The epidemiology of candidemia in two United States cities: results of a population-based active surveillance

Experience with caspofungin in the treatment of persistent fungemia in neonates

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Survey of neonatal candidiasis in Greece

In order to estimate the extent of neonatal candidiasis in Greece and to identify trends in clinical management, the present study was conducted using a questionnaire directed to Greek neonatologists and pediatric infectious disease specialists. The respondents represented 15 hospitals in the country's seven largest cities, which are currently the only Greek cities with neonatal intensive care units. Based on the responses, the incidence of neonatal candidiasis was determined to be 1.87 and 1.94 cases per unit-year for the years 2001 and 2002, respectively. Although a shift toward the isolation of non-Candida albicans isolates was noted, C. albicans was still the predominant pathogenic species. Deoxycholate amphotericin B remains the most frequently used antifungal agent in neonatal units nationwide.

Seminational surveillance of fungemia in Denmark: notably high rates of fungemia and numbers of isolates with reduced azole susceptibility

The aim of this study was to present the first set of comprehensive data on fungemia in Denmark including the distribution of species and range of susceptibility to major antifungal compounds based on a seminational surveillance study initiated in 2003. The catchment area of the participating hospitals had a population of 2.8 million, or 53% of the Danish population. A total of 303 episodes of fungemia were registered (annual rate, 11 of 100,000 people or 0.49 of 1,000 hospital discharges). Candida species accounted for 97.4% of the fungal pathogens. C. albicans was the predominant species (63%), but the proportion varied from 57% to 72% among participating departments of clinical microbiology. C. glabrata was the second most frequent species (20%; range, 8% to 32%). C. krusei was a rare isolate (3%) and occurred only at two of the participating hospitals. Retrospective data retrieved from the Danish laboratory systems documented a continuous increase of candidemia cases since the early 1990s. For the 272 susceptibility-tested isolates, MICs of amphotericin B and caspofungin were within the limits expected for the species or genus. However, decreased azole susceptibility, defined as a fluconazole MIC of >8 microg/ml and/or itraconazole MIC of >0.125 microg/ml, was detected for 11 Candida isolates that were neither C. glabrata nor C. krusei. Including intrinsically resistant fungi, we detected decreased susceptibility to fluconazole and/or itraconazole in 87 (32%) current Danish bloodstream fungal isolates. We showed a continuous increase of fungemia in Denmark and an annual rate in 2003 to 2004 higher than in most other countries. The proportion of bloodstream fungal isolates with reduced susceptibility to fluconazole and/or itraconazole was also notably high.

Azole resistance in neonatal intensive care units in Argentina

The aim of this study was to determine the antifungal susceptibility profile and to detect resistant strains of yeast species isolated from neonates in Intensive Care Units. 92 strains isolated from 25 bloodstream cultures, 20 venous catheters, 23 suprapubic aspirations and 24 rectal swabs were studied. A Candida glabrata strain resistant to fluconazole was detected. Candida krusei appeared with its inherent resistance to fluconazole and showed cross-resistance to itraconazole. Two Candida albicans strains were resistant to azoles, one to itraconazole and the other to fluconazole with a high minimum inhibitory concentration (MIC) for itraconazole. All Candida tropicalis strains were susceptible to fluconazole but two of them showed resistance to itraconazole. The detection of resistant strains in neonates whom had not received previous antifungal therapy is noteworthy. The variations in the epidemiology of fungal infections observed and the antifungal resistance detected emphasize the importance of performing a regular surveillance to observe and to assess them.

Hyperglycaemia and mortality of diabetic patients with candidaemia

AIMS

To determine whether the degree of hyperglycaemia has an impact on in-hospital mortality in diabetic patients with candidaemia.

METHODS

A retrospective cohort study of 87 diabetic patients with candidaemia admitted between June 1995 and June 2003 was carried out at two medical centres. Patients were stratified into two groups: those with moderate hyperglycaemia (7 days post-candidaemia mean blood glucose < 13.9 mmol/l) and those with severe hyperglycaemia (7 days post-candidaemia mean blood glucose > or = 13.9 mmol/l). A stepwise logistic regression analysis was performed to determine whether the degree of hyperglycaemia was a significant predictor of mortality.

RESULTS

During the follow-up period from admission till discharge, 34 (39.1%) patients had died. Nine (69.2%) of 13 patients with severe hyperglycaemia have died while 25 (33.8%) of 74 patients with moderate hyperglycaemia have died. Multivariate analysis identified three independent determinants of death; Apache II score > or = 23 [OR 8.1, 95% CI (2.6, 25.3), P = 0.0003], mean blood glucose levels 7 days post-candidaemia > or = 13.9 mmol/l [OR 6.8, 95% CI (1.2, 38.2), P = 0.03], and mechanical ventilation [OR 6.5, 95% CI (2.21), P = 0.03].

CONCLUSION

Severe hyperglycaemia is an important marker of increased mortality among hospitalized diabetic patients with candidaemia.

Management of invasive candidiasis in critically ill patients

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

Echinocandins: role in antifungal therapy, 2005

Novel therapies to treat invasive fungal infections have revolutionised the care of patients with candidiasis, aspergillosis and other less common fungal infections. Physicians in the twenty first century have access to safer versions of conventional drugs (i.e., lipid amphotericin B products), extended-spectrum versions of established drugs (i.e., voriconazole), as well as a new class of antifungal agents; the echinocandins. The increased number of options in the antifungal armamentarium is well timed, as the incidence of both invasive candidiasis and invasive aspergillosis, and the financial burden associated with these infections, have increased significantly in the past several decades. The increasing incidence of fungal infections has risen in parallel with the increase in critically ill and immunocompromised patients. Candida is the fourth most common bloodstream isolate, approximately 50% of which are non-albicans species. Estimates suggest there to be 9.8 episodes of invasive candidiasis per 1000 admissions to surgical intensive care units, with attributable mortality at 30% and cost per episode of US44,000 dollars. The burden of candidiasis is even higher in the paediatric population, with Candida being the second most common bloodstream infection. The increase in non-albicans candidiasis mandates the introduction of new antifungal agents capable of treating these often azole-resistant isolates. In addition, there has been a rise in the incidence of invasive aspergillosis, the most common invasive mould infection following haematopoietic stem cell transplantation, with an estimated incidence of 10 - 20%. The mortality associated with invasive aspergillosis has increased by 357% since 1980. Unfortunately, the overall survival rate among patients treated with amphotericin B, and even voriconazole, remains suboptimal, as evidenced by the failure of treatment in 47% of patients in the landmark voriconazole versus amphotericin B trial. Given the increasing incidence and suboptimal outcomes of these serious fungal infections, novel therapies represent an opportunity for significant advancement in clinical care. The current challenge is to discover the optimal place for the echinocandins in the treatment of invasive fungal infections.

Rapid identification of Candida species by FT-IR microspectroscopy

Due to the continuous increase of human candidiasis and the great diversity of yeasts of the Candida genera, it is indispensable to identify this yeast as early as possible. Early identification enables an early diagnostic and patient-adapted anti-fungal therapy, thus reducing morbidity and mortality related to these infections. In view of this, we have in this study investigated microcolonies using a method based on Fourier transform-infrared microspectroscopy (FTIRM) for a rapid and early identification of the most frequent Candida species encountered in human pathology. FTIR spectroscopy is a whole-cell "fingerprinting" method by which microorganisms can be identified. By exploiting the huge discriminating capacity of this technique, we identified 6 species (Candida albicans, Candida glabrata, Candida parapsilosis, Candida tropicalis, Candida krusei, and Candida kefyr) from a collection of 57 clinical strains of Candida, isolated from hospitalised patients. Data obtained on 10- to 18-h-old microcolonies were compared to cultures of 24 h. Our results clearly show the efficiency and the robustness of FTIR (micro)spectroscopy in identifying species with a classification rate of 100% for both microcolonies and 24-h cultures. FTIR microspectroscopy is thus a promising clinical approach, because compared to conventional and molecular techniques, it is time and money saving, has great identification and discriminating potentials, and is amenable to an automated high-throughput routine system.

Invasive Candida species infections: a 5 year population-based assessment

OBJECTIVES

Candida species have emerged as important causes of invasive infections and rates of resistance to standard antifungal therapies are rising. The objective of this study was to define the occurrence of, risk factors for, and antifungal susceptibilities of invasive Candida species infections in a large Canadian health region.

METHODS

Population-based surveillance was conducted for invasive Candida species infections in the Calgary Health Region during a 5 year period and susceptibility testing was performed.

RESULTS

The annual incidence of invasive Candida species infection was 2.9 per 100,000 population (0.2 and 2.8 per 100,000 for central nervous system and bloodstream infection, respectively). The very young and elderly were at highest risk for invasive Candida species infections. Several risk factors for developing invasive Candida species infection were identified with chronic haemodialysis, organ transplant recipient, and cancer patients at highest risk. Thirty percent (56/184; 43 susceptible, dose-dependent and 13 resistant) of isolates demonstrated reduced susceptibility to fluconazole. Only one (1%) isolate had reduced susceptibility to amphotericin B and six (3%) and three (2%) isolates had minimum inhibitory concentrations of >or=1 mg/L to voriconazole and caspofungin, respectively. Overall, 40% of patients died in-hospital for an annual mortality rate of 1.2 per 100,000.

CONCLUSIONS

Candida species are an important cause of invasive infection and patients with co-morbidities and extremes of age are at highest risk. Alternatives to fluconazole should be considered for initial empiric therapy in patients with severe invasive Candida species infections.

Candidaemia in an Irish tertiary referral hospital: epidemiology and prognostic factors

There were two parts to this study. Part 1 evaluated the epidemiology of Candida bloodstream isolates within the Southern Health Board (SHB) of Ireland from 1992 to 2003 by retrospective surveillance of all such isolates of patients reported from SHB hospitals to our laboratory database during that period. Part 2 reviewed candidaemia cases occurring in Cork University Hospital (CUH) from 1999 to 2003 using surveillance of all positive blood culture isolates in CUH microbiology laboratory during the 5-year period. In part 1, 250 Candida bloodstream isolates were reported in the SHB over 12 years. There was a pattern of decreasing percentage of C. albicans with time. Whereas in part 2, 63 cases of candidaemia were identified in CUH from 1999 to 2003. Candida albicans constituted 50% of all isolates, while C. parapsilosis and C. glabrata accounted for 21.2% and 18.2% respectively. Average annual incidence rate was 0.48 episodes/1000 admissions and 0.70 episodes/10 000 patient-days. Vascular catheters were the commonest source of candidaemia (61.9%) followed by the urinary tract (12.7%). Risk factors included exposure to multiple antibiotics (75%); central vascular catheterization (73%); multiple colonization sites (71%); severe gastrointestinal (GI) dysfunction (54%) and acute renal failure (43%). Crude 7-day and 30-day mortality rates were 20.6% and 39.7% respectively. Logistic regression multivariate analysis identified the following to be independent predictors for mortality: age > or =65 years [odds ratio (OR) 7.2, P = 0.013]; severe GI dysfunction (OR 10.6, P = 0.01); acute renal failure (OR 7.6, P = 0.022); recent/concurrent bacteraemia (OR 5.2, P = 0.042); endotracheal intubation (OR 7.7, P = 0.014); while major surgery was associated with a better prognosis (OR 0.05, P = 0.002). Appropriate antifungal treatment was also found to be associated with survival (Fisher's exact test, P < 0.001). The epidemiology of Candida bloodstream isolates within our health board had changed over the years. Incidence and mortality of candidaemia were relatively high in our hospital. Dysfunction of major organ systems and recent bacteraemia were found to predict mortality.

Determining risk factors for candidemia among newborn infants from population-based surveillance: Baltimore, Maryland, 1998-2000

BACKGROUND

Our objective was to determine risks factors for late onset candidemia, independent of birth weight, in newborn infants.

METHODS

We performed a matched case-control study. Cases were identified through active, population-based surveillance for candidemia, conducted in Baltimore City and County during 1998-2000, and were defined as the incident isolation of any Candida species from the bloodstream of an infant 3 months old or younger. Four controls, matched by age, hospital, birth weight category, hospital stay and admission date, were selected for each case. Potential risk factors included clinical, demographic and maternal prenatal data.

RESULTS

Of the 35 cases, 19 (54%) infections were with Candida albicans, 9 (26%) were with Candida parapsilosis and 5 (14%) were with Candida glabrata. Cases had a median birth weight of 680 g (range, 430-3200 g); median gestational ages of cases and controls were 25 and 27 weeks, respectively. Compared with controls, cases had significant higher mortality (20% versus 4%; P = 0.004). No maternal factors were associated with increased risk of disease; cases were as likely as controls to be of black race. Multivariable conditional logistic regression analysis revealed that gestational age younger than 26 weeks [adjusted odds ratio, 6.5; 95% confidence interval (95% CI), 1.3-32], vaginal delivery (adjusted odds ratio, 4.3; 95% CI 1.3-14.2) and abdominal surgery (adjusted odds ratio, 10.9; 95% CI 1.9-62) were independently associated with increased risk of candidemia.

CONCLUSIONS

Independent of birth weight, infants born at <26 weeks or those who have had abdominal surgery are at a significantly increased risk of candidemia. This study helps define a subgroup of preterm infants at high risk of developing bloodstream infections with Candida species.

Frequency of fungemia in hospitalized pediatric inpatients over 11 years at a tertiary care institution

OBJECTIVES

To determine the frequency of bloodstream fungal infections in children who were admitted to our tertiary institution over an 11-year period.

METHODS

We conducted a retrospective cohort study of patients who were aged 0 to 21 years, had bloodstream fungal infections, and were admitted to the University of California, Los Angeles from 1991 through 2001. Patients were identified through the microbiology laboratory database. All positive fungal cultures for pediatric inpatients were reviewed. For each fungemic patient, a review of clinical course, cause, and outcome was performed.

RESULTS

Over 11 years, 1124 pediatric inpatients with 3633 positive cultures had evidence of fungal colonization or infection. The mean incidence of positive fungal cultures increased from 105 between 1991 and 1996 to 129 patients per year between 1997 and 2001. Fungal isolates were mainly Candida species (85%) obtained primarily from respiratory (41%) and urine (27%) cultures. Only 7.5% of positive fungal cultures were from blood, although 24490 pediatric admissions prompted 72960 bacterial and fungal blood cultures, at charges of 2.52 million dollars. Of 14592 fungal blood cultures, <2% (n = 272) were positive, involving <1% (n = 97) of patients. The mean rise in number of children with fungemia was significant, from 6.8 between 1991 and 1996 to 13.0 patients per year between 1997 and 2001. Fungemia was associated with a high all-cause mortality rate (46%), particularly in immunocompromised patients (57%). Organisms recovered were primarily Candida species (91%). There was a decline in C albicans and C glabrata fungemia and an increase in C parapsilosis organisms. In 84% of patients, fungal organisms were isolated from both bacterial and fungal blood cultures, and in 74%, the same organism was isolated from additional body sites.

CONCLUSIONS

Episodes of fungemia increased significantly over 11 years as compared with a moderate increase in positive fungal cultures and were associated with high all-cause mortality rates. More sensitive assays for early identification of fungal bloodstream infections are warranted.

A comparative study of risk factors and outcome among outpatient-acquired and nosocomial candidaemia

Candidaemia is perceived as a nosocomial infection. The aim of this study was to describe all cases of candidaemia that occurred in the outpatient setting, and to compare risk factors and outcome among patients with outpatient-acquired and nosocomial candidaemia. During 1995 and 2003, 210 patients developed candidaemia at our institution, and 9.0% were outpatient acquired. Major underlying diseases were cancer (47.4%) and chronic renal failure (36.8%). Most occurred within 24 h of hospitalization (63.2%), and 83.7% were caused by species other than Candida albicans, mainly Candida parapsilosis (36.8%). Candida spp. were isolated from catheters in 21% of cases, and 52.6% of patients had been admitted to hospital in the 60 days preceding candidaemia. Compared with patients with nosocomial candidaemia, chronic renal failure was more frequent in the outpatient group, who were also more commonly exposed to haemodialysis. Ileus, gastrointestinal bleeding, previous bacteraemia, use of proton pump inhibitors, previous stay in the intensive care unit and requirement for antibiotics, blood transfusion, vasopressors and invasive medical procedures were more frequent in the nosocomial group. Overall mortality was high in both groups. Candidaemia must be considered as a potential cause of sepsis in the community, and it is associated with a high mortality rate.

Pseudomonas aeruginosa, Candida albicans, and device-related nosocomial infections: implications, trends, and potential approaches for control

For many years, device-associated infections and particularly device-associated nosocomial infections have been of considerable concern. Recently, this concern was heightened as a result of increased antibiotic resistance among the common causal agents of nosocomial infections, the appearance of new strains which are intrinsically resistant to the antibiotics of choice, and the emerging understanding of the role biofilms may play in device-associated infections and the development of increased antibiotic resistance. Pseudomonas aeruginosa and Candida albicans are consistently identified as some of the more important agents of nosocomial infections. In light of the recent information regarding device-associated nosocomial infections, understanding the nature of P. aeruginosa and C. albicans infections is increasingly important. These two microorganisms demonstrate: (1) an ability to form biofilms on the majority of devices employed currently, (2) increased resistance/tolerance to antibiotics when associated with biofilms, (3) documented infections noted for virtually all indwelling devices, (4) opportunistic pathogenicity, and (5) persistence in the hospital environment. To these five demonstrated characteristics, two additional areas of interest are emerging: (a) the as yet unclear relationship of these two microorganisms to those species of highly resistant Pseudomonas spp and Candida spp that are of increasing concern with device-related infections, and (b) the recent research showing the dynamic interaction of P. aeruginosa and C. albicans in patients with cystic fibrosis. An understanding of these two opportunistic pathogens in the context of their ecosystems/biofilms also has significant potential for the development of novel and effective approaches for the control and treatment of device-associated infections.

Initial management of candidemia at an academic medical center: Evaluation of the IDSA guidelines

Treatment of candidemia is more complicated because of the changing epidemiology of Candida and introduction of newer antifungal agents. Utilization and benefit of practice guidelines and infectious disease consultation for the management of candidemia has not been previously described in the routine clinical setting. We prospectively studied the impact of the Infectious Disease Society of America (IDSA) guidelines for the management of candidemia and infectious disease consultation on clinical outcomes in 119 patients with candidemia at a tertiary care hospital. Medical records were reviewed to capture data concerning use of antifungal agents, management of central venous catheters, and infectious disease consultation. Initial antifungal therapy was consistent with the IDSA guidelines in 76% of patients. Variation from the guidelines was independently associated with higher mortality (24% versus 57%, P = 0.003). Infectious disease consultation was independently associated with lower mortality (18% versus 39%, P < 0.01). Use of the IDSA guidelines and infectious disease consultation service was found to improve patient outcomes in patients with candidemia at our institution. Further studies should be performed to validate newer guidelines in a clinical setting at other institutions.

Risk factors for fatal candidemia caused by Candida albicans and non-albicans Candida species

Background

Invasive fungal infections, such as candidemia, caused by Candida species have been increasing. Candidemia is not only associated with a high mortality (30% to 40%) but also extends the length of hospital stay and increases the costs of medical care. Sepsis caused by Candida species is clinically indistinguishable from bacterial infections. Although, the clinical presentations of the patients with candidemia caused by Candida albicans and non-albicans Candida species (NAC) are indistinguishable, the susceptibilities to antifungal agents of these species are different. In this study, we attempted to identify the risk factors for candidemia caused by C. albicans and NAC in the hope that this may guide initial empiric therapy.

Methods

A retrospective chart review was conducted during 1996 to 1999 at the Veterans General Hospital-Taipei.

Results

There were 130 fatal cases of candidemia, including 68 patients with C. albicans and 62 with NAC. Candidemia was the most likely cause of death in 55 of the 130 patients (42.3 %). There was no significant difference in the distribution of Candida species between those died of candidemia and those died of underlying conditions. Patients who had one of the following conditions were more likely to have C. albicans, age ≧ 65 years, immunosuppression accounted to prior use of steroids, leukocytosis, in the intensive care unit (ICU), and intravascular and urinary catheters. Patients who had undergone cancer chemotherapy often appeared less critically ill and were more likely to have NAC.

Conclusion

Clinical and epidemiological differences in the risk factors between candidemia caused by C. albicans and NAC may provide helpful clues to initiate empiric therapy for patients infected with C. albicans versus NAC.

Epidemiology and predictors of mortality in cases of Candida bloodstream infection: results from population-based surveillance, barcelona, Spain, from 2002 to 2003

We conducted population-based surveillance for Candida bloodstream infections in Spain to determine its incidence, the extent of antifungal resistance, and risk factors for mortality. A case was defined as the first positive blood culture for any Candida spp. in a resident of Barcelona, from 1 January 2002 to 31 December 2003. We defined early mortality as occurring between days 3 to 7 after candidemia and late mortality as occurring between days 8 to 30. We detected 345 cases of candidemia, for an average annual incidence of 4.3 cases/100,000 population, 0.53 cases/1,000 hospital discharges, and 0.73 cases/10,000 patient-days. Outpatients comprised 11% of the cases, and 89% had a central venous catheter (CVC) at diagnosis. Overall mortality was 44%. Candida albicans was the most frequent species (51% of cases), followed by Candida parapsilosis (23%), Candida tropicalis (10%), Candida glabrata (8%), Candida krusei (4%), and other species (3%). Twenty-four isolates (7%) had decreased susceptibility to fluconazole (MIC > or = 16 microg/ml). On multivariable analysis, early death was independently associated with hematological malignancy (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.1 to 10.4). Treatment with antifungals (OR, 0.05; 95% CI, 0.01 to 0.2) and removal of CVCs (OR, 0.3; 95% CI, 0.1 to 0.9) were protective factors for early death. Receiving adequate treatment, defined as having CVCs removed and administration of an antifungal medication (OR, 0.2; 95% CI, 0.08 to 0.8), was associated with lower odds of late mortality; intubation (OR, 7.5; 95% CI, 2.6 to 21.1) was associated with higher odds. The incidence of candidemia and prevalence of fluconazole resistance are similar to other European countries, indicating that routine antifungal susceptibility testing is not warranted. Antifungal medication and catheter removal are critical in preventing mortality.

Fungal Liver Infection in Immunocompromised Patients: Depiction with Multiphasic Contrast-enhanced Helical CT

PURPOSE

To retrospectively assess multiphasic (nonenhanced, arterial phase, and portal venous phase) computed tomography (CT) of the liver for depiction of hepatic fungal infection in immunocompromised patients.

MATERIALS AND METHODS

The institutional ethics review board approved the study and waived the requirement for informed consent. Sixty multiphasic hepatic CT examinations were performed in 39 immunocompromised patients who fulfilled the criteria for having probable or proved fungal liver infection. The detection and conspicuity of focal liver lesions were assessed on scans obtained during each CT phase. The lesion enhancement pattern was determined, and, accordingly, lesions were stratified into two groups: lesions suggestive of infection (with ring enhancement patterns or high attenuation) and nonspecific hypoattenuating lesions. Statistical analyses were performed by using logistic regression with generalized estimating equations.

RESULTS

A total of 536 liver lesions detected at 36 CT examinations with results positive for fungal infection were assessed. All 36 (100%) examinations yielded positive results during the arterial phase, whereas 25 (69%) of them yielded positive results during the portal venous phase (P < .001). At lesion-by-lesion analysis, the arterial phase scans depicted significantly more lesions (483 of 536 [90%]) than the portal venous phase (329 of 536 [61%]) and nonenhanced (265 of 465 [57%]) scans (P < .001 for both comparisons). In addition, on arterial phase scans, 386 of 483 lesions, as compared with 134 of 329 lesions on portal venous phase scans (P < .001), were judged to have an enhancement pattern suggestive of infection. The CT phases did not differ significantly in terms of the conspicuity of detected lesions.

CONCLUSION

In patients suspected of having hepatic fungal infection, arterial phase CT depicts significantly more hepatic lesions than does CT performed during the other phases, and it reveals more lesions with enhancement patterns suggestive of infection. Arterial phase CT should be performed in addition to portal venous phase CT in patients suspected of having hepatic fungal infection.

Antifungal susceptibilities of clinical isolates of Candida species, Cryptococcus neoformans, and Aspergillus species from Taiwan: surveillance of multicenter antimicrobial resistance in Taiwan program data from 2003

The susceptibilities of nonduplicate isolates to six antifungal agents were determined for 391 blood isolates of seven Candida species, 70 clinical isolates (from blood or cerebrospinal fluid) of Cryptococcus neoformans, and 96 clinical isolates of four Aspergillus species, which were collected in seven different hospitals in Taiwan (as part of the 2003 program of the study group Surveillance of Multicenter Antimicrobial Resistance in Taiwan). All isolates of Candida species other than C. glabrata and C. krusei were susceptible to fluconazole. Among the 59 C. glabrata isolates, 16 (27%) were not susceptible to fluconazole, and all were dose-dependently susceptible or resistant to itraconazole. For three (5.1%) C. glabrata isolates, voriconazole MICs were 2 to 4 microg/ml, and for all other Candida species isolates, voriconazole MICs were </=0.5 microg/ml. The proportions of isolates for which amphotericin B MICs were >/=2 microg/ml were 100% (3 isolates) for C. krusei, 11% (23 of 207 isolates) for Candida albicans, 3.0% (2 of 67 isolates) for Candida tropicalis, 20% (12 of 59 isolates) for C. glabrata, and 0% for both Candida parapsilosis and Candida lusitaniae. For three (4%) Cryptococcus neoformans isolates, fluconazole MICs were >/=16 microg/ml, and two (3%) isolates were not inhibited by 1 mug of amphotericin B/ml. For four (4.2%) of the Aspergillus isolates, itraconazole MICs were 8 microg/ml. Aspergillus flavus was less susceptible to amphotericin B, with the MICs at which 50% (1 microg/ml) and 90% (2 microg/ml) nsrsid417869\delrsid7301351 of isolates were inhibited being twofold greater than those for Aspergillus fumigatus and Aspergillus niger. All Aspergillus isolates were inhibited by </=1 microg of voriconazole/ml, including isolates with increased resistance to amphotericin B and itraconazole. This study revealed the emergence in Taiwan of decreased susceptibilities of Candida species to amphotericin B and of C. neoformans to fluconazole and amphotericin B. Voriconazole was the most potent agent against the fungal isolates tested, including fluconazole- and amphotericin B-nonsusceptible strains.

Novel modes of antifungal drug administration

Administration of antifungals by routes other than that for which the agent was designed or approved have been utilised in attempts to provide directed therapy, reduce adverse effects and improve drug penetration into selected infection sites, such as the central nervous system, lungs and peritoneum. The most widely investigated agent utilising a novel method of drug delivery is amphotericin B. Dose forms for this agent include topicals (aerosol, nasal spray, irrigations, pastes, absorbable sponges, impregnated bone cement and gelatin), oral dosage forms (solutions, suspensions, tablets and so on) and ophthalmic preparations (drops, ointments and injections). Amphotericin B has been administered by routes such as oral, endobronchial, intrathecal, intracisternal, intra-articular, intraperitoneal, ophthalmic and as an antibiotic 'line lock'. Nystatin has been administered as an aerosol, percutaneous paste and bladder washes. Azoles, such as miconazole, fluconazole, ketoconazole and posaconazole, have been administered by novel methods but to a lesser degree. Most of these reports involve miconazole. The dose forms and routes of administration for azoles have included irrigants (bladder, joint), ophthalmic preparations (eye drops, intraocular injections, ointments), impregnated bone cement, endobronchial and intrathecal administration. Finally, both methylene blue (bladder washes) and flucytosine (peritoneal lavage, ophthalmic eye drops) have also been employed. Adequate evaluations of both the safety and efficacy of these therapies are most often hindered by prior or concomitant antifungal therapies, comorbidities and the lack of controlled clinical trials. In addition, the availability of newer treatment options, which demonstrate significant improvement in drug distribution and treatment-related adverse effects make many such novel modes of administration less practical or necessary. In contrast, the inhalation of antifungal aerosols, such as amphotericin B, is rapidly becoming a viable prophylactic option.

Study of molecular epidemiology of candidiasis in portugal by PCR fingerprinting of Candida clinical isolates

PCR fingerprinting was used to type 177 yeast isolates obtained from two medical institutions. Candida albicans was the predominant species found, followed by C. tropicalis, C. glabrata, C. parapsilosis, C. guilliermondii, and C. krusei, which accounted for over 20% of the strains isolated. This survey represents the first study of molecular epidemiology of candidiasis in Portugal.

In vitro susceptibilities of bloodstream isolates of Candida species to six antifungal agents: results from a population-based active surveillance programme, Barcelona, Spain, 2002–2003

OBJECTIVES

The antifungal drug susceptibilities of 351 isolates of Candida species, obtained through active laboratory-based surveillance in the period January 2002-December 2003, were determined (Candida albicans 51%, Candida parapsilosis 23%, Candida tropicalis 10%, Candida glabrata 9%, Candida krusei 4%).

METHODS

The MICs of amphotericin B, flucytosine, fluconazole, itraconazole, voriconazole and caspofungin were established by means of the broth microdilution reference procedure of the European Committee on Antibiotic Susceptibility Testing.

RESULTS AND CONCLUSIONS

Amphotericin B and flucytosine were active in vitro against all strains. A total of 24 isolates (6.8%) showed decreased susceptibility to fluconazole (MIC > or = 16 mg/L) and 43 (12.3%) showed decreased susceptibility to itraconazole (MIC > or = 0.25 mg/L). Voriconazole and caspofungin were active in vitro against the majority of isolates, even those that were resistant to fluconazole.

In vitro fluconazole susceptibility of 1565 clinical isolates of candida species evaluated by the disk diffusion method performed using NCCLS M44-A guidelines

We determined the in vitro activity of fluconazole against 1565 clinical Candida spp. isolates collected from different specimens of non-AIDS outpatients and inpatients in 3 different regions of Italy. Susceptibility testing was performed by agar disk diffusion using the NCCLS document M44-A guidelines. Candida albicans was the most frequently isolated yeast (68%) followed by C. glabrata (15%), C. tropicalis (5%), C. parapsilosis (5%), and C. krusei (5%). Other yeasts represented 4% of all isolates. Of the 1565 isolates tested, 1449 (92.6%) were susceptible (S) to fluconazole, 43 (2.7%) were susceptible dose-dependent (S-DD) and 73 (4.7%) were resistant (R). Almost all (98.2%) of the C. albicans isolates were classified as S or S-DD. Despite its widespread use, fluconazole displayed good activity against the isolates we tested, and the disk diffusion method was confirmed as a reliable approach to the evaluation of in vitro susceptibility of yeasts to this antimycotic agent.

Animal models in the analysis of Candida host-pathogen interactions

An increasingly diverse array of clinically relevant animal models of candidiasis have been established that mimic both the immune perturbations of the host and tissue-specific features of candidiasis in humans. Cause-and-effect analysis of Candida host-pathogen interactions using these animal models has made a quantum leap forward in the genomic era, with the concurrent construction of C. albicans mutants with targeted mutations of putative virulence factors, the application of microarrays and other emerging technologies to comprehensively assess C. albicans gene expression in vivo, and construction of transgenic and knockout mice to simulate specific host immunodeficiencies. The opportunity to combine these powerful tools will yield an unprecedented wealth of new information on the molecular and cellular pathogenesis of candidiasis.

The distinct morphogenic states of Candida albicans

The human fungal pathogen, Candida albicans can grow in at least three different morphologies: yeast, pseudohyphae and hyphae. Further morphological forms exist during colony switching, for example, opaque phase cells are oblong, rather than the oval shape of yeast cells. Pseudohyphae and hyphae are both elongated and sometimes there has been little attempt to distinguish between them, as both are "filamentous forms" of the fungus. We review here the differences between them that suggest that they are distinct morphological states. We argue that studies on "filamentous forms" should always include a formal analysis to determine whether the cells are hyphae or pseudohyphae and we suggest some simple experimental criteria that can be applied to achieve this.

The Design of Clinical Trials That Evaluate Antifungal Prophylaxis and Combination Therapy: Introduction and Overview

On 8 February 2003, the second in a series of meetings in honor of John E. Bennett, M.D., was convened in New York City. A report from the previous meeting was published in 2003. The goal of this second meeting was to discuss the design of clinical trials in prophylaxis and combination therapy. This supplement presents 12 articles by leading clinicians who are currently active in trials in this area and presents a current view of the unmet needs and challenges.

Utility of real-time antifungal susceptibility testing for fluconazole in the treatment of candidemia

Our study prospectively examined the use of real-time antifungal susceptibility testing among 119 patients with candidemia at a large tertiary university medical center over a 1-year period. Susceptibility results to fluconazole were reported to physicians a mean of 5.1 days after the initial positive blood culture for Candida. Physicians believed that receiving antifungal susceptibility testing results was helpful and not infrequently altered therapy on the basis of results. Outcomes, including mortality and resolution of infection, among 20 (17%) patients with fluconazole-resistant and fluconazole-susceptible dose-dependent isolates were relatively poor compared to those among patients with fluconazole-susceptible isolates, but probably reflect severity of illness. Routine susceptibility testing as an adjunct to the treatment of candidemia has significant potential and warrants further study.

Immunopathogenesis of oropharyngeal candidiasis in human immunodeficiency virus infection

Oropharyngeal and esophageal candidiases remain significant causes of morbidity in human immunodeficiency virus (HIV)-infected patients, despite the dramatic ability of antiretroviral therapy to reconstitute immunity. Notable advances have been achieved in understanding, at the molecular level, the relationships between the progression of HIV infection, the acquisition, maintenance, and clonality of oral candidal populations, and the emergence of antifungal resistance. However, the critical immunological defects which are responsible for the onset and maintenance of mucosal candidiasis in patients with HIV infection have not been elucidated. The devastating impact of HIV infection on mucosal Langerhans' cell and CD4(+) cell populations is most probably central to the pathogenesis of mucosal candidiasis in HIV-infected patients. However, these defects may be partly compensated by preserved host defense mechanisms (calprotectin, keratinocytes, CD8(+) T cells, and phagocytes) which, individually or together, may limit Candida albicans proliferation to the superficial mucosa. The availability of CD4C/HIV transgenic mice expressing HIV-1 in immune cells has provided the opportunity to devise a novel model of mucosal candidiasis that closely mimics the clinical and pathological features of candidal infection in human HIV infection. These transgenic mice allow, for the first time, a precise cause-and-effect analysis of the immunopathogenesis of mucosal candidiasis in HIV infection under controlled conditions in a small laboratory animal.

Diagnosis and treatment of Candida vertebral osteomyelitis: Clinical experience with a short course therapy of amphotericin B lipid complex

BACKGROUND

Musculoskeletal candidiasis occurs in some patients with candidemia resulting from organ infection, IV drug use, or indwelling central venous catheters. Diagnosis is often difficult because of vague symptomatology and a frequent afebrile course.

CASE DESCRIPTION

Three patients with Candida vertebral osteomyelitis are presented. All followed the use of indwelling central venous access catheters and antimicrobial therapy between 6 months and 3 years earlier. In 2, fungemia with the same Candida spp. preceded the spondylodiskitis. These 3 patients bring to nearly 75 the number of reported individuals with what was once quite rare. Although IV amphotericin B doxycholate and fluconazole have usually been effective therapy over prolonged periods of time, we used liposomal amphotericin B to treat 2 of our 3 patients. Both received 5 mg/kg daily for 18-42 days that resulted in total disappearance of signs and symptoms.

CONCLUSION

This relatively brief duration of therapy reduces treatment time and is cost-effective.

Fungemia caused by Zygoascus hellenicus in an allogeneic stem cell transplant recipient

Zygoascus hellenicus (Candida hellenica) was isolated from a blood culture from a patient who had received an allogeneic stem cell transplant. The isolate displayed an antifungal susceptibility pattern of decreased susceptibility to fluconazole and itraconazole, high susceptibility to voriconazole, and low susceptibility to caspofungin. The organism was misidentified by a commercial yeast identification system. This is the first reported case of human infection with this rare ascomycetous yeast.

Candida parapsilosis characterization in an outbreak setting

Candida parapsilosis is an important non-albicans species which infects hospitalized patients. No studies have correlated outbreak infections of C. parapsilosis with multiple virulence factors. We used DNA fingerprinting to determine genetic variability among isolates from a C. parapsilosis outbreak and from our clinical database. We compared phenotypic markers of pathogenesis, including adherence, biofilm formation, and protein secretion (secretory aspartic protease [SAP] and phospholipase). Adherence was measured as colony counts on silicone elastomer disks immersed in agar. Biofilms formed on disks were quantified by dry weight. SAP expression was measured by hydrolysis of bovine albumin; a colorimetric assay was used to quantitate phospholipase. DNA fingerprinting indicated that the outbreak isolates were clonal and genetically distinct from our database. Biofilm expression by the outbreak clone was greater than that of sporadic isolates (p < 0.0005). Adherence and protein secretion did not correlate with strain pathogenicity. These results suggest that biofilm production plays a role in C. parapsilosis outbreaks.

Yeasts species distribution in Neonatal Intensive Care Units in northeast Argentina. Das Hefeartenspektrum in Neugeborenen-Intensivstationen in Nordost-Argentinien

The aim of this study was to determine the distribution and antifungal susceptibility profile of yeast species isolated from neonates in Neonatal Intensive Care Units (NICU) in northeast of Argentina. With this purpose 92 strains isolated from 25 blood stream cultures, 20 venous catheters, 23 suprapubic aspirations and 24 rectal swabs were studied. Candida albicans and C. parapsilosis appeared with similar frequencies (36%) in blood stream isolates. Candida parapsilosis (50%) was the most frequent catheters colonizer and C. tropicalis (54.2%) was the most frequent yeast associated with gastrointestinal tract colonization. Candida krusei, C. glabrata and Trichosporon cutaneum appeared with a very low frequency. A high rate of susceptibility to amphotericin B, fluconazole, and itraconazole was observed.

Evidence for aneuploidy and recombination in the human commensal yeast Candida parapsilosis

Isolates of Candida parapsilosis, including representatives of the three major sub-species groups, were screened for single nucleotide polymorphisms (SNPs) by sequencing five independent loci totaling 4kb per isolate. Group I isolates were highly conserved and in some cases, group I alleles were found in group II and III strains. Unique alleles were also associated with groups II and III, consistent with earlier observations of intergroup divergence. There was no heterozygosity in any strain, and a FACS analysis demonstrated that for all three groups nuclei are variant in size, ranging from 0.5 to 1.0 x the size of other diploid yeast genomes. This suggests that natural isolates of C. parapsilosis are aneuploid, with some isolates being essentially haploid. Taken collectively with the observation of group I alleles within group II and III strains, we propose that some form of recombination is occurring between groups.

Phase 2, randomized, dose-ranging study evaluating the safety and efficacy of anidulafungin in invasive candidiasis and candidemia

This study evaluated the safety and efficacy of anidulafungin, a novel echinocandin, in patients with invasive candidiasis, including candidemia. A total of 123 eligible patients were randomized to one of three intravenous regimens, 50, 75, or 100 mg once daily. Treatment continued for 2 weeks beyond resolution or improvement of signs and symptoms. The primary efficacy criterion was a successful global response rate (i.e., clinical and microbiological success) in the evaluable population at the follow-up (FU) visit, 2 weeks after end of therapy (EOT). One hundred twenty (120) patients received at least one dose of anidulafungin; 68 were evaluable. Review of adverse events and laboratory data indicated no dose response for safety parameters. Non-albicans Candida species accounted for approximately one-half of all isolates. Success rates at EOT were 84, 90, and 89% in the 50-, 75-, and 100-mg groups, respectively. At FU, the success rates were 72, 85, and 83%. Phase 3 studies of anidulafungin for the treatment of invasive candidiasis and candidemia are warranted.

Sensing the host environment: recognition of hemoglobin by the pathogenic yeast Candida albicans

Adhesion to host cells and tissues is important for several steps in the pathogenesis of disseminated Candida albicans infections. Although such adhesion is evident in vivo and for C. albicans grown in vitro in complex medium, some adhesive activities are absent when cultures are grown in defined media. However, addition of hemoglobin to defined media restores binding and adhesion to several host proteins. This activity of hemoglobin is independent of iron acquisition and is mediated by a cell surface hemoglobin receptor. In addition to regulating expression of adhesion receptors, hemoglobin rapidly induces expression of several genes. One of these, a heme oxygenase, allows the pathogen to utilize exogenous heme or hemoglobin to acquire iron and to produce the cytoprotective molecules alpha-biliverdin and carbon monoxide. The specific recognition of and responses to hemoglobin demonstrate a unique adaptation of C. albicans to be both a commensal and an opportunistic pathogen in humans.

Fungal peritonitis at a tertiary care community teaching hospital: epidemiology, treatments, and outcome over a 3 year timespan*. Pilzbedingte Peritonitis in einem kommunalen Lehrkrankenhaus: Epidemiologie uber eine Dreijahresperiode

Fungal species isolated from the peritoneal cavity over a 3-year period were equally divided among dialysis and intra-abdominal sources and demonstrated that triazole antifungal susceptible species predominated. The evolution toward triazole-resistant species/strains noted in bloodstream infections has not yet developed in fungal peritonitis. A trend toward non-albicans species in continuous ambulatory peritoneal dialysis (CAPD) cases, however, requires careful monitoring. .

In vitro activities of voriconazole (UK-109, 496), fluconazole, itraconazole and amphotericin B against 132 non-albicans bloodstream yeast isolates (CANARI study). In-vitro-Wirkung von Voriconazol (UK-109, 496), Fluconazol, Itraconazol und Amphotericin B gegen 132 Nicht-albicans-Hefepilzisolate aus dem Blut (CANARI-Studie)

The aim was to evaluate the in vitro activity of voriconazole compared with those of amphotericin B, itraconazole and fluconazole against 132 bloodstream isolates of Candida non-albicans and Saccharomyces cerevisiae species. The minimal inhibitory concentrations (MICs) were determined by an adapted National Committee for Clinical Laboratory Standards (NCCLS) M27-A method using RPMI 1640 as test medium supplemented with 2% glucose. MIC end-points were determined with a spectrophotometer after incubation for 48 h at 35 degrees C. Optical density data were used for the calculation of the MIC end-points. For amphotericin B, the end-point was defined as the minimal antifungal concentration that exerts 90% inhibition compared with the control well growth. For the azoles, the end-points were determined at 50% inhibition of growth. Amphotericin B is highly active with 97% of isolates inhibited by < or =1 microg ml(-1). Decreased susceptibility or resistance to fluconazole was the rule among C. krusei, which is intrinsically resistant to fluconazole. For C. glabrata isolates, resistance to fluconazole and itraconazole was measured in 13% and 17% of the isolates respectively. Voriconazole was quite active in vitro against all the isolates with a MIC90% of < or =1 microg ml(-1) and we conclude that it may be useful in the treatment of non-albicans bloodstream infections.

The predictors of outcome in immunocompetent patients with hematogenous candidasis

OBJECTIVE

Clinical parameters that predict outcome in non-immunosuppressed candidemic patients are not fully understood.

METHODS

Eighty-one consecutive episodes of candidemia were retrospectively evaluated in 75 patients during 1998-2000.

RESULTS

Infection due to Candida albicans was common (n = 30; 37%) followed by Candida glabrata (n = 25; 31%), Candida parapsilosis (n = 14; 17%), Candida tropicalis (n = 6; 7%), Candida krusei (n = 5; 6%), and Candida lusitaniae (n = 1; 1%). Among 70 evaluable patients, 31 (44%) had fungemia-associated mortality; advanced age (P < 0.004), underlying malignancy (P < 0.025), coronary artery disease (P < 0.01), and concurrent non-Candida species fungal infection (P < 0.047) were significant prognosticators of compromised short-term survival by multivariate analysis. Mortality was higher in patients with Candida glabrata (60%) and C. tropicalis (75%) infection compared to 44% deaths in individuals with C. albicans infection (P > 0.1). 11/25 (44%) of non-immunocompromised individuals died and 20/45 (44%) immunosuppressed patients succumbed to fungemia: persistent vs. non-persistent (< 3 days) Candida bloodstream invasion, neutropenia, diabetes mellitus, renal insufficiency, prior antimicrobial therapy, cirrhosis of liver, abdomino-pelvis surgery, and critical-care-unit vs. non critical-care-unit admission did not significantly impact outcome in either group. All 11 infants, including nine with prematurity, survived Candida species bloodstream infection (P < 0.025).

CONCLUSIONS

Short-term mortality in candidemic non-immunocompromised patients was comparable to fungemia-associated deaths in immunosuppressed patients. Ischemic heart disease has appeared as a new predictor of unfavorable outcome in patients with hematogenous candidiasis.

Identification of clinically relevant yeasts by PCR/RFLP

For molecular diagnosis of fungal disease using DNA amplification procedures in the routine laboratory, choice of appropriate target structures and rapid and inexpensive identification of amplification products are important prerequisites. Most diagnostic procedures described thus far are characterized by limited applicability, considerable cost for laboratory equipment or low power of discrimination between species. This study aimed at identification of a PCR target appropriate for diagnosis of clinically relevant yeasts and an affordable procedure for characterization of the PCR products to the species level. Here, we describe a PCR-based system using amplification of intergenic spacers ITS1 and ITS2 and restriction length polymorphism of PCR products after sequence-specific enzymatic cleavage. We show the evaluation of the system for clinically relevant Candida species. The simple and inexpensive procedure should be instrumental for rapid identification of medically important yeasts.

Clinical factors associated with fluconazole resistance and short-term survival in patients with Candida bloodstream infection

In a 1-year national surveillance program of Candida bloodstream infections in Japan, clinical factors predicting fluconazole resistance and survival of the patients were analyzed. Blood isolates and complete clinical histories were obtained from 326 patients. Fluconazole-resistant isolates were found in 15 (4.6%) of the cases. Univariate analysis of the demographic and clinical factors associated with fluconazole resistance revealed that age, hematologic malignancy, neutropenia, and immunosuppression were of statistical significance. A multiple logistic regression model showed that only hematologic malignancy as the underlying disease (odds ratio, 6.6; 95% confidence interval, 1.6-26.9; P=0.009) was independently associated with resistance. In 242 cases in which data regarding management and prognosis were available, the 30-day survival rate was 68.4%. In the univariate analysis of factors predicting survival, a significant association was found for Candida species, age of the patient, neutropenia, recent abdominal surgery, removal of the central venous catheter, and use of appropriate antifungal therapy. In the multivariate analysis, removal of the central venous catheter (odds ratio, 6.0; 95% confidence interval, 2.2-16.1; P<0.001) and the use of appropriate therapy (odds ratio, 2.1; 95% confidence interval, 1.1-4.1; P=0.03) were independent factors significantly associated with survival after the diagnosis of Candida bloodstream infection.

A prospective epidemiological survey of candidaemia in Sweden

A prospective epidemiological survey of candidaemia was performed in central Sweden from January 1998 to December 1999. In total, 191 episodes were reported with an overall rate of 0.32/1000 admissions. Candida albicans was identified in 128 cases (67%), followed by Candida glabrata in 30 (15.7%) and Candida parapsilosis in 14 (7.3%). Predisposing factors included surgery (31.4%), intensive care (18.8%), solid tumour or haematological malignancy (15.7%), and foetal immaturity (15.7%). Non-albicans Candida species were more prevalent among patients with haematological malignancies (56%), compared to surgical (30%) and ICU patients (19%). The crude mortality rate of candidaemia was 31%. The highest mortality rate was observed in patients with haematological malignancies (41.2%), age > 70 y (41%), surgery (38.5%) and infections with > 1 Candida species (40%) or C. glabrata (38%).

Incidence of bloodstream infections due to Candida species and in vitro susceptibilities of isolates collected from 1998 to 2000 in a population-based active surveillance program

To determine the incidence of Candida bloodstream infections (BSI) and antifungal drug resistance, population-based active laboratory surveillance was conducted from October 1998 through September 2000 in two areas of the United States (Baltimore, Md., and the state of Connecticut; combined population, 4.7 million). A total of 1,143 cases were detected, for an average adjusted annual incidence of 10 per 100,000 population or 1.5 per 10,000 hospital days. In 28% of patients, Candida BSI developed prior to or on the day of admission; only 36% of patients were in an intensive care unit at the time of diagnosis. No fewer than 78% of patients had a central catheter in place at the time of diagnosis, and 50% had undergone surgery within the previous 3 months. Candida albicans comprised 45% of the isolates, followed by C. glabrata (24%), C. parapsilosis (13%), and C. tropicalis (12%). Only 1.2% of C. albicans isolates were resistant to fluconazole (MIC, > or = 64 microg/ml), compared to 7% of C. glabrata isolates and 6% of C. tropicalis isolates. Only 0.9% of C. albicans isolates were resistant to itraconazole (MIC, > or = 1 micro g/ml), compared to 19.5% of C. glabrata isolates and 6% of C. tropicalis isolates. Only 4.3% of C. albicans isolates were resistant to flucytosine (MIC, > or = 32 microg/ml), compared to < 1% of C. parapsilosis and C. tropicalis isolates and no C. glabrata isolates. As determined by E-test, the MICs of amphotericin B were > or = 0.38 microg/ml for 10% of Candida isolates, > or =1 microg/ml for 1.7% of isolates, and > or = 2 microg/ml for 0.4% of isolates. Our findings highlight changes in the epidemiology of Candida BSI in the 1990s and provide a basis upon which to conduct further studies of selected high-risk subpopulations.

Distribution and antifungal susceptibility of Candida species causing candidemia from 1996 to 1999

Susceptibilities to amphotericin B and fluconazole of 383 Candida species isolated from blood were determined. Candida albicans was the most common species (55.6%), followed by Candida parapsilosis (17.5%), Candida tropicalis (16.5%), Candida glabrata (5.2%), Candida guilliermondii (2.3%), and others (2.9%). All but three isolates, Candida ciferrii, C. tropicalis, and C. glabrata, one each, were susceptible to amphotericin B. A total of 367 (95.8%) and 15 (4.2%) isolates were susceptible and susceptible-dose dependent to fluconazole, respectively. Only one isolate, a C. glabrata, was resistant to fluconazole. Few patients (13%) having prior fluconazole treatments may explain the low rate of resistance to fluconazole in this study.

Epidemiology of candidaemia in Europe: results of 28-month European Confederation of Medical Mycology (ECMM) hospital-based surveillance study

In order to update the epidemiological and mycological profile of candidaemia in Europe, the European Confederation of Medical Mycology conducted a prospective, sequential, hospital population-based study from September 1997 to December 1999. A total of 2,089 cases were documented by 106 institutions in seven European countries. Rates of candidaemia ranging from 0.20 to 0.38 per 1,000 admissions were reported. Candida albicans was identified in 56% of cases. Non-albicans Candida species were most frequently isolated from patients with haematological malignancies (65%). With increasing age, an increasing incidence of Candida glabrata was seen. The 30-day mortality rate was 37.9%. The survey results underline the burden of candidaemia in a wide range of patient populations, confirm the importance of non- albicans species, and provide baseline data for future surveillance studies at a European level.

Caspofungin in a pediatric patient with persistent candidemia

OBJECTIVE

To describe the response of a child with persistent fungemia to caspofungin, a member of the echinocandin class of antifungals.

DESIGN

Descriptive case report.

SETTING

Pediatric intensive care unit at a university teaching hospital.

PATIENT

A 3-yr-old female with persistent candidemia.

INTERVENTION

After >5 wks of persistent candidemia, caspofungin was added to an antifungal regimen that included amphotericin B and flucytosine.

MEASUREMENTS AND MAIN RESULTS

The addition of caspofungin resulted in rapid clearance of the candidemia. The child recovered without evidence of further fungal infection or overt toxicity.

CONCLUSION

Caspofungin was administered safely in this pediatric patient and possibly contributed to her clinical improvement. Caspofungin may be considered in children with severe persistent fungal infections that are not responsive to standard therapy. More study in pediatric patients is necessary before recommending its general use.

Caspofungin activity against clinical isolates of fluconazole-resistant Candida

A total of 7,837 clinical isolates of Candida were tested against fluconazole, and 351 resistant (fluconazole MIC >/=64 micro g/ml) isolates were identified (4% of the total tested). All fluconazole-resistant isolates were inhibited by caspofungin at concentrations that can be exceeded by standard doses (MIC at which 90% of the isolates were inhibited, 1 micro g/ml; 99% of the MICs were </=2 micro g/ml).

Economic evaluations of treatments for systemic fungal infections: a systematic review of the literature

We systematically reviewed published economic evaluations of systemic antifungal therapies and assessed their strengths and weaknesses. The study identified all economic evaluations published before May 2002 and critically appraised their methods using a published checklist. Over 1000 papers on antifungal treatments and costs were retrieved, 40 of which were economic evaluations. Fifteen of these were evaluations of systemic antifungal therapy. The majority of studies examined prophylaxis (11 out of 15), two examined empiric treatment and two examined the treatment of confirmed infections. Methods varied quite dramatically and the quality of the studies was, in general, very poor. Consequently, we were unable to find a coherent body of economic evidence for any particular patient group and/or indication. Three methodological issues were identified as requiring improvement in future economic evaluations of the prevention and treatment of systemic mucoses: cost estimates, outcome measures and evidence of effectiveness. Costs of both antifungal infection and treatment are important, and despite this, seven of the studies only collected cost information on drug acquisition costs. This is such a fundamental flaw that these studies should not be used to inform decision making on the use of antifungal medication. The estimation of costs in the other studies appeared appropriate, although limited reporting obscured other important issues, such as the appropriate use of per diem costs. Outcome measures were necessarily produced in all evaluations, yet only two studies produced cost-effectiveness ratios. This makes comparisons across studies very difficult. Also, small samples sizes meant that 'hard' outcome measures such as life-years saved could not be used, as deaths were rare within the studies. Both studies that produced incremental cost-effectiveness ratios were model-based studies. These allow simulations to be run on large cohorts of hypothetical patients, thus allowing differences in mortality between treatments to be evaluated. Evidence of effectiveness was limited, with many of the studies based on non-randomised clinical studies and consequently open to bias. Future clinical trials of the effectiveness of antifungal prophylaxis and treatment need to incorporate the collection of costs and economic outcome measures. Even quite simple analyses can be quite powerful, particularly when combined with modelling work to allow other data sources to be added.