing human infections has gradually increased in recent years, conventional biochemical methods may offer limited usefulness for identifying these rare organisms. Accordingly, MALDI-TOF mass spectrometry or molecular assays may be required to identify these uncommon fungal species.

Systematic Review of the Presentation, Treatment, and Outcome of Chronic Disseminated Candidiasis in Children With Cancer or Following Hematopoietic Cell Transplant

Chronic disseminated candidiasis (CDC) is a rare complication of immunosuppression. This review describes the presentation, management, and outcomes of CDC in pediatric patients with cancer or following hematopoietic cell transplant (HCT). PubMed, Embase, and Medline were searched identifying 32 studies, describing 95 cases of CDC. CDC occurred almost exclusively in patients with leukemia (91%), with only 5% occurring in lymphoma, 1% post HCT, and 3% in solid tumor. The most frequent presenting symptoms were fever (97%) and abdominal pain (45%), with lesions in liver in 63% and spleen in 54% (less common in kidney, lungs and skin/soft tissue). Of the 67 (71%) episodes with microbiological confirmation, Candida tropicalis (28%) was the most common causative species. Antifungal treatment durations varied from 14 days to 28 months. Additionally, 31 (33%) patients received an adjuvant therapy, the most common being corticosteroids. Mortality, directly attributable to CDC, occurred in nine (9%). There remains insufficient data to guide a unified approach to management.

1-Minute Pearls/Pitfalls for the Clinician

This article explores important insights and potential challenges in managing patients with candidemia and prolonged QTc. It also offers guidance on managing patients with VTE and prolonged APTT.

Association of doses based on body constitutional parameters with the efficacy of micafungin in candidemia

BACKGROUND

Invasive candidiasis is a life-threatening infection associated with high mortality, necessitating early and effective treatment. Micafungin, an echinocandin, is recommended as initial therapy for invasive candidiasis. However, the optimal micafungin dose relative to patients' body constitutional parameters (BCPs) remains unclear. This study aimed to evaluate the relationship between the dose of micafungin per BCPs (Dose/BCPs) and treatment outcomes.

METHODS

This two-center retrospective study included patients treated with micafungin who had confirmed positive blood cultures for Candida species between January 1, 2010, and December 31, 2020. We assessed the association between Dose/BCP and treatment success, as well as time to recovery following micafungin therapy.

RESULTS

Eighty-three patients were included in the analysis, with a median age of 78 years. The primary isolated Candida species were Candida albicans (n = 34), Candida parapsilosis (n = 19), and Candida glabrata (n = 16). The treatment success rate was 44.6 % and was significantly associated with age ≥75 years. Although no significant differences in Dose/BCP were observed between the success and failure groups, patients with a Dose/BSA ≥100 mg/m2 experienced a significantly shorter time to recovery with micafungin therapy.

CONCLUSION

Our study identified an association between Dose/BSA and the time to recovery with micafungin therapy. While some missing data, including APACHE-II scores, limit the robustness of the findings because of the retrospective design, dose adjustment to achieve Dose/BSA ≥100 mg/m2 may be beneficial in antifungal stewardship. This adjustment could reduce treatment duration with this broad-spectrum antifungal agent.

Fungal Infections in People Who Use Drugs

Illicit drug use in the United States continues to rise, alongside an increasing number of severe infections associated with drug use. Surveillance studies report that 28%-34% of candidemia cases are linked to intravenous drug use, with Candida albicans being the most commonly isolated species, followed by Candida parapsilosis and Candida glabrata. Marijuana use is associated with lung infections caused by Aspergillus and the Mucorales, showing a 3.5-fold increased risk of mold infections and a 2.2-fold increased risk for other fungal infections. Intravenous drug use also presents a recognized risk factor for Aspergillus and Mucorales infections. Additionally, substances like cannabis, methamphetamines, and opioids share metabolic pathways with triazoles, a class of antifungal, and terbinafine through the CYP enzyme system. These antifungal drugs strongly inhibit CYP3A4 and CYP2D6, leading to potential drug interactions, adverse effects, overdose risks, and even death.

It's Here, It's There, There's Fungi Everywhere: A Case Series Utilizing Rezafungin for Invasive Candidiasis

Rezafungin is a long-acting echinocandin with broad coverage against Candida. Rezafungin has primarily been indicated for candidemia, with limited literature available on its use for infections outside of the bloodstream. Herein, three patient cases are presented from an academic medical center. Infectious processes presented include drug-resistant mucosal candidiasis, prosthetic joint infection, and candidemia involving Candida auris. In all three cases, patients received rezafungin. Clinical response was demonstrated in all patients as was tolerability of rezafungin. Together these cases provide further evidence for the use of rezafungin, including its use for treatment of invasive infections other than candidemia.

Silver secnidazole nano-hybrid emulsion-based probiotics as a novel antifungal formula against multidrug-resistant vaginal pathogens

This study presents a novel approach to manage vaginal infections due to Candidiasis, utilizing a novel silver secnidazole nano-hybrid emulsion (Ag-Secn-NHE)-based probiotics and free Ag-Secn-NHE. Ag-Secn-NHE was prepared by simple homogenization‒ultrasonication technique and validated by using a ultraviolet‒visible scan, dynamic light scattering, transmission electron microscopy (TEM), Fourier-transform infrared spectroscopy, and zeta potential. Saccharomyces cerevisiae (RCMB 002Y001) is the most effective probiotic-producing organism that demonstrates significant effects when combined with Ag-Secn-NHE. Ag-Secn-NHE-based probiotics showed significant antifungal effect compared to free Ag-Secn-NHE, silver nitrate, silver nanoparticles, secnidazole, secnidazole nanoemulsion, and commercial vaginal wash against multidrug-resistant vaginal pathogens. The highest inhibitory effect was achieved with Ag-Secn-NHE-based probiotic against Candida auris, Candida albicans, and Cryptococcus neoformans with minimal inhibitory concentration (MIC) 0.625 ± 0.002, 0.00625:1.25 ± 0.012 and 0.00625:1.25 ± 0.032 mg/mL, respectively, in comparison with Ag-Secn-NHE that show MIC at 0.00625:1.25 ± 0.612, 0.0125:2.5 ± 0.812, and 0.0125:2.5 ± 0.112 mg/mL (Ag:Secn). Ag-Secn-NHE-based- probiotic show minimum fungicidal concentration (MFC) at range from 2.5 to 20 mg/mL, wherever free Ag-Secn-NHE show MFC range from 5 to >20 mg/mL. Additionally, Ag-Secn-NHE-based probiotics have 75% inhibition of biofilm formation against C. auris and 60% inhibition of biofilm formation against both Cryptococcus neoformans and C. albicans in comparison with free Ag-Secn-NHE. Time-kill curves showed that the antifungal effect of Ag-Secn-NHE-based probiotics was fungistatic at 2MIC value after 4 h and after 16 h for Ag-Secn-NHE. TEM photographs showed that C. auris cells treated with Ag-Secn-NHE-based probiotic formula revealed severe deformations and distored ultrastructural changes. furthermore, results indicated that the Gamma radiation up to 15 kGy increases production of Ag-Secn-NHE in comparison with non-irradiated one.

Efficacy of Low-Dose Fluconazole for Primary Prophylaxis of Invasive Candida Infections in Patients With Acute Leukemia: A Double-Blind Randomized Clinical Trial

BACKGROUND

Invasive fungal infections (IFIs), particularly Candida infections, are a significant cause of morbidity and mortality in patients with acute leukemia. While fluconazole is widely used for prophylaxis, the optimal dosing regimen remains uncertain. This study aimed to evaluate the efficacy of low-dose fluconazole for primary prophylaxis against invasive Candida infections in patients with acute leukemia receiving intensive chemotherapy.

METHODS

A double-blind, randomized clinical trial was conducted with patients diagnosed with acute leukemia. Patients were assigned to receive either low-dose (150 mg/day) or standard high-dose (400 mg/day) fluconazole for primary prophylaxis against invasive Candida infections during intensive chemotherapy. The primary outcomes were the efficacy of antifungal prophylaxis and the safety profile.

RESULTS

A total of 120 patients (60 per group) were enrolled. The overall incidence of Candida infections was similar between the groups (p = 0.615). Candida colonization was higher in the low-dose fluconazole group during the first week, particularly with non-albicans Candida at oral and subaxillary sites (p < 0.001). However, by the third week, both groups showed a significant decline in colonization, with the reduction in the oral cavity being statistically significant (p = 0.03). Aspergillosis occurred in 38.3% of patients, with no significant difference between groups (p > 0.99). Adverse events were similar in both groups (p > 0.05).

CONCLUSION

Low-dose fluconazole is an effective alternative to high-dose regimens for preventing Candida infections in acute leukemia patients, with similar efficacy and safety. The rising threat of aspergillosis highlights the need for targeted prophylaxis. Further research is needed to refine strategies for high-risk patients.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT) number: IRCT20140818018842N37.

Bloodstream infections: mechanisms of pathogenesis and opportunities for intervention

Bloodstream infections (BSIs) are common in hospitals, often life-threatening and increasing in prevalence. Microorganisms in the blood are usually rapidly cleared by the immune system and filtering organs but, in some cases, they can cause an acute infection and trigger sepsis, a systemic response to infection that leads to circulatory collapse, multiorgan dysfunction and death. Most BSIs are caused by bacteria, although fungi also contribute to a substantial portion of cases. Escherichia coli, Staphylococcus aureus, coagulase-negative Staphylococcus, Klebsiella pneumoniae and Candida albicans are leading causes of BSIs, although their prevalence depends on patient demographics and geographical region. Each species is equipped with unique factors that aid in the colonization of initial sites and dissemination and survival in the blood, and these factors represent potential opportunities for interventions. As many pathogens become increasingly resistant to antimicrobials, new approaches to diagnose and treat BSIs at all stages of infection are urgently needed. In this Review, we explore the prevalence of major BSI pathogens, prominent mechanisms of BSI pathogenesis, opportunities for prevention and diagnosis, and treatment options.

Progressive Severe Hemophagocytic Syndrome due to Disseminated Histoplasmosis in a Patient with HIV-1 Infection

Histoplasmosis is caused by Histoplasma capsulatum and is prevalent in areas of the world where H. capsulatum is endemic. We herein report a patient diagnosed with human immunodeficiency virus-1 (HIV-1) who developed histoplasmosis from a non-H. capsulatum endemic area who experienced severe hemophagocytic syndrome due to a delayed diagnosis. The patient's symptoms emerged four years after residing in regions with a high histoplasmosis prevalence. The unrestricted administration of antifungal medication for oral candidiasis delayed the diagnosis because it improved the patient's condition. This case underscores the importance of prudent antifungal drug use in undiagnosed disseminated conditions and evaluating the travel history going back several years to facilitate a diagnosis.

The Impact of Maternal Antibiotic Consumption on the Development of Oral Thrush Infection in Breastfeeding Infants: A Quasi-Experimental Study

Background: Oral thrush is a common yeast infection caused by Candida albicans in infants during their first few weeks or months. Infant mothers' antibiotics consumption can contribute to this opportunistic fungal growth due to their weaker immune systems. Objectives: To investigate the relationship between maternal antibiotic consumption and oral thrush infection in breastfeeding infants, this study aims to provide insights for health care professionals regarding antibiotic prescriptions and preventive strategies for managing oral thrush. Methods: A quasi-experimental design with a control group was used. Eighty-two breastfeeding infants were divided into two groups: Group 1 (n = 40) infants of antibiotic-consuming mothers and Group 2 (n = 42) infants of nonantibiotic-consuming mothers. The oral samples were collected using sterile cotton swabs and cultured on Sabouraud's dextrose agar C. albicans, confirmed by simple staining and a germ tube test. Results: Infants aged 1-11 months with a mean ± standard deviation of 4.8 ± 3.51. Within all 82 oral swabs, 42.7% were positive for C. albicans growth and 57.3% were negative. The highest percentage was in 1-month-old infants (n = 9, 25.71%), and the lowest was in 11 months old (n = 2, 5.71%). Group 2 infants had significantly fewer positive C. albicans growth (n = 12, 28.57%) compared with group 1 (n = 23; 57.5%) (χ2 = 7.0, p = 0.007; odds ratio = 3.332, 95% confidence interval = 1.35-8.46). Oral thrush clinical signs were identified in 66.6% and 33.4% of group 1 and 2 infants, respectively, while 31.4% of C. albicans-positive colonization showed no clinical manifestations. Conclusion: Maternal antibiotic consumption for more than 1 week is associated with the occurrence of oral thrush in breastfeeding infants. Differences in clinical signs in two groups of infants indicate the importance of laboratory tests for early oral thrush diagnosis. This can help health care professionals understand oral thrush causes, enable early detection, improve treatment, and enhance appropriate antibiotic use in breastfeeding mothers.

Optimizing fluconazole dosing in acute renal failure patients undergoing continuous renal replacement therapy: A population pharmacokinetic/pharmacodynamic study

Fluconazole pharmacokinetics in acute renal failure (ARF) patients undergoing continuous renal replacement therapy (CRRT) are significantly influenced by the combined effects of impaired renal function and CRRT, yet current dosing guidelines do not account for these complexities, leading to suboptimal therapy and treatment failure. This study aimed to address these limitations by developing a population pharmacokinetic model for fluconazole in ARF patients receiving CRRT, evaluating guideline-recommended dosing regimens for pharmacokinetic/pharmacodynamic target attainment, and then developing software to optimize fluconazole dosing in complex clinical CRRT scenarios. A total of 297 literature-sourced plasma concentration data points from 15 ARF patients and one patient with normal renal function, all receiving CRRT, were used for model construction. The treatment target was set as the 24-h area under the free drug concentration-time curve to the minimum inhibitory concentration ratio ≥100. The web application was developed using R and R packages. The final pharmacokinetic model comprised a central and CRRT compartment, with renal failure and CRRT doses influencing clearance and body weight affecting central compartment distribution volume. Simulations revealed that the guideline-recommended loading (800 mg or 12 mg/kg QD) and maintenance doses (400 mg or 6 mg/kg QD) achieved limited target attainment at low CRRT doses and failed at moderate to high CRRT doses. Consequently, dose adjustments based on body weight and CRRT parameters are recommended. A user-friendly, visual, and interactive Shiny application was developed to assist clinicians in optimizing fluconazole dosing in this challenging patient population.

Invasive Candidiasis in the Intensive Care Unit: Where Are We Now?

Invasive fungal infections in the intensive care unit (ICU) are not uncommon and most cases are caused by Candida species, specifically Candida albicans. However, recently, there has been an increase in non-albicans Candida spp. (C. glabrata; C. parapsilosis) causing invasive fungal infections. This has led to an increasing awareness of this infection due to the increase in documented antifungal resistance in many of these Candida species. In addition, manifestations of invasive candidiasis are often non-specific, and the diagnosis remains extremely challenging. Unfortunately, delays in antifungal therapy continue to hamper the morbidity; length of stay; and the mortality of these infections. Although the echinocandins are the drugs of choice in these infections, antifungal resistance among the non-albicans species (C. glabrata; C. krusei; C. auris; C. parapsilosis) is being observed more frequently. This has led to an increase in morbidity and mortality, specifically in critically ill patients. Overall, the diagnosis and management of invasive candidiasis in the ICU remain challenging. It is imperative that the critical care physician keeps this infection at the forefront of their differential diagnosis in order to decrease the mortality rate of these individuals. In this review, we discuss the current epidemiologic trends, diagnosis, and management of invasive candidiasis in the intensive care unit setting.

Clinical significance of nosocomial Trichosporon asahii in urine: A retrospective cohort study

OBJECTIVES

To describe the clinical characteristics and outcomes of patients with urine cultures positive for Trichosporon sp with nosocomial acquisition.

METHODS

Retrospective cohort study between 2019 and 2023 that included all patients with urinary isolates of Trichosporon sp; their clinical data and outcomes were drawn from medical records.

RESULTS

Twenty-six patients had urinary Trichosporon asahii. Length of hospital stay before urinary culture with T. asahii averaged 25 days. Seventy percent stayed in the intensive care unit. All patients had an additional bacterial infection and were receiving antibiotic therapy. During the first 30 days, only 57 % were alive. There were no factors significantly associated with mortality.

CONCLUSIONS

The isolation of T. asahii in urine cultures of patients with extended hospital stay does not suggest invasive disease. T. asahii in urine may be a marker of critically ill patients with a high risk of mortality.

Biofilm-Associated Candidiasis: Pathogenesis, Prevalence, Challenges and Therapeutic Options

The rising prevalence of fungal infections, especially those caused by Candida species, presents a major risk to global health. With approximately 1.5 million deaths annually, the urgency for effective treatment options has never been greater. Candida spp. are the leading cause of invasive infections, significantly impacting immunocompromised patients and those in healthcare settings. C. albicans, C. parapsilosis and the emerging species C. auris are categorized as highly dangerous species because of their pathogenic potential and increasing drug resistance. This review comparatively describes the formation of microbial biofilms of both bacterial and fungal origin, including major pathogens, thereby creating a novel focus. Biofilms can further complicate treatment, as these structures provide enhanced resistance to antifungal therapies. Traditional antifungal agents, including polyenes, azoles and echinocandins, have shown effectiveness, yet resistance development continues to rise, necessitating the exploration of novel therapeutic approaches. Antimicrobial peptides (AMPs) such as the anti-biofilm peptides Pom-1 and Cm-p5 originally isolated from snails represent promising candidates due to their unique mechanisms of action and neglectable cytotoxicity. This review article discusses the challenges posed by Candida infections, the characteristics of important species, the role of biofilms in virulence and the potential of new therapeutic options like AMPs.

Emergence of invasive candidiasis with multiple Candida species exhibiting azole and echinocandin resistance

Background

Invasive candidiasis (IC) is an increasingly common, expensive, and potentially fatal infection. However, IC caused by multiple Candida species is rarely reported in China. Herein, we revealed a complex IC caused by multiple Candida species, comprising the rare C. norvegensis, C. albicans, C. glabrata, and C. tropicalis. The resistance mechanism of azole and echinocandin resistance were explored further.

Methods

The isolates were confirmed using internal transcribed spacer (ITS) sequencing. The resistance mechanisms were investigated using PCR-based sequencing, quantitative real-time reverse transcription PCR, and rhodamine 6G efflux quantification.

Results

Antifungal susceptibility testing showed this complex infection was associated with cross-resistance to azole and echinocandin drugs. For C. glabrata, the acquired echinocandin resistance was likely caused by a novel mutational pattern (1,3-beta-D-glucan synthase subunits FKS1-S629P and FKS2-W1497stop) while the acquired azole resistance in C. glabrata RJ05 was related to complex mechanisms including enhanced efflux activity, pleiotropic drug resistance 1 (PDR1) mutation, and increased expression of Candida drug resistance 1 (CDR1) and CDR2. Additionally, the azole resistance of C. tropicalis was caused by two lanosterol 14-alpha demethylase (ERG11) mutations: Y132F and S154F.

Conclusion

Our study revealed a case of clinically complex, multiple Candida invasive infections, further uncovering the resistance mechanisms to azoles and echinocandins. These findings provide valuable references for the diagnosis and treatment of invasive candidiasis (IC) in clinical practice.

A Comprehensive Review of Candidemia and Invasive Candidiasis in Adults: Focus on the Emerging Multidrug-Resistant Fungus Candida auris

Candidemia and invasive candidiasis represent critical healthcare-associated fungal infections that pose substantial challenges to medical systems worldwide. These conditions arise when fungi from the Candida genus infiltrate the bloodstream or deeper tissues, leading to a range of clinical manifestations. Among the various species, Candida albicans continues to hold its position as the most frequently encountered causative agent, largely due to its prevalence and adaptability within human hosts. However, it is far from the only significant player; other Candida species, such as Candida glabrata, Candida parapsilosis, and the particularly concerning Candida auris, contribute significantly to the disease burden and exhibit varying dominance depending on geographic regions. The clinical presentation of these infections can differ widely, spanning from subtle, almost imperceptible symptoms in some patients to severe, life-threatening fulminant sepsis in others, often accompanied by alarmingly high mortality rates that underscore the urgency of effective management strategies. Several well-established risk factors predispose individuals to developing invasive candidiasis and candidemia. Breaches in the body's natural barriers-such as the skin (cutaneous) or the gastrointestinal (GI) tract-provide entry points for these opportunistic pathogens. Additionally, deficiencies in the host's immune responses, whether due to medical treatments, underlying diseases, or genetic predispositions, heighten vulnerability to infection. Among the diverse Candida species, Candida auris has emerged as an especially troubling entity in recent years. This multidrug-resistant species is notorious for its resistance to standard antifungal therapies, which complicates treatment efforts and contributes to elevated morbidity and mortality rates. Its rapid global spread has positioned it as a formidable public health threat, prompting heightened surveillance and research into its behavior and control.

Empirical versus pre-emptive antifungal therapies for invasive fungal infections in critically ill patients

BACKGROUND

The initiation strategy of antifungal therapy (AT) is among the most discussed practices for patients vulnerable to invasive fungal infections (IFI). In low-resource countries, there are also no appropriate consensus or guidelines for this issue. Given this clinical gap, we aimed to investigate the use of empirical and pre-emptive therapy in an Asian intensive care setting.

METHODS

We conducted a retrospective cohort study (timeframe 2019-2020) on critically ill adults receiving systemic antifungals for ≥ 3 days. The exposure was empirical or pre-emptive therapy of systemic antifungals. The primary outcome was IFI-related mortality (in percentage, including in-hospital death or discharge/transfer with death prognosis). The secondary outcomes included overall rationale of AT (in percentage) and length of AT (LoAT, in days). We used logistic and linear regression to investigate the outcomes and reported the estimates with the 95% confidence interval (95% CI).

RESULTS

During a median follow-up of 27 days, among 157 included patients (median age 68, 48.4% being female), we recorded 77 deaths (49.0% [95% CI 41.0-57.1%]) that were related to IFI (60 [51.7%] in the empirical group; 17 [41.5%] in the pre-emptive group; adjusted odds ratio of IFI-related mortality 1.86 [95% CI 0.74 to 4.63; p = 0.184]). The overall rationale of AT was at 45.2% (95% CI 37.2-53.4%; 41.4% [95% CI 32.3-50.9%] in the empirical group; 56.1% [95% CI 40.0-71.5%] in the pre-emptive group; adjusted odds ratio of receiving rational AT: 0.75 [95% CI 0.31 to 1.87]). The median LoAT was 8 days (IQR 6-14; 8 days [IQR 6-13.3] in the empirical group; 9 days [IQR 6-14] in the pre-emptive group; adjusted mean difference - 1.1 days [95% CI -3.2 to 1.0]).

CONCLUSION

Among critically ill patients on systemic antifungals for ≥ 3 days, the proportion of IFI-related mortality was high. The overall rationale of AT was at a low level, with the median LoAT lower than the generally recommended duration of at least 14 days. There were no significant differences in IFI-related mortality, overall rationale of AT, and LoAT between those receiving empirical and pre-emptive therapy.

CLINICAL TRIAL NUMBER

Not applicable.

Pharmacokinetic novelties of isavuconazole. Use in special situations

Isavuconazole, a next generation triazole, exhibits unique pharmacokinetic and pharmacodynamic properties that make it ideal for treating invasive fungal infections in critically ill and immunocompromised patients. This antifungal agent stands out for its broad spectrum of activity, which includes filamentous fungi such as Aspergillus and Mucorales, with an efficacy comparable to that of voriconazole and additional advantages against these pathogens. Its high oral bioavailability (close to 100%), prolonged half-life (>100h), and linear, predictable pharmacokinetic profile minimize the need for frequent dose adjustments and therapeutic monitoring. Its lipophilic structure facilitates penetration into key tissues, such as the central nervous system and pulmonary tissue, as validated by clinical studies showing survival rates exceeding 70% in patients with complicated invasive fungal infection. Its use is safe in populations with renal impairment, mild to moderate hepatic impairment, paediatrics, and obesity, although dose adjustment is recommended for severe hepatic impairment. Recent studies in critically ill patients undergoing extracorporeal membrane oxygenation or continuous renal replacement therapy have revealed moderate reductions in plasma concentration, without significant clinical impact. Adaptive dosing strategies have been proposed to optimize efficacy in these cases. Compared to other triazoles, isavuconazole demonstrates a robust safety profile, with lower incidences of hepatotoxicity and neurotoxicity. Its antifungal activity, favorable pharmacokinetics, and excellent safety profile underscore its role as a reference antifungal agent, particularly in challenging clinical scenarios.

Emerging Treatments in Neonatal Fungal Infections: Progress and Prospects

Fungal infections in neonates are potentially life threatening. The differential diagnosis for neonatal rashes is extensive, with common culprits including both bacteria and fungi. Candida albicans is the predominant fungal pathogen, causing infections that range from superficial disease to severe systemic conditions, including sepsis and meningitis. Neonates, especially those who are preterm, are particularly susceptible because of developmentally immature immune systems and the use of invasive procedures and devices in neonatal intensive care units. Congenital cutaneous candidiasis, acquired in utero or during delivery, can lead to disseminated infection with high mortality rates. Early diagnosis and prompt antifungal treatment are crucial but challenging because of subtle clinical presentations, making accurate identification of the offending organism essential for selecting the appropriate treatment. Candida species account for the majority of neonatal fungal infections, with different species necessitating distinct treatments because of varying susceptibility profiles. Aspergillus, another significant pathogen, poses high mortality risks and can present either cutaneously or systemically. Malassezia, though less common, primarily affects preterm infants with catheter-related fungemia. Other fungal species, including Zygomycetes, Trichosporon, and Cryptococcus, rarely produce neonatal infections but are noteworthy for consideration. Treatment of fungal infection is critical despite the relative paucity of information regarding the clinical pharmacology of many antifungal drugs in neonates. We review the major antifungal agents (e.g., amphotericin B, the echinocandins, the azoles) and provide pharmacologic and dosing information. Finally, preventive strategies, including the use of stringent aseptic techniques and careful clinical monitoring, are essential to mitigate both the incidence and severity of these infections in neonates and infants in the first months of life.

Improving Vaginal Health with a Zinc-Containing Vaginal Hydrogel

Vulvovaginal symptoms affect up to 39% of women. These symptoms have a significant impact on quality of life and are often linked to imbalances in the vaginal microbiota. This study evaluates the therapeutic efficacy of a zinc-containing hydroxyethyl cellulose-based hydrogel in 37 women with different vulvovaginal symptoms (itching, burning, irritation, pain, dryness, discharge, and odor). Over 12 weeks, participants applied the gel intravaginally with both assessments conducted at baseline and follow-ups. Results revealed substantial improvements in symptoms, including reductions in vaginal discharge, itching, and burning, as measured by the Vulvovaginal Symptom Questionnaire (VSQ-21), with scores decreasing from 10.78 ± 3.66 at baseline to 3.17 ± 4.16 at week 12 (p < 0.01). Vaginal Health Index (VHI) scores improved significantly, from 20.78 ± 1.74 at baseline to 23.64 ± 2.59 (p < 0.01). Cervicovaginal lavage (CVL) zinc levels decreased from 110 ± 102 µg/L at baseline to 62 ± 48 µg/L at week 4 (p < 0.01), increased to 80 ± 55 µg/L at week 8 (p = 0.04), and reached 99 ± 92 µg/L by week 12 (NS). A correlation analysis showed an inverse relationship between baseline CVL zinc levels and VSQ-21 scores (r = -0.3586, p = 0.034), while no significant correlation was observed with VHI scores (r = -0.0187, p = 0.9545). Vaginal pH levels decreased significantly, dropping from 4.03 ± 0.42 to 3.71 ± 0.48 (p < 0.01). These findings support the gel's role as an effective, nonhormonal, drug-free, and local adjunct treatment for a variety of vulvovaginal symptoms.

Impact of Fluconazole Resistance on the Outcomes of Patients With Candida parapsilosis Bloodstream Infections: A Retrospective Multicenter Study

BACKGROUND

This study assesses the impact of fluconazole resistance on 30-day all-cause mortality and 1-year recurrence in patients with Candida parapsilosis bloodstream infections (BSI).

METHODS

A multicenter retrospective study was performed at 3 hospitals in Italy and Spain between 2018 and 2022. Adult patients with positive blood cultures for C. parapsilosis who received appropriate targeted therapy with either echinocandins or fluconazole were included.

RESULTS

Among 457 patients, 196 (42.9%) had fluconazole-resistant C. parapsilosis (FLZR-CP) BSI and 261 (57.1%) had fluconazole-susceptible C. parapsilosis (FLZS-CP) BSI. All FLZR-CP patients received targeted echinocandins, while FLZS-CP patients received either echinocandins (60.5%) or fluconazole (39.5%). Unadjusted 30-day all-cause mortality rates were 28.6% for FLZR-CP and 28.4% for FLZS-CP (log-rank test, P = .998). In multivariable analysis, increased mortality was associated with age (adjusted hazard ratio [aHR] 1.03 per year; 95% confidence interval [CI], 1.01-1.05; P = .0005), solid tumor (aHR 1.91; 95% CI, 1.06-3.46; P = .0302), previous antifungal treatment (aHR 1.84; 95% CI, 1.12-3.10; P = .0192), and septic shock (aHR 2.39; 95% CI, 1.42-4.06; P = .0010), but not fluconazole resistance (aHR 1.00; 95% CI, .62-1.63; P = .9864) nor the type of initial antifungal therapy (aHR 1.46; 95% CI, .69-3.06; P = .3202). Propensity score-matched analysis showed no 30-day all-cause mortality difference between echinocandin-treated FLZR-CP and fluconazole-treated FLZS-CP patients (HR 0.81; 95% CI, .37-1.75; P = .5915). However, a higher 1-year recurrence risk was observed in FLZR-CP patients (odds ratio, 7.37; 95% CI, 2.11-25.80; P = .0018).

CONCLUSIONS

Our results suggest that fluconazole resistance is not associated with a higher mortality risk in patients with C. parapsilosis BSI, though 1-year recurrence rates were higher in the FLZR-CP group.

Antibacterial and Antifungal Properties of New Synthetic Tricyclic Flavonoids

Background/Objectives: The discovery of new molecules to which bacteria have not yet developed resistance is a significant medical priority. Synthetic flavonoids are good candidates for developing new antimicrobials. Our study investigates a series of newly synthesized tricyclic flavonoids with several different substituents on the flavonoid core. Methods: By varying the nature of the substituents on rings A and B, a structure-activity relationship study using different microbial strains has been performed. The antibacterial and antifungal properties of these compounds have been investigated against Gram-positive and Gram-negative bacteria and several Candida strains. Results: All seven tested compounds have been found to exhibit the highest antimicrobial activity against S. aureus, with an inhibition zone of up to 23 mm. The tricyclic flavonoids 5c, 5e, and 5f showed good antifungal properties against C. parapsilosis, with an inhibition zone of around 17 mm. Conclusions: All the data support the idea that flavonoids 5 are reliable candidates for developing effective antimicrobial agents.

Endogenous Fungal Endophthalmitis in a Patient After Fetal Reduction Surgery With a Literature Review: A Case Report

Endogenous fungal endophthalmitis (EFE) is a rare but severe ophthalmic emergency that often results in vision-threatening complications and, in extreme cases, can be life-threatening. This report presents a successfully treated case of fungal endophthalmitis, offering insights into clinical management. A 35-year-old female experienced decreased vision in her right eye following fetal reduction surgery. Her best-corrected visual acuity was limited to 10 cm finger counting in the affected eye. Following systemic antifungal therapy combined with vitrectomy, her vision recovered significantly. Through a detailed case analysis and literature review, this study aims to guide clinical practice. In patients with suspected EFE, obtaining early vitreous samples for pathogen identification and initiating timely treatment is critical. Furthermore, early vitrectomy during disease progression, along with an appropriate dosage and duration of antifungal therapy, is essential for restoring visual function and preventing vision loss.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

Vitreoretinal Involvement in Patients With Fungemia at a Tertiary Care Hospital

Purpose: To identify the prevalence of fungal ophthalmic involvement and evaluate risk factors for positive screening for inpatients at an academic tertiary care hospital by assessing a priori screening criteria that may determine which patients need ophthalmic evaluation. Methods: This retrospective cohort study comprised patients with a documented positive blood culture for fungemia and an ophthalmic screening examination from January 1, 2015, to September 30, 2019. Ophthalmology notes and laboratory results taken during admission were evaluated. The primary outcomes were ocular involvement, presence of visual complaints, and duration of blood culture positivity. Variables assessed included recent gastrointestinal surgery, organ transplantation, HIV infection, diabetes mellitus, intravenous drug use, and central venous access. Analyses, including the Student t test, χ2 test, and logistic regression, were performed. Results: Of 291 patients with fungemia, 7 had ocular involvement (3 with chorioretinitis; 4 with endophthalmitis). One patient with endophthalmitis required an intravitreal antifungal injection. No patient with chorioretinitis required injections or surgery. The mean culture positivity length was 5 days for those with vitreoretinal involvement and 4 days for those without vitreoretinal involvement (P > .05). Of patients with ocular involvement, 40.0% had a visual complaint compared with 4.2% without ocular involvement (P < .05). The negative predictive value was 99.3% for patients without complaints or persistent fungemia. Conclusions: Patients with visual complaints at the time of a positive blood culture for fungemia are at risk for ocular disease and require screening.

Fungal arthritis

Fungal arthritis is a rare infection with a global distribution that affects neonates, the elderly, and immunocompromised individuals, resulting in severe outcomes. It presents a challenge for healthcare professionals due to its rarity, lack of characteristic features, and difficulty isolating and identifying responsible organisms. Studies on their pathophysiology and treatment have been limited, and evidence-based treatment options are lacking. The pathogens infect through direct inoculation, extension from adjacent infective foci, or distant dissemination via the bloodstream. Typically, it manifests as either monoarthritis or oligoarthritis, with the knee joint being the most common target. Systemic disease is often absent, while pulmonary and cutaneous diseases are the most frequent extra-articular manifestations. Diagnosis frequently necessitates the direct visualisation of the organism in specimens and cultures of synovial fluid and membranes. A combination of medical (antifungal) and surgical treatments is often required.

Candida auris: A Continuing Threat

Candida auris is a World Health Organization critical-priority fungal pathogen that has variable resistance to antifungal treatments. Multiple clades have been identified through genomic analysis and have appeared in different geographic locations simultaneously. Due to a combination of factors including antifungal resistance, ability to colonize and persist in the environment, and thermotolerance, it can thrive. Infected patients are associated with a high mortality rate, especially those with multiple health risk factors like those associated with other Candida species. This review highlights the current situation of this pathogen to help provide guidance for future work.

A 10-Year Study of Neonatal Sepsis from Tuen Mun Hospital, Hong Kong

BACKGROUND

Neonatal sepsis is a major cause of infant mortality, and it accounts for a significant consumption of antimicrobials in paediatrics. This is the first comprehensive study on neonatal sepsis in Hong Kong.

METHODS

From 2014 to 2023, all neonates admitted to a single institution with culture-proven infections from the blood and/or cerebrospinal fluid were selected and reviewed retrospectively. The infecting organisms, their antibiotic nonsusceptibility pattern, and the concordance of empirical antimicrobial therapy with the microbiological profiles were described and were further compared between infants of normal/low birth weight (≥1.5 kg) and very low/extremely low birth weight (<1.5 kg), early-onset sepsis (<72 h), and late-onset sepsis (4-28 days), the first and the second 5-year periods (2014-2018 vs. 2019-2023).

RESULTS

After contaminants were excluded, there were 118 affected neonates with 125 organisms identified. Fifty-nine were male. Thirty-four were very low/extremely low birth weight infants, and twenty-eight infants had early-onset sepsis. Patient demographics and the microbiology findings did not differ between the first 5 years and the latter 5 years. However, the incidence of neonatal sepsis was significantly lower in the latter 5 years (3.23 vs. 1.61 per 1000 live births, p < 0.001), the period that coincided with the COVID-19 pandemic. Escherichia coli was the most common Gram-negative pathogen. Streptococcus agalactiae and Streptococcus bovis group infections were more common in early-onset sepsis, while coagulase-negative Staphylococcus and non-E. coli Gram-negative pathogens were more likely to occur in late-onset sepsis. In very low/extremely low birth weight infants, the rate of cefotaxime or ceftriaxone nonsusceptibility among Gram-negative isolates was higher (p = 0.01), and concordance of empirical antimicrobial therapy was lower (p = 0.006).

CONCLUSIONS

Management of neonatal sepsis remains challenging, and there is a need for optimising antimicrobial therapy, especially in preterm patients. Antepartum screening with intrapartum antibiotic prophylaxis is effective in reducing the risk of early-onset sepsis associated with S. agalactiae, while stringent infection control measures are important for the prevention of late-onset sepsis.

Epidemiology and Clinical Features of Candida Bloodstream Infections: A 10-Year Retrospective Study in a Korean Teaching Hospital

Candida species are major pathogens of bloodstream infections (BSIs) in hospitalized patients, with high mortality. This study examined Candida species distribution, clinical characteristics, and the mortality of patients with Candida BSIs. Adult patients (≥16 years) with Candida BSIs at a teaching hospital (2014-2023) were retrospectively reviewed. Over 10 years, 487 Candida isolates were obtained from 462 patients. C. albicans was the most frequent (38.2%), followed by C. glabrata (21.1%), C. parapsilosis (20.5%), and C. tropicalis (13.3%). The annual incidence of Candida BSIs remained stable (p = 0.525). However, non-albicans species BSIs increased 1.61-fold compared to C. albicans (95% CI: 1.19-2.19, p = 0.002). Fluconazole-non-susceptible Candida isolates increased after 2021 (p = 0.040). The overall 30-day mortality was 40.6%. In the multivariate analysis, a high Charlson comorbidity index (aHR: 1.20, 95% CI: 1.07-1.35, p = 0.001) and high SOFA score (aHR: 1.12, 95% CI: 1.02-1.23, p = 0.022) were the strongest predictors of 30-day mortality. Meanwhile, C. parapsilosis BSIs (aHR: 0.46, 95% CI: 0.22-0.99, p = 0.047) and central venous catheter removal at any time (aHR: 0.22, 95% CI: 0.13-0.37, p < 0.001) were associated with reduced 30-day mortality. The mortality of patients with Candida BSIs was mainly determined by disease severity, while catheter removal was associated with improved survival.