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

Interleukin 17-Mediated Host Defense against Candida albicans

Candida albicans is part of the normal microbiota in most healthy individuals. However, it can cause opportunistic infections if host defenses are breached, with symptoms ranging from superficial lesions to severe systemic disease. The study of rare congenital defects in patients with chronic mucocutaneous candidiasis led to the identification of interleukin-17 (IL-17) as a key factor in host defense against mucosal fungal infection. Experimental infections in mice confirmed the critical role of IL-17 in mucocutaneous immunity against C. albicans. Research on mouse models has also contributed importantly to our current understanding of the regulation of IL-17 production by different cellular sources and its effector functions in distinct tissues. In this review, we highlight recent findings on IL-17-mediated immunity against C. albicans in mouse and man.

Epidemiology and risk factors for nosocomial Non-Candida albicans candidemia in adult patients at a tertiary care hospital in North China

Nosocomial candidemia extends the length of hospital stay, increases the costs of medical care, and is associated with a high mortality rate. Epidemiological data that assist in the choice of initial therapy may help to improve the prognosis. The present study was undertaken to investigate the epidemiology of nosocomial candidemia and identify risk factors for nosocomial candidemia caused by C. albicans and non-albicans Candida species (NAC). A retrospective chart review was undertaken to analyze cases of nosocomial candidemia treated at the Beijing Friendship Hospital between January 2008 and December 2012. All cases of candidemia were identified using the previously published criteria. Among 106 patients analyzed, 53.8% had nosocomial candidemia caused by NAC. Candida albicans was the most common causative agent, accounting for 46.2% of all cases, followed by C. glabrata (25.5%), C. tropicalis (15.1%), C. parapsilosis (10.4%) and C. Krusei (0.9%). Comparison of nosocomial C. albicans and NAC candidemia by multivariate logistic regression showed that factors independently associated with nosocomial NAC candidemia included exposure to azole agents (odds ratio [OR]: 3.359; 95% confidence interval [CI]: 1.136-10.154; P = .031) and artificial surgical implants (OR: 37.519; 95% CI: 2.5-562.998; P = .009). A significant risk factor for nosocomial C. albicans candidemia was cancer surgery (OR: 0.075; 95% CI: 0.013-0.437; P = .004). Clinical and epidemiological differences in the risk factors between nosocomial candidemia caused by C. albicans and NAC should be considered when selecting an initial antifungal regimen for the treatment of adult patients. This should be undertaken before the availability of species identification and/or antifungal susceptibility results.

Clinical features and risk factors for blood stream infections of Candida in neonates

Candida species are the leading cause of invasive fungal infections in children admitted to hospital. However, few data exist with regard to the clinical features, risk factors and prognosis for candidemia in neonates. The present retrospective study included 40 neonates from the Affiliated Children's Hospital of the Capital Institute of Pediatrics (Beijing, China) in the time period between January 1, 2006 and December 31, 2010 (candidemia group, n=19; non-candidemia group, n=21). The clinical characteristics, prognosis and previously identified risk factors for the two groups were recorded. According to the forward stepwise multivariate logistic regression analysis, administration of antibiotics >2 weeks prior, the use of glycopeptide antibiotics, maternal candidal vaginitis and secondary gastrointestinal surgery were identified as predictors of candidiasis. When compared with the non-gastrointestinal dysfunction group, the proportion of neonates that had been subjected to parenteral nutrition, central venous catheters, gastrointestinal surgery, secondary gastrointestinal surgery, repeated tracheal intubation and glycopeptide antibiotic administration was significantly higher in the gastrointestinal dysfunction group (P<0.05). Long-term application of antibiotics, use of glycopeptide antibiotics, maternal candidal vaginitis and secondary gastrointestinal surgery appeared to be the risk factors of candidemia in neonates. The neonates co-existed with gastrointestinal dysfunction suffering from candidemia were likely to experience growth retardation at 6 months after hospital discharge. Candidemia is potentially life-threatening situation for neonates, and if patients do not succumb it may affect their early development.

The economic impact of rapid Candida species identification by T2Candida among high-risk patients

ABSTRACT 

Introduction: This study estimates the cost–effectiveness and hospital budget impact of rapid candidemia identification using T2Candida, a novel diagnostic panel with same-day species-specific results. Materials & Methods: A 1-year decision-tree model estimates hospital costs (2013 US$) and effects (candidemia-related deaths) for faster diagnostics versus blood culture (BC), accounting for disease prevalence, distribution of Candida species, test characteristics (sensitivity/specificity/time to result), antifungal medication and differential length-of-stay and mortality by appropriate treatment timing. Results: The model estimates a hospital with 5100 annual high-risk patients could possibly save $5,858,448 with T2Candida versus BC, a 47.6% decrease in candidemia diagnosis and treatment budget ($1149/patient tested), while averting 60.6% of candidemia-related mortality. Conclusion: Hospitals may observe lower candidemia-related inpatient costs and mortality with rapid Candida diagnosis.

Evaluation of a Novel Plasma (1,3)-β-d-Glucan Detection Assay for Diagnosis of Candidemia in Pediatric Patients

We evaluated a novel plasma (1,3)-β-d-glucan (BDG) detection assay for the diagnosis of candidemia in children. The median BDG levels were 73.4 pg/ml in patients with candidemia and <10 pg/ml in patients without candidemia (P < 0.001). Receiver operating characteristic analysis revealed a cutoff point of 14 pg/ml and an area under the curve of 0.802. At these values, the assay demonstrated 68% sensitivity, 91% specificity, 66% positive predictive value, and 91% negative predictive value. Plasma BDG levels were undetectable in 18 candidemia cases.

Twenty-two years of candidaemia surveillance: results from a Norwegian national study

Several studies have reported an increased incidence of candidaemia and a redistribution of species, with a decrease in the number of Candida albicans isolates. In Norway, a prospective, national surveillance study of candidaemia has been ongoing since 1991. Data from the period 1991-2003 have been published previously. The aim of this study was to follow up the incidence, species distribution and antifungal susceptibility of Candida species isolates from blood cultures in the period 2004-2012, and compare them with the corresponding findings from the period 1991-2003. Blood culture isolates of Candida species from all medical microbiological laboratories in Norway were identified and susceptibility tested at the Norwegian Mycological Reference Laboratory. A total of 1724 isolates were recovered from 1653 patients in the period 2004-2012. Comparison of the two periods showed that the average incidence of candidaemia episodes per 100 000 inhabitants increased from 2.4 (1991-2003) to 3.9 (2004-2012). The increase in incidence in the latter period was significantly higher in patients aged >40 years (p 0.001), and a marked increase was observed in patients aged >60 years (p < 0.001). In conclusion, the average incidence in Norway over a period of 22 years modestly increased from 2.4 to 3.9 per 100,000 inhabitants, this being mainly accounted for by candidaemia in the elderly. The species distribution was stable, and the rate of acquired resistance was low.

Database Research for Pediatric Infectious Diseases

Multiple electronic and administrative databases are available for the study of pediatric infectious diseases. In this review, we identify research questions well suited to investigations using these databases and highlight their advantages, including their relatively low cost, efficiency, and ability to detect rare outcomes. We discuss important limitations, including those inherent in observational study designs and the potential for misclassification of exposures and outcomes, and identify strategies for addressing these limitations. We provide examples of commonly used databases and discuss methodologic considerations in undertaking studies using large databases. Last, we propose a checklist for use in planning or evaluating studies of pediatric infectious diseases that employ electronic databases, and we outline additional practical considerations regarding the cost of and how to access commonly used databases.

Multicenter evaluation of Candida QuickFISH BC for identification of Candida species directly from blood culture bottles

Candida species are common causes of bloodstream infections (BSI), with high mortality. Four species cause >90% of Candida BSI: C. albicans, C. glabrata, C. parapsilosis, and C. tropicalis. Differentiation of Candida spp. is important because of differences in virulence and antimicrobial susceptibility. Candida QuickFISH BC, a multicolor, qualitative nucleic acid hybridization assay for the identification of C. albicans (green fluorescence), C. glabrata (red fluorescence), and C. parapsilosis (yellow fluorescence), was tested on Bactec and BacT/Alert blood culture bottles which signaled positive on automated blood culture devices and were positive for yeast by Gram stain at seven study sites. The results were compared to conventional identification. A total of 419 yeast-positive blood culture bottles were studied, consisting of 258 clinical samples (89 C. glabrata, 79 C. albicans, 23 C. parapsilosis, 18 C. tropicalis, and 49 other species) and 161 contrived samples inoculated with clinical isolates (40 C. glabrata, 46 C. albicans, 36 C. parapsilosis, 19 C. tropicalis, and 20 other species). A total of 415 samples contained a single fungal species, with C. glabrata (n = 129; 30.8%) being the most common isolate, followed by C. albicans (n = 125; 29.8%), C. parapsilosis (n = 59; 14.1%), C. tropicalis (n = 37; 8.8%), and C. krusei (n = 17; 4.1%). The overall agreement (with range for the three major Candida species) between the two methods was 99.3% (98.3 to 100%), with a sensitivity of 99.7% (98.3 to 100%) and a specificity of 98.0% (99.4 to 100%). This study showed that Candida QuickFISH BC is a rapid and accurate method for identifying C. albicans, C. glabrata, and C. parapsilosis, the three most common Candida species causing BSI, directly from blood culture bottles.

Alterations of serum cytokine levels and their relation with inflammatory markers in candidemia

The roles of CRP, PCT, serum amyloid A (SAA), and cytokines in the diagnosis of fungal infections have not yet been clearly demonstrated. This study aims to measure the serum levels of interleukin (IL)-23, IL-17, IL-1β, tumor necrosis factor (TNF)-α, IL-10, transforming growth factor (TGF)-β, C-reactive protein (CRP), procalcitonin (PCT), and serum amyloid A (SAA) in cases of candidemia and to compare them with those observed in cases of bacteremia. For this purpose, the serum cytokine levels from 50 patients with candidemia were compared with those of 14 patients with polymicrobial sepsis, 30 patients with bacteremia, and 27 healthy control subjects. The cytokine levels were studied using sandwich ELISAs according to the manufacturer protocol. The serum levels of TGF-β, IL-23, and IL-17 were found to be significantly higher in the candidemia group in comparison with the samples from those with bacteremia and healthy controls. The PCT and SAA levels were higher in samples from the group with bacteremia those from individuals with candidemia and the healthy control group. Assuming an IL-17 level threshold of >38.79 pg/ml, the sensitivity and specificity were 38% and 96.6%, respectively but considering an IL-23 threshold of >59.97 pg/ml, the sensitivity and specificity values were found to be 72% and 60%, respectively. The sensitivity and the specificity of the TGF-ß levels were found to be 85.71% and 53.33%, respectively, when the TGF-ß threshold is >560 pg/ml. PCT and SAA demonstrated a superior performance for the differentiation of candidemia and bacteremia. Our study demonstrates that IL-17, IL-23, TGF-ß, PCT, and SAA levels could be a diagnostic marker for candidemia.

The RIG-I-like helicase receptor MDA5 (IFIH1) is involved in the host defense against Candida infections

The induction of host defense against Candida species is initiated by recognition of the fungi by pattern recognition receptors and activation of downstream pathways that produce inflammatory mediators essential for infection clearance. In this study, we present complementary evidence based on transcriptome analysis, genetics, and immunological studies in knockout mice and humans that the cytosolic RIG-I-like receptor MDA5 (IFIH1) has an important role in the host defense against C. albicans. Firstly, IFIH1 expression in macrophages is specifically induced by invasive C. albicans hyphae, and patients suffering from chronic mucocutaneous candidiasis (CMC) express lower levels of MDA5 than healthy controls. Secondly, there is a strong association between missense variants in the IFIH1 gene (rs1990760 and rs3747517) and susceptibility to systemic Candida infections. Thirdly, cells from Mda5 knockout mice and human peripheral blood mononuclear cells (PBMCs) with different IFIH1 genotypes display an altered cytokine response to C. albicans. These data strongly suggest that MDA5 is involved in immune responses to Candida infection. As a receptor for viral RNA, MDA5 until now has been linked to antiviral host defense, but these novel studies show unexpected effects in antifungal immunity as well. Future studies are warranted to explore the potential of MDA5 as a novel target for immunotherapeutic strategies.

Analysis of Independent Risk Factors for Death Among Pediatric Patients With Candidemia and a Central Venous Catheter in Place

Objective.

To use multivariate analysis to determine risk factors for death among pediatric patients with candidemia and a central venous catheter in place.

Design.

Retrospective cohort study conducted at Santa Casa Complexo Hospitalar, a 1,200-bed teaching hospital in southern Brazil.

Methods.

All cases of candidemia in pediatric patients (age, ≤ 13 years) at our medical center over a 9-year period were reviewed. A diagnosis of sepsis was required for inclusion in the study. Severity of illness was confirmed by the presence of hypotension requiring inotropes and according to the following scores: the Pediatric Risk of Mortality (PRISM) II score, the PRISM III score, and the Pediatric Logistic Organic Dysfunction score. The following 2 outcomes were evaluated: early death, defined as death occurring within 7 days after candidemia was diagnosed, and late death, defined as death 8-30 days after candidemia was diagnosed.

Results.

A total of 61 patients were included in the study, including 14 neonates. Most (63.9%) of these patients were girls, and the median age was 0.3 years. A total of 80.3% of candidemia cases were due to species other than Candida albicans, primarily Candida parapsilosis (32.8% of cases) and Candida tropicalis (24.6% of cases). Using multivariate analysis, we demonstrated that failure to remove the central venous catheter was an independent risk factor for early death among pediatric patients with candidemia. However, patients whose catheters were retained were sicker than patients whose catheters were removed, and catheter removal had no impact on late death. Instead, severity of illness determined using the PRISM III score was also an independent predictor of late death.

Conclusions.

Results from this study suggest that systematic removal of catheters from pediatric patients with candidemia does not reduce the occurrence of late death.

Secular Trends in Candidemia-Related Hospitalization in the United States, 2000–2005

In the United States, from January 1, 2000, through December 31, 2005, the incidence of candidemia-related hospitalization per 100,000 population rose by 52%, from 3.65 to 5.56 cases; and the incidence per 1,000 hospitalizations rose by 49%, from 0.28 to 0.42 cases. The proportion of all candidemia-related hospitalizations in which candidemia was the principal diagnosis remained stable at approximately 14%.

Antifungal susceptibilities of Candida glabrata species complex, Candida krusei, Candida parapsilosis species complex and Candida tropicalis causing invasive candidiasis in China: 3 year national surveillance

OBJECTIVES

To define the antifungal susceptibility patterns of the most common non-albicans Candida spp. in China.

METHODS

We evaluated the susceptibilities to nine antifungal drugs of Candida parapsilosis species complex, Candida tropicalis, Candida glabrata species complex and Candida krusei isolates from patients with invasive candidiasis at 11 hospitals over 3 years. Isolates were identified by MALDI-TOF MS supplemented by DNA sequencing. MICs were determined by Sensititre YeastOne(TM) using current clinical breakpoints/epidemiological cut-off values to assign susceptibility (or WT), and by CLSI M44-A2 disc diffusion for fluconazole and voriconazole.

RESULTS

Of 1072 isolates, 392 (36.6%) were C. parapsilosis species complex. C. tropicalis, C. glabrata species complex and C. krusei comprised 35.4%, 24.3% and 3.7% of the isolates, respectively. Over 99.3% of the isolates were of WT phenotype to amphotericin B and 5-flucytosine. Susceptibility/WT rates to azoles among C. parapsilosis species complex were ≥97.5%. However, 11.6% and 9.5% of C. tropicalis isolates were non-susceptible to fluconazole and voriconazole, respectively (7.1% were resistant to both). Approximately 14.3% of C. glabrata sensu stricto isolates (n = 258) were fluconazole resistant, and 11.6% of C. glabrata sensu stricto isolates were cross-resistant to fluconazole and voriconazole. All C. krusei isolates were susceptible/WT to voriconazole, posaconazole and itraconazole. Overall, 97.7%-100% of isolates were susceptible to caspofungin, micafungin and anidulafungin, but 2.3% of C. glabrata were non-susceptible to anidulafungin. There was no azole/echinocandin co-resistance. Disc diffusion and Sensititre YeastOne(TM) methods showed >95% categorical agreement for fluconazole and voriconazole.

CONCLUSIONS

In summary, reduced azole susceptibility was seen among C. tropicalis. Resistance to echinocandins was uncommon.

Candida speciation, antifungal treatment and adverse events in pediatric invasive candidiasis: results from 441 infections in a prospective, multi-national study

A multi-national prospective study of pediatric patients with invasive candidiasis between August 2007 and September 2012 was performed and included 441 infections. Variation in infecting Candida species and antifungals used was noted between US and non-US sites. Antifungal-associated adverse events were most common with polyene use.

The epidemiology, antifungal use and risk factors of death in elderly patients with candidemia: a multicentre retrospective study

Background

The elderly patients affected by candidemia are growing in proportion to inpatients, but available data are limited. We aimed to determine the epidemiology, antifungal management and clinical risk factors of death in the elderly population with candidemia in China.

Methods

This retrospective study included 63 elderly (≥65 years) and 84 younger patients (16–60 years) at 4 tertiary hospitals. Multivariable logistic regression model was used to identify independent risk factors of death in elderly patients.

Results

The distribution of Candida species did not differ between elderly and younger patients (p >0.05). Resistance to fluconazole and voriconazole for non-Candida albicans species in elderly patients was approximately double that in younger patients. Host-related risk factors (e.g., underlying solid tumour, diabetes mellitus and chronic renal failure) and hospital-related factors (e.g., prior stay in an intensive care unit, mechanical ventilation, central vascular and urethral catheters placement) were identified more common in elderly patients. Elderly patients less often received triazoles and were less likely to receive antifungal therapies mostly because elderly or their guardians quit antifungal therapies. APACHE II scores and 30-day mortality were higher for elderly than younger patients (31.7% vs. 16.7%, p =0.032). For elderly patients, antifungal therapy administered before microbiological documentation was the only protective factor for death, whereas absence of antifungal therapies, receipt of mechanical ventilation and APACHE II score ≥20 were independent predictors of death.

Conclusions

Elderly patients with candidemia had poor prognoses characterized by certain host and hospital-related risk factors and special pathogen resistance features. More awareness of the burden of this disease is required, and the absence of antifungal therapies should be avoided to improve the prognoses of elderly patients with this severe infection.

Catheter-related Candida bloodstream infection in intensive care unit patients: a subgroup analysis of the China-SCAN study

Background

In patients hospitalized in intensive care units (ICU), Candida infections are associated with increased morbidity, mortality and costs. However, previous studies reported confused risk factors for catheter-related Candida bloodstream infection (CRCBSI). The objective was to describe the risk factors, microbiology, management and outcomes of CRCBSI in the China-SCAN population.

Methods

Patients with ≥1 Candida-positive peripheral blood culture were selected from the China-SCAN study. Peripheral and catheter blood samples were collected for Candida isolation. Patients with the same strain of Candida in peripheral and catheter blood samples were considered as being with CRCBSI, while patients with Candida-positive peripheral blood cultures only or different strains were considered as non-CRCBSI. Data were collected from the China-SCAN study.

Results

CRCBSI incidence in ICU was 0.03% (29/96,060), accounting for 9.86% of all candidemia observed in ICU (29/294). The proportion of CRCBSI due to Candida parapsilosis reached 33.3%, more than that of Candida albicans (28.6%). In univariate analyses, older age (P = 0.028) and lower body weight (P = 0.037) were associated with CRCBSI. Multivariate analysis showed that the sequential organ failure assessment (SOFA) score was independently associated with CRCBSI (odds ratio (OR) = 1.142, 95% confidence interval = 1.049-1.244, P = 0.002). Catheter removal and immune enhancement therapy were often used for CRCBSI treatment.

Conclusions

In China, CRCBSI was more likely to occur in old patients with low body weight. SOFA score was independently associated with CRCBSI. Candida parapsilosis accounted for a high proportion of CRCBSI, but the difference from non-CRCBSI was not significant.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0594-0) contains supplementary material, which is available to authorized users.

Treatment principles for Candida and Cryptococcus

The yeasts Candida and Cryptococcus spp. are important human opportunistic pathogens. Candida spp. rely on skin or mucosal breach to cause bloodstream infection, whereas Cryptococcus spp. exploit depressed cell-mediated immunity characteristic of advanced HIV infection. The treatment for both organisms relies on the administration of rapidly fungicidal agents. In candidaemia, source control is important, with removal of prosthetic material and drainage of collections, as well as hunting for and tailoring therapy to disseminated sites of infection, particularly the eyes and heart. For cryptococcal meningitis, restoration of immune function through antiretroviral therapy (ART) is key, together with careful management of the complications of raised intracranial pressure and relapsed infection, both pre- and post-ART.

Novel strategies to fight Candida species infection

In recent years, there has been a significant increase in the incidence of human fungal infections. The increase in cases of infection caused by Candida species, and the consequent excessive use of antimicrobials, has favored the emergence of resistance to conventional antifungal agents over the past decades. Consequently, Candida infections morbidity and mortality are also increasing. Therefore, new approaches are needed to improve the outcome of patients suffering from Candida infections, because it seems unlikely that the established standard treatments will drastically lower the morbidity of mucocutaneous Candida infections and the high mortality associated with invasive candidiasis. This review aims to present the last advances in the traditional antifungal therapy, and present an overview of novel strategies that are being explored for the treatment of Candida infections, with a special focus on combined antifungal agents, antifungal therapies with alternative compounds (plant extracts and essential oils), adjuvant immunotherapy, photodynamic therapy and laser therapy.

Different doses of micafungin for prophylaxis of invasive fungal diseases in hemato-oncological high-risk patients: a web-based non-interventional trial in four large university hospitals in Germany

INTRODUCTION

Treatment indications of new antifungals in clinical practice often deviate from the strict criteria used in controlled clinical trials. Under routine clinical conditions, beneficial and adverse effects, not previously described in clinical trials may be observed. The aim of this study was to describe customary prescription and treatment strategies of micafungin (MCFG).

METHODS

A registry was set up on www.ClinicalSurveys.net and physicians were invited to provide retrospective information on cases they had treated with MCFG. Documentation comprised demographic information, underlying disease, effectiveness, safety, and tolerability of MCFG.

RESULTS

A total of 125 episodes of patients hospitalized between September 2009 and February 2012 were documented, of which 7 had to be excluded because of incomplete documentation. The most common risk factors of patients were hematological malignancy (n = 116, 98.3%) and antibiotic treatment >3 days (n = 115, 97.5%). MCFG was administered as prophylaxis in 106 (89.9%) patients. Median duration of MCFG application as prophylaxis was 21 days (range: 3-78); 53 of the patients (50%) received a dose of 50 mg, while the other 53 (50%) received 100 mg/day. For the different doses, prophylactic outcome was rated as success in 42 (79.2%) vs. 52 (98.1%; P = 0.004) patients. Fifty-five patients (51.9%) were treated with posaconazole before initiation of MCFG. Four patients (7.5%) developed a proven invasive fungal disease (IFD) while being treated with 50 mg MCFG, compared to no patient treated with 100 mg (P = 0.118). At the end of MCFG prophylaxis, 24 (22.6%) patients were switched to fluconazole and 64 (60.3%) patients to posaconazole.

CONCLUSION

Our study shows clinical effectiveness of MCFG prophylaxis with low rates of breakthrough fungal infections. In most cases, MCFG was part of a multi-modal antifungal prophylactic strategy. Investigators reported fewer proven IFDs in patients receiving therapeutic doses of MCFG as prophylaxis.

Relationship of fluconazole prophylaxis with fungal microbiology in hospitalized intra-abdominal surgery patients: a descriptive cohort study

INTRODUCTION

Historically, Candida albicans has represented the most common cause of candidemia. However, the proportion of bloodstream infections due to non-albicans Candida species has increased. Because of the risk for candidemia in intra-abdominal surgical patients, some experts advocate the use of fluconazole prophylaxis. The impact of this practice on the distribution of Candida species isolated in breakthrough fungal infections in this population is unknown. We examined the association of fluconazole prophylaxis with the distribution of Candida species in intra-abdominal surgery patients.

METHODS

We retrospectively identified cases with a positive blood culture (BCx) for Candida among hospitalized adult intra-abdominal surgery patients between July 2005 and October 2012. Distribution of Candida species isolated represented our primary endpoint. Qualifying surgical cases were determined based on a review of discharge International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Patients receiving low-dose fluconazole prior to the positive BCx with a known indication for prophylaxis including neutropenia, ICU exposure or history of organ transplantation were classified as prophylaxis. Appropriateness of fungal treatment was determined by the timing and selection of antifungal agent based on fungal isolate.

RESULTS

Among 10,839 intra-abdominal surgery patients, 227 had candidemia. The most common Candida species isolated was C. albicans (n = 90, 39.6%) followed by C. glabrata (n = 81, 35.7%) and C. parapsilosis (n = 38, 16.7%). Non-albicans Candida accounted for 57.7% of isolates among the 194 non-prophylaxis patients and 75.8% among the 33 prophylaxis patients (P = 0.001). C. glabrata, the most common non-C. albicans species, was more prevalent than C. albicans in persons given prophylaxis, but not in those without prophylaxis. A total of 63% of those with candidemia were treated inappropriately based on the timing and selection of antifungal administration.

CONCLUSIONS

Selection pressure from fluconazole prophylaxis in at-risk surgical patients may be associated with a drift toward fluconazole-resistant species in subsequent candidemia. Tools are needed to guide appropriate treatment through the prompt recognition and characterization of candidemia.

A case of pediatric acute lymphoblastic leukemia with invasive candidiasis: short review

Mortality rate associated with invasive fungal infections is very high. Early suspicion for fungal infections is important during intensive chemotherapy for acute leukemia. Empirical treatment with antifungals amphotericin B or caspofungin should be started if patient is not responding to broad spectrum antibiotics and if expected duration of neutropenia is prolonged. We are reporting a 3 years old girl child with diagnosis of pre-B acute lymphoblastic leukemia who developed invasive candidiasis with typical clinical and radiological findings during induction chemotherapy. Candida non-albicans was isolated and she was treated with amphotericin B followed by caspofungin. Patient deteriorated after initial response and succumbed to death. Species identification and sensitivity pattern of fungus can help in selecting appropriate antifungal drug.

The epidemiological profile of candidemia at an Indian trauma care center

Purpose:

Candida spp. is a common cause of bloodstream infections. Candidemia is a potentially fatal infection that needs urgent intervention to salvage the patients. Trauma patients are relatively young individuals with very few comorbidities, and the epidemiology of candidemia is relatively unknown in this vulnerable and growing population. In this study, we report the epidemiology of candidemia in a tertiary care Trauma Center of India.

Materials and Methods:

The study was conducted from January 2009 to July 2012. All patients from whose blood samples a Candida spp. was recovered were included in this study. A detailed history and follow up of the patients was done. The isolates of Candida were identified to the species level. The speciation was done by conventional methods, including morphology on Corn Meal Agar, color development on Triphenyl Tetrazolium Chloride Agar and CHROMagar, and germ tube tests. The VITEK 2 YST ID colorometric card, a fully automated identification system was also used. Antifungal susceptibility was performed using the VITEK 2 system.

Results:

A total of 212 isolates of the Candida species were recovered from blood samples of 157 patients over the study period. Candida tropicalis, 82 (39%), was the most common, followed by C. parapsilosis, 43 (20%), C. albicans, 29 (14%), C. glabrata, 24 (11%), C. rugosa, 20 (9%), C. hemulonii,; 6 (3%), C. guilliermondii, 4 (2%), C. famata, 3 (1.5%), and C. lusitaniae 1 (0.5%). Out of all the candidemia patients, 68 (43%) had a fatal outcome. Fluconazole and Amphotericin B resistance was seen in seven (3.3%) and seven (3.3%) of the isolates, respectively.

Conclusion:

Candidemia is a significant cause of mortality in trauma patients in our center, with C. tropicalis and C. parapsilosis being the predominant pathogens. Resistance to antifungal drugs is a matter of concern. Better hospital infection control practices and good antibiotic stewardship policies could possibly help in reducing the morbidity and mortality associated with candidemia.

Functional regions of Candida albicans hyphal cell wall protein Als3 that determine interaction with the oral bacterium Streptococcus gordonii

The opportunistic pathogen Candida albicans colonizes the oral cavity and gastrointestinal tract. Adherence to host cells, extracellular matrix and salivary glycoproteins that coat oral surfaces, including prostheses, is an important prerequisite for colonization. In addition, interactions of C. albicans with commensal oral streptococci are suggested to promote retention and persistence of fungal cells in mixed-species communities. The hyphal filament specific cell wall protein Als3, a member of the Als protein family, is a major determinant in C. albicans adherence. Here, we utilized site-specific in-frame deletions within Als3 expressed on the surface of heterologous Saccharomyces cerevisiae to determine regions involved in interactions of Als3 with Streptococcus gordonii. N-terminal region amino acid residue deletions Δ166-225, Δ218-285, Δ270-305 and Δ277-286 were each effective in inhibiting binding of Strep. gordonii to Als3. In addition, these deletions differentially affected biofilm formation, hydrophobicity, and adherence to silicone and human tissue proteins. Deletion of the central repeat domain (Δ434-830) did not significantly affect interaction of Als3 with Strep. gordonii SspB protein, but affected other adherence properties and biofilm formation. Deletion of the amyloid-forming region (Δ325-331) did not affect interaction of Als3 with Strep. gordonii SspB adhesin, suggesting this interaction was amyloid-independent. These findings highlighted the essential function of the N-terminal domain of Als3 in mediating the interaction of C. albicans with S. gordonii, and suggested that amyloid formation is not essential for the inter-kingdom interaction.

Risk prediction for invasive candidiasis

Over past few years, treatment of invasive candidiasis (IC) has evolved from targeted therapy to prophylaxis, pre-emptive and empirical therapy. Numerous predisposing factors for IC have been grouped together in various combinations to design risk prediction models. These models in general have shown good negative predictive value, but poor positive predictive value. They are useful in selecting the population which is less likely to benefit from empirical antifungal therapy and thus prevent overuse of antifungal agents. Current article deals with various risk prediction models for IC and their external validation studies.

Invasive Candida infections in surgical patients in intensive care units: a prospective, multicentre survey initiated by the European Confederation of Medical Mycology (ECMM) (2006-2008)

A prospective, observational, multicentre study of invasive candidosis (IC) in surgical patients in intensive care units (ICUs) was conducted from 2006 to 2008 in 72 ICUs in 14 European countries. A total of 779 patients (62.5% males, median age 63 years) with IC were included. The median rate of candidaemia was 9 per 1000 admissions. In 10.8% the infection was already present at the time of admission to ICU. Candida albicans accounted for 54% of the isolates, followed by Candida parapsilosis 18.5%, Candida glabrata 13.8%, Candida tropicalis 6%, Candida krusei 2.5%, and other species 5.3%. Infections due to C. krusei (57.9%) and C. glabrata (43.6%) had the highest crude mortality rate. The most common preceding surgery was abdominal (51.5%), followed by thoracic (20%) and neurosurgery (8.2%). Candida glabrata was more often isolated after abdominal surgery in patients ≥60 years, and C. parapsilosis was more often isolated in neurosurgery and multiple trauma patients as well as children ≤1 year of age. The most common first-line treatment was fluconazole (60%), followed by caspofungin (18.7%), liposomal amphotericin B (13%), voriconazole (4.8%) and other drugs (3.5%). Mortality in surgical patients with IC in ICU was 38.8%. Multivariate analysis showed that factors independently associated with mortality were: patient age ≥60 years (hazard ratio (HR) 1.9, p 0.001), central venous catheter (HR 1.8, p 0.05), corticosteroids (HR 1.5, p 0.03), not receiving systemic antifungal treatment for IC (HR 2.8, p <0.0001), and not removing intravascular lines (HR 1.6, p 0.02).

Emerging drugs and vaccines for candidemia

Candidemia and other forms of invasive candidiasis are important causes of morbidity and mortality. The evolving challenge of antimicrobial resistance among fungal pathogens continues to highlight the need for potent, new antifungal agents. MEDLINE, EMBASE, Scopus and Web of Science searches (up to January 2014) of the English-language literature were performed with the keywords 'Candida' or 'Candidemia' or 'Candidiasis' and terms describing investigational drugs with activity against Candida spp. Conference abstracts and the bibliographies of pertinent articles were also reviewed for relevant reports. ClinicalTrials.gov was searched for relevant clinical trials. Currently available antifungal agents for the treatment of candidemia are summarised. Investigational antifungal agents with potential activity against Candida bloodstream infections and other forms of invasive candidiasis and vaccines for prevention of Candida infections are also reviewed as are selected antifungal agents no longer in development. Antifungal agents currently in clinical trials include isavuconazole, albaconazole, SCY-078, VT-1161 and T-2307. Further data are needed to determine the role of these compounds in the treatment of candidemia and other forms of invasive candidiasis. The progressive reduction in antimicrobial drug development may result in a decline in antifungal drug discovery. Still, there remains a critical need for new antifungal agents to treat and prevent invasive candidiasis and other life-threatening mycoses.

Cost analysis of voriconazole versus liposomal amphotericin B for primary therapy of invasive aspergillosis among patients with haematological disorders in Germany and Spain

Background

The current healthcare climate demands pharmacoeconomic evaluations for different treatment strategies incorporating drug acquisition costs, costs incurred for hospitalisation, drug administration and preparation, diagnostic and laboratory testing and drug-related adverse events (AEs). Here we evaluate the pharmacoeconomics of voriconazole versus liposomal amphotericin B as first-line therapies for invasive aspergillosis (IA) in patients with haematological malignancy and prolonged neutropenia or who were undergoing haematopoietic stem-cell transplantation in Germany or Spain.

Methods

A decision analytic model based on a decision tree was constructed to estimate the potential treatment costs of voriconazole versus liposomal amphotericin B. Each model pathway was defined by the probability of an event occurring and the costs of clinical outcomes. Outcome probabilities and cost inputs were derived from the published literature, clinical trials, expert panels and local database costs. In the base case, patients who failed to respond to first-line therapy were assumed to experience a single switch between comparator drugs or the other drug was added as second-line treatment. Base-case evaluation included only drug-management costs and additional hospitalisation costs due to severe AEs associated with first- and second-line therapies. Sensitivity analyses were conducted to assess the robustness of the results. Cost estimates were inflated to 2011 euros (€).

Results

Based on clinical trial success rates of 52.8% (voriconazole) and 50.0% (liposomal amphotericin B), voriconazole had lower total treatment costs compared with liposomal amphotericin B in both Germany (€12,256 versus €18,133; length of therapy [LOT] = 10-day intravenous [IV] + 5-day oral voriconazole and 15-day IV liposomal amphotericin B) and Spain (€8,032 versus €10,516; LOT = 7-day IV + 8-day oral voriconazole and 15-day IV liposomal amphotericin B). Assuming the same efficacy (50.0%) in first-line therapy, voriconazole maintained a lower total treatment cost compared with liposomal amphotericin B. Cost savings were primarily due to the lower drug acquisition costs and shorter IV LOT associated with voriconazole. Sensitivity analyses showed that the results were sensitive to drug price, particularly the cost of liposomal amphotericin B.

Conclusions

Voriconazole is likely to be cost-saving compared with liposomal amphotericin B when used as a first-line treatment for IA in Germany and Spain.

Prospective observational multicenter study to define a diagnostic algorithm for biliary candidiasis

AIM: To develop an algorithm to improve the diagnosis and treatment of patients with biliary candidiasis.

METHODS: We performed a prospective study of 127 patients who underwent endoscopic retrograde cholangiopancreatography, for various biliary disorders, at 3 tertiary referral centers in Germany from July 2011 through July 2012 (ClinicalTrials.gov: NCT01109550). Bile, buccal, and stool samples were collected. When indicated, endoscopic transpapillary bile duct biopsies were performed to clarify the etiology of bile duct strictures and to prove invasive fungal infections.

RESULTS: Candida species were detected in 38 of the 127 bile samples (29.9%). By multivariate analysis patients’ age and previous endoscopic sphincterotomy were independent risk factors for biliary candidiasis (P < 0.05). Patients with immunosuppression (P = 0.058) and recent long-term antibiotic therapy (> 7 d) (P = 0.089) tend to be at risk for biliary candidiasis. One patient was negative in mycological culture of bile fluid but invasive biliary candidiasis was diagnosed histologically. Of Candida subspecies detected, 36.7% were azole-resistant, such as C glabrata. Eight patients received anti-mycotic therapy, based on our algorithm. Of these, 3 had cancer with biliary tract involvement, 2 had secondary sclerosing cholangitis, 1 had retroperitoneal fibrosis, and 5 had septicemia. In all patients contamination was ruled out by smears of the endoscope channel.

CONCLUSION: Gastroenterologists should be aware of frequent candida colonization in patients with cholangitis and biliary disorders. Our suggested algorithm facilitates the further clinical management.

Prevalence of fungal infections using National Health Insurance data from 2009-2013, South Korea

OBJECTIVES

The symptoms of fungal infections vary from minor to severe. According to recent reports, fungal infection prevalence is increasing due to increases in the aging population and in patients with compromised immune systems. However, the total prevalence of fungal infections in South Korea is unknown. We investigated the recent 5-year prevalence of each type of fungal infection in South Korea across age, sex, and regional groups.

METHODS

Nationwide data from the National Health Insurance of South Korea were used. The target population included patients who had received treatment for a fungal infection that was listed as the main disease. For each patient, multiple treatments were counted as one case per year in the data analysis.

RESULTS

The annual prevalence of all-type mycoses increased from 6.9% in 2009 to 7.4% in 2013. Among the specific groups, the prevalence of dermatophytosis was highest (5.2%), followed by that of opportunistic mycoses (1.7%) and superficial mycoses (0.2%). The prevalence of subcutaneous mycoses and generalized mycoses was very low (8 cases per 100,000 persons and 3 cases per 1 million persons, respectively).

CONCLUSIONS

Every year, approximately 7.1% of the Korean population receives treatment for fungal diseases. Cases of opportunistic mycoses are assumed to increase each year. Therefore, further research is needed to understand and monitor the prevalence of mycoses to establish management policies to reduce the burden of fungal diseases.

Current Epidemiology of Candida Infection

Candidemia and candidiasis are among the most frequent healthcare care-associated infections and lead to significant morbidity and mortality. The predominant species causing candidemia remains Candida albicans, but it has declined from the majority species to causing less than 50% of U.S. cases. Increasing proportions of infections are being caused by C. glabrata, which now causes almost 30% of U.S. cases, as well as C. parapsilosis and other non-C. albicans species. Outside the United States, the predominant species is dependent upon the region. Pediatric candidemia rates are declining in the U.S., but the cause of this decline has not been fully elucidated. While overall resistance to antifungal agents has remained low among Candida species, there is some concern for echinocandin resistance, as well as multidrug resistance, in C. glabrata. Although some aspects of candidemia and candidiasis have remained constant, rates, species, and susceptibility are in a constant state of flux.

Insufficient fluconazole exposure in pediatric cancer patients and the need for therapeutic drug monitoring in critically ill children

BACKGROUND

Fluconazole is recommended as first-line treatment in invasive candidiasis in children and infants. Although timely achievement of adequate exposure of fluconazole improves outcome, therapeutic drug monitoring is currently not recommended.

METHODS

We conducted a retrospective study of critically ill children treated with fluconazole from January 2007 to October 2013 and for whom fluconazole concentrations were available. We collected demographic, clinical, and treatment data through review of the medical records and determined the correlation of clinical variables with the fluconazole concentration. Additionally, we assessed the relation between the fluconazole concentration and the time to culture conversion in patients with proven invasive candidiasis.

RESULTS

In total, 99 pediatric patients met the inclusion criteria. The fluconazole concentration was considered subtherapeutic in 40% of the patients. Multiple linear regression analysis showed a significant, independent, and positive association of the fluconazole trough concentration with the fluconazole dose (P <.001), weight (P = .009), and the serum urea concentration (P = .003), and a significant, independent, and negative association with age (P = .004) and cancer as an underlying condition (P = .003). A higher fluconazole concentration was associated with a shorter time to culture conversion (hazard ratio = 1.076 [95% confidence interval, 1.017-1.138]; P = .011).

CONCLUSIONS

The fluconazole concentration is not sufficient in pediatric cancer patients with the currently recommended dose regimen, and a higher fluconazole dose is required to achieve adequate drug exposure. Therapeutic drug monitoring of fluconazole can be a valuable tool to detect possible underexposure in critically ill children.

Worrisome trends in incidence and mortality of candidemia in intensive care units (Paris area, 2002-2010)

Purpose

To analyze trends in incidence and mortality of candidemia in intensive care units (ICUs) vs. non-ICU hospitalized patients and to determine risk factors for infection by specific species and for death.

Methods

Active hospital-based surveillance program of incident episodes of candidemia due to common species in 24 tertiary care hospitals in the Paris area, France between October 2002 and September 2010.

Results

Among 2,507 adult cases included, 2,571 Candida isolates were collected and species were C. albicans (56 %), C. glabrata (18.6 %), C. parapsilosis (11.5 %), C. tropicalis (9.3 %), C. krusei (2.9 %), and C. kefyr (1.8 %). Candidemia occurred in ICU in 1,206 patients (48.1 %). When comparing ICU vs. non-ICU patients, the former had significantly more frequent surgery during the past 30 days, were more often preexposed to fluconazole and treated with echinocandin, and were less frequently infected with C. parapsilosis. Risk factors and age remained unchanged during the study period. A significant increased incidence in the overall population and ICU was found. The odds of being infected with a given species in ICU was influenced by risk factors and preexposure to fluconazole and caspofungin. Echinocandins initial therapy increased over time in ICU (4.6 % first year of study, to 48.5 % last year of study, p < 0.0001). ICU patients had a higher day-30 death rate than non-ICU patients (odds ratio [OR] 2.12; 95 % confidence interval [CI] 1.66–2.72; p < 0.0001). The day-30 and early (<day 8) death rates increased over time in ICU (from 41.5 % the first to 56.9 % the last year of study (p = 0.001) and 28.7–38.8 % (p = 0.0292), respectively). Independent risk factors for day-30 death in ICU were age, arterial catheter, Candida species, preexposure to caspofungin, and lack of antifungal therapy at the time of blood cultures results (p < 0.05).

Conclusions

The availability of new antifungals and the publication of numerous guidelines did not prevent an increase of candidemia and death in ICU patients in the Paris area.

Per-species risk factors and predictors of invasive Candida infections in patients admitted to pediatric intensive care units: development of ERICAP scoring systems

BACKGROUND

Prediction rules for invasive Candida infection (ICI) are available for adult but not for infants and children managed in pediatric intensive care units (PICU).

METHODS

Observational study in 24 PICU with prospective phase (all children admitted during 1 year) and retrospective review of ICI records. Four logistic regression models were performed using ICI by Candida spp., Candida albicans, Candida parapsilosis or Candida tropicalis as dependent variables. Scores were constructed.

RESULTS

One hundred and twenty five ICI (47 C. albicans, 37 C. parapsilosis, 19 C. tropicalis and 22 others) and 1022 controls were included. Incidence (cases/100 PICU admissions): 4.22 (all Candida), 2.44 (C. albicans), 1.41 (C. parapsilosis), 0.19 (C. tropicalis). ICI was associated [Area under the receiver operating characteristics curve (AUC) = 0.764, 95% confidence interval (CI) = 0.719-0.809, P < 0.001] with pre-PICU hospitalization ≥ 15 days [odds ratio (OR) = 3.3; score: +3], fever (OR = 2.6; +2), thrombopenia (OR = 2.0; +1) and parenteral nutrition (OR=2.4; +2). Additionally, the following associations were noted: C. albicans ICI (AUC = 0.716, 95% CI = 0.640-0.792, P < 0.001) with chronic metabolic disease (OR = 10.7; score:+4), surgical digestive process (OR = 2.8; +1), fever (OR = 2.8; +1) and parenteral nutrition (OR = 2.3; +1); C. parapsilosis ICI (AUC = 0.808, 95% CI = 0.739-0.877, P < 0.001) with previous colonization (OR = 7.1; score:+3), tracheostomy (OR = 5.1; +2), parenteral nutrition (OR = 4.3; +2), thrombopenia (OR = 3.6; +1) and previous bacterial infection (OR = 3.0; +1) and ICI by C. tropicalis (AUC = 0.941, 95% CI=0.886-0.995, P < 0.001) with thrombopenia (OR = 53.8; score: +10), neutropenia (OR = 7.2; +1), pre-PICU hospitalization ≥ 15 days (OR = 17.2; +3) and hematologic (OR = 22.4; +4) and cardiovascular infectious processes (OR = 5.5; +1). Specificity was >90% for cut offs of 5 (all Candida), 3 (C. albicans), 3 (C. parapsilosis) and 11 (C. tropicalis).

CONCLUSIONS

Once validated, these scores may help for identification of ICI by specific species allowing adequate empiric/prophylactic treatment.

Candidaemia observed at a university hospital in Milan (northern Italy) and review of published studies from 2010 to 2014

BACKGROUND

Candida species represent the fourth leading cause of nosocomial bloodstream infections (BSI) worldwide. However, candidaemia rates and species involved vary geographically.

OBJECTIVES

To evaluate the epidemiological pattern, risk factors for mortality and antifungal therapy of Candida BSI over a 5-year period (2008-2012) in a university hospital in northern Italy together with a review of the recent literature concerning candidaemia.

METHODS

A retrospective cohort study cross-linked with microbiology database was performed.

RESULTS

A total of 89 Candida BSI were identified in 42 males (47 %) and 47 females (52.8 %). The median age was 69 years (interquartile range 55-78) with 61.8 % of patients being older than 65 years. Considering all hospitalized patients, the overall incidence rate of candidaemia increased significantly from 2008 to 2012 (from 0.4 to 1.68 episodes per 10,000 patient/days) (p = 0.0001) with a mean linear increase in 5 new cases per year. Candida albicans was the predominant species isolated (64 %) followed by C. glabrata (19.1 %). The latter species was observed with significantly higher frequency in Internal Medicine and Intensive Care Units (ICU). In-hospital crude mortality was 41.6 %.

CONCLUSIONS

Candidaemia is an increasing BSI in our university hospital, in accordance with that observed in northern Italy, and it is still associated with high in-hospital crude mortality.

New insights into innate immune control of systemic candidiasis

Systemic infection caused by Candida species is the fourth leading cause of nosocomial bloodstream infection in modern hospitals and carries high morbidity and mortality despite antifungal therapy. A recent surge of immunological studies in the mouse models of systemic candidiasis and the parallel discovery and phenotypic characterization of inherited genetic disorders in antifungal immune factors that are associated with enhanced susceptibility or resistance to the infection have provided new insights into the cellular and molecular basis of protective innate immune responses against Candida. In this review, the new developments in our understanding of how the mammalian immune system responds to systemic Candida challenge are synthesized and important future research directions are highlighted.

Breakthrough candidaemia caused by phenotypically susceptible Candida spp. in patients with haematological malignancies does not correlate with established interpretive breakpoints

In a study of 27,864 patients with haematological malignancies, 40 patients with candidaemia were identified, among whom 21 developed candidaemia while receiving systemic antifungal therapy [breakthrough candidaemia (BTC)]. Demographic, clinical, microbiological and molecular features of these episodes were analysed. Compared with 19 patients with de novo candidaemia, patients with BTC were more likely to have neutropenia (81% vs. 63%), longer median duration of neutropenia (27 days vs. 15 days), hypogammaglobulinaemia (62% vs. 37%) and central venous catheters (CVCs) (86% vs. 68%). The median duration of prior antifungal exposure was 46 days (range 3-108 days). Among the 18 available Candida spp. isolates, 15 (83%) were phenotypically susceptible to the antifungal agent that the patient was receiving. Emergence of resistance was the mechanism leading to BTC in three cases of patients receiving echinocandins. Other possible mechanisms of BTC were (i) elevated (≥2) minimum lethal concentration/minimum inhibitory concentration (MLC/MIC) ratio (reduced ability for a fungicidal agent to kill a fungal pathogen) in all patients receiving amphotericin B and (ii) elevated MLC/MIC ratios in all Candida parapsilosis isolates with MICs≤1 μg/mL to echinocandins. DNA sequencing of the hotspot 1 region of the fks1 and fks2 genes in seven different isolates of C. parapsilosis group demonstrated P660A in Fks1 but no polymorphisms in fks2. In conclusion, mechanisms for BTC in the setting of prolonged neutropenia may be host-based (hypogammaglobulinaemia and CVC) and pathogen-based. CLSI interpretive breakpoints do not reliably predict BTC in patients with haematological malignancies and warrant further investigation.

Candida albicans and cancer: Can this yeast induce cancer development or progression?

There is currently increasing concern about the relation between microbial infections and cancer. More and more studies support the view that there is an association, above all, when the causal agents are bacteria or viruses. This review adds to this, summarizing evidence that the opportunistic fungus Candida albicans increases the risk of carcinogenesis and metastasis. Until recent years, Candida spp. had fundamentally been linked to cancerous processes as it is an opportunist pathogen that takes advantage of the immunosuppressed state of patients particularly due to chemotherapy. In contrast, the most recent findings demonstrate that C. albicans is capable of promoting cancer by several mechanisms, as described in the review: production of carcinogenic byproducts, triggering of inflammation, induction of Th17 response and molecular mimicry. We underline the need not only to control this type of infection during cancer treatment, especially given the major role of this yeast species in nosocomial infections, but also to find new therapeutic approaches to avoid the pro-tumor effect of this fungal species.