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Lin SY, Huang HY, Chang LL, Wang YL, Chen TC, Chang K, Tu HP, Lu PL. The impact of the fluconazole trailing effect on the persistence of Candida albicans bloodstream infection when treated with fluconazole. Clin Microbiol Infect 2024; 30:945-950. [PMID: 38527614 DOI: 10.1016/j.cmi.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 03/10/2024] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVES The trailing effect of Candida species is a phenomenon characterized by reduced but persistent growth at antifungal concentrations above the MIC. We assessed the impact of trailing growth on the persistence of Candida albicans candidemia in patients receiving fluconazole (FLC) therapy. METHODS We retrospectively investigated candidemia isolates at three hospitals in southern Taiwan between 2013 and 2020. Patients treated with FLC for FLC-susceptible C. albicans candidemia were enrolled. The degree of trailing was determined as the average growth above the MIC divided by the measured growth at the lowest drug concentration using the EUCAST method and classified into four categories: residual (0.1-5%), slight (6-10%), moderate (11-15%), and heavy trailers (>15%). RESULTS Among isolates from 190 patients, the proportions of heavy trailers at 24 hours, 48 hours, and 72 hours were 63.7% (121/190), 63.2% (120/190), and 74.7% (142/190), respectively. Persistent candidemia was observed in 17 (8.9 %) patients. The proportion of persistent C. albicans candidemia in heavy trailing isolates at 48 hours was higher than in isolates without heavy trailing (13.3% [16/120] vs. 1.4% [1/70], p = 0.007). A multivariate analysis showed that immunosuppression (OR = 7.92; 95% CI: 2.38-26.39, p = 0.001), hospitalization days after the index date of C. albicans identification (OR = 1.03; 95% CI: 1.01-1.05, p = 0.011), and heavy trailing isolates at 48 hours (OR = 10.04; 95% CI: 1.27-79.88, p = 0.029) were independent factors for persistent candidemia. DISCUSSION The current study revealed that heavy trailing in C. albicans isolates is associated with persistent candidemia in patients receiving FLC treatment.
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Affiliation(s)
- Shang-Yi Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ho-Yin Huang
- Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Lin-Li Chang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Microbiology and Immunology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ya-Ling Wang
- Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tun-Chieh Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ko Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Pin Tu
- Department of Public Health and Environmental Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Liang Lu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Wattier RL, Bucayu RFT, Boge CLK, Ross RK, Yildirim I, Zaoutis TE, Palazzi DL, Vora SB, Castagnola E, Avilés-Robles M, Danziger-Isakov L, Tribble AC, Sharma TS, Arrieta AC, Maron G, Berman DM, Yin DE, Sung L, Green M, Roilides E, Belani K, Romero J, Soler-Palacin P, López-Medina E, Nolt D, Bin Hussain IZ, Muller WJ, Hauger SB, Halasa N, Dulek D, Pong A, Gonzalez BE, Abzug MJ, Carlesse F, Huppler AR, Rajan S, Aftandilian C, Ardura MI, Chakrabarti A, Hanisch B, Salvatore CM, Klingspor L, Knackstedt ED, Lutsar I, Santolaya ME, Shuster S, Johnson SK, Steinbach WJ, Fisher BT. Adjunctive Diagnostic Studies Completed Following Detection of Candidemia in Children: Secondary Analysis of Observed Practice From a Multicenter Cohort Study Conducted by the Pediatric Fungal Network. J Pediatric Infect Dis Soc 2023; 12:487-495. [PMID: 37589394 PMCID: PMC10533205 DOI: 10.1093/jpids/piad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/11/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Adjunctive diagnostic studies (aDS) are recommended to identify occult dissemination in patients with candidemia. Patterns of evaluation with aDS across pediatric settings are unknown. METHODS Candidemia episodes were included in a secondary analysis of a multicenter comparative effectiveness study that prospectively enrolled participants age 120 days to 17 years with invasive candidiasis (predominantly candidemia) from 2014 to 2017. Ophthalmologic examination (OE), abdominal imaging (AbdImg), echocardiogram, neuroimaging, and lumbar puncture (LP) were performed per clinician discretion. Adjunctive diagnostic studies performance and positive results were determined per episode, within 30 days from candidemia onset. Associations of aDS performance with episode characteristics were evaluated via mixed-effects logistic regression. RESULTS In 662 pediatric candidemia episodes, 490 (74%) underwent AbdImg, 450 (68%) OE, 426 (64%) echocardiogram, 160 (24%) neuroimaging, and 76 (11%) LP; performance of each aDS per episode varied across sites up to 16-fold. Longer durations of candidemia were associated with undergoing OE, AbdImg, and echocardiogram. Immunocompromised status (58% of episodes) was associated with undergoing AbdImg (adjusted odds ratio [aOR] 2.38; 95% confidence intervals [95% CI] 1.51-3.74). Intensive care at candidemia onset (30% of episodes) was associated with undergoing echocardiogram (aOR 2.42; 95% CI 1.51-3.88). Among evaluated episodes, positive OE was reported in 15 (3%), AbdImg in 30 (6%), echocardiogram in 14 (3%), neuroimaging in 9 (6%), and LP in 3 (4%). CONCLUSIONS Our findings show heterogeneity in practice, with some clinicians performing aDS selectively, potentially influenced by clinical factors. The low frequency of positive results suggests that targeted application of aDS is warranted.
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Affiliation(s)
- Rachel L Wattier
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Robert F T Bucayu
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Craig L K Boge
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rachael K Ross
- Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | - Inci Yildirim
- Department of Pediatrics, Yale University School of Medicine, Connecticut, USA
- Yale Institute for Global Health, Yale University, New Haven, Connecticut, USA
- Yale Center for Infection and Immunity, New Haven, Connecticut, USA
- Department of Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Theoklis E Zaoutis
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Debra L Palazzi
- Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas, USA
| | - Surabhi B Vora
- Department of Pediatrics, University of Washington, Division of Infectious Diseases, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Elio Castagnola
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Martha Avilés-Robles
- Department of Infectious Diseases, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alison C Tribble
- Division of Infectious Diseases, Department of Pediatrics, University of Michigan and C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Tanvi S Sharma
- Division of Infectious Diseases, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antonio C Arrieta
- Department of Infectious Diseases, Children’s Hospital of Orange County, Orange, California, USA
- Department of Pediatrics, University of California Irvine, Irvine, California, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - David M Berman
- Division of Pediatric Infectious Diseases, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA
| | - Dwight E Yin
- Department of Pediatrics, Children’s Mercy and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Michael Green
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University and Hippokration Hospital, Thessaloniki, Greece
| | - Kiran Belani
- Pediatric Infectious Diseases, Children’s Minnesota, Minneapolis, Minnesota, USA
| | - José Romero
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Pere Soler-Palacin
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d’Hebron, Barcelona, Catalonia, Spain
| | - Eduardo López-Medina
- Centro de Estudios en Infectología Pediátrica, Clínica Imbanaco Grupo Quirónsalud and Universidad del Valle, Cali, Colombia
| | - Dawn Nolt
- Department of Pediatrics, Oregon Health and Science University and Doernbecher Children’s Hospital, Portland, Oregon, USA
| | - Ibrahim Zaid Bin Hussain
- Pediatric Infectious Diseases, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - William J Muller
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sarmistha B Hauger
- Department of Pediatrics, University of Texas at Austin and Dell Children’s Medical Center, Austin, Texas, USA
| | - Natasha Halasa
- Department of Pediatrics, Vanderbilt University Medical Center and Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Daniel Dulek
- Department of Pediatrics, Vanderbilt University Medical Center and Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Alice Pong
- Department of Pediatrics, University of California San Diego and Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Blanca E Gonzalez
- Center for Pediatric Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark J Abzug
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Fabianne Carlesse
- Instituto de Oncologia Pediatrica–IOP/GRAACC-UNIFESP, São Paulo, Brazil
| | - Anna R Huppler
- Department of Pediatrics, Medical College of Wisconsin and Children’s Wisconsin, Milwaukee, Wisconsin, USA
| | - Sujatha Rajan
- Division of Pediatric Infectious Diseases, Cohen Children’s Medical Center, New Hyde Park, New York, USA
| | - Catherine Aftandilian
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Monica I Ardura
- Division of Infectious Diseases and Host Defense Program, Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University, Columbus, Ohio, USA
| | | | - Benjamin Hanisch
- Pediatric Infectious Diseases, Children’s National Health System, Washington, District of Columbia, USA
| | - Christine M Salvatore
- Division of Pediatric Infectious Diseases, Weill Cornell Medicine and Komansky Children’s Hospital, New York, New York, USA
| | - Lena Klingspor
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Irja Lutsar
- Department of Microbiology, University of Tartu, Tartu, Estonia
| | - Maria E Santolaya
- Hospital Dr. Luis Calvo Mackenna, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Sydney Shuster
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah K Johnson
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - William J Steinbach
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Brian T Fisher
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Li Y, Gu C, Yang Y, Ding Y, Ye C, Tang M, Liu J, Zeng Z. Epidemiology, antifungal susceptibility, risk factors, and mortality of persistent candidemia in adult patients in China: a 6-year multicenter retrospective study. BMC Infect Dis 2023; 23:369. [PMID: 37264301 DOI: 10.1186/s12879-023-08241-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/11/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Data on persistent candidemia (PC), a recognized complication of candidemia, are lacking in China. This study aimed to investigate the clinical characteristics and risk factors for the mortality of PC among adults in China. METHODS This 6-year retrospective study analyzed the prevalence, species distribution, antifungal susceptibility, risk factors, and patient mortality of PC among adults in three regional tertiary teaching hospitals in China from 2016 to 2021. We collected electronic laboratory records data of PC and non-PC patients and used the Student test or Mann-Whitney U test for a retrospective study. Logistic regression was used to identify risk factors associated with persistent candidemia. RESULTS The definition of PC was fulfilled by 36 patients (13.7%, 36/263). The mean age of the patients was 59.9 years (60 years for patients with PC; 59.8 years for those with non-PC; P > 0.05) and 131 (60.1%) were men [16 with PC (44.4%), 115 with non-PC (63.2%), P < 0.05]. The mean annual incidence was 0.15/1000 admissions (including PC 0.03/1000 admissions vs. non-PC 0.12/1000 admissions, P < 0.05). Candida parapsilosis (14/36, 38.9%) and Candida albicans (81/182, 44.5%) were the predominant pathogens in patients with PC and non-PC, respectively. Most isolates were susceptible to flucytosine (99.0%) and amphotericin B (99.5%), and the activity of antifungal agents against Candida species was not statistically significantly different between patients with PC and non-PC (P > 0.05). The 30-day mortality rate was 20.2% (16.7% with PC vs. 20.9% with non-PC, P > 0.05). Multivariable regression analysis showed that use of broad-spectrum antibiotics (odds ratio (OR), 5.925; 95% confidence interval (CI), 1.886-18.616, P = 0.002), fluconazole (OR, 3.389; 95% CI, 1.302-8.820, P = 0.012) and C. parapsilosis infection (OR, 6.143; 95% CI, 2.093-18.031, P = 0.001) were independent predictors of PC, sex (male) (OR, 0.199; 95% CI, 0.077-0.518, P = 0.001) was the protective factor for PC. Respiratory dysfunction (OR, 5.763; 95% CI, 1.592-20.864, P = 0.008) and length of hospital stay(OR, 0.925; 95% CI, 0.880-0.973, P = 0.002) were independent predictors of 30-day mortality in patients with non-PC. C. tropicalis bloodstream infection (OR, 12.642; 95% CI, 1.059-150.951; P = 0.045) was an independent predictor of 30-day mortality in patients with PC. CONCLUSIONS The epidemiological data of patients with PC and non-PC were different in the distribution of Candida species, the mean annual incidence and independent predictors of 30-day mortality. Flucytosine and amphotericin B could be used as first-choice drugs in the presence of PC infections.
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Affiliation(s)
- Yanping Li
- Department of Laboratory Medicine, the Affiliated Hospital of Southwest Medical University, 25 Taiping street, Luzhou, 646000, P.R. China
- Department of Laboratory Medicine, Luxian People's Hospital, Luxian, 646100, Sichuan Province, P.R. China
- Sichuan Province Engineering Technology Research Center of Clinical Diseases Molecular Diagnosis, Luzhou, 646000, P.R. China
- Clinical Diseases Molecular Diagnosis Key Laboratory of LuZhou, Luzhou, 646000, P.R. China
| | - Chenghong Gu
- Department of Laboratory Medicine, the Affiliated Hospital of Southwest Medical University, 25 Taiping street, Luzhou, 646000, P.R. China
- Department of Laboratory Medicine, Zigong Fourth People's Hospital, Zigong, 643000, P.R. China
| | - Yuling Yang
- Department of Laboratory Medicine, the Affiliated Hospital of Southwest Medical University, 25 Taiping street, Luzhou, 646000, P.R. China
- Department of Laboratory Medicine, The Second People's Hospital of Neijiang, Neijiang, 641000, P.R. China
| | - Yinhuan Ding
- Department of Laboratory Medicine, the Affiliated Hospital of Southwest Medical University, 25 Taiping street, Luzhou, 646000, P.R. China
- Sichuan Province Engineering Technology Research Center of Clinical Diseases Molecular Diagnosis, Luzhou, 646000, P.R. China
- Clinical Diseases Molecular Diagnosis Key Laboratory of LuZhou, Luzhou, 646000, P.R. China
| | - Caihong Ye
- Department of Laboratory Medicine, the Affiliated Hospital of Southwest Medical University, 25 Taiping street, Luzhou, 646000, P.R. China
- Sichuan Province Engineering Technology Research Center of Clinical Diseases Molecular Diagnosis, Luzhou, 646000, P.R. China
- Clinical Diseases Molecular Diagnosis Key Laboratory of LuZhou, Luzhou, 646000, P.R. China
| | - Min Tang
- Department of Laboratory Medicine, the Affiliated Hospital of Southwest Medical University, 25 Taiping street, Luzhou, 646000, P.R. China
- Sichuan Province Engineering Technology Research Center of Clinical Diseases Molecular Diagnosis, Luzhou, 646000, P.R. China
- Clinical Diseases Molecular Diagnosis Key Laboratory of LuZhou, Luzhou, 646000, P.R. China
| | - Jinbo Liu
- Department of Laboratory Medicine, the Affiliated Hospital of Southwest Medical University, 25 Taiping street, Luzhou, 646000, P.R. China.
- Sichuan Province Engineering Technology Research Center of Clinical Diseases Molecular Diagnosis, Luzhou, 646000, P.R. China.
- Clinical Diseases Molecular Diagnosis Key Laboratory of LuZhou, Luzhou, 646000, P.R. China.
| | - Zhangrui Zeng
- Department of Laboratory Medicine, the Affiliated Hospital of Southwest Medical University, 25 Taiping street, Luzhou, 646000, P.R. China.
- Sichuan Province Engineering Technology Research Center of Clinical Diseases Molecular Diagnosis, Luzhou, 646000, P.R. China.
- Clinical Diseases Molecular Diagnosis Key Laboratory of LuZhou, Luzhou, 646000, P.R. China.
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Phongkhun K, Pothikamjorn T, Srisurapanont K, Manothummetha K, Sanguankeo A, Thongkam A, Chuleerarux N, Leksuwankun S, Meejun T, Thanakitcharu J, Walker M, Gopinath S, Torvorapanit P, Langsiri N, Worasilchai N, Moonla C, Plongla R, Kates OS, Nematollahi S, Permpalung N. Prevalence of Ocular Candidiasis and Candida Endophthalmitis in Patients With Candidemia: A Systematic Review and Meta-Analysis. Clin Infect Dis 2023; 76:1738-1749. [PMID: 36750934 PMCID: PMC10411939 DOI: 10.1093/cid/ciad064] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/29/2022] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Infectious diseases and ophthalmology professional societies have disagreed regarding ocular screening in patients with candidemia. We aimed to summarize the current evidence on the prevalence of ocular candidiasis (OC) and Candida endophthalmitis (CE) according to the standardized definitions. METHODS A literature search was conducted from the inception date through 16 October 2022 using PubMed, Embase, and SCOPUS. Pooled prevalence of ocular complications was derived from generalized linear mixed models (PROSPERO CRD42022326610). RESULTS A total of 70 and 35 studies were included in the meta-analysis for OC and concordant CE (chorioretinitis with vitreous involvement), respectively. This study represented 8599 patients with candidemia who underwent ophthalmologic examination. Pooled prevalences (95% CI) of OC, overall CE, concordant CE, and discordant CE were 10.7% (8.4-13.5%), 3.1% (2.1-4.5%), 1.8% (1.3-2.6%), and 7.4% (4.5-12%) of patients screened, respectively. Studies from Asian countries had significantly higher concordant CE prevalence (95% CI) of patients screened (3.6%; 2.9-4.6%) compared with studies from European countries (1.4%; .4-5%) and American countries (1.4%; .9-2.2%) (P <.01). Presence of total parenteral nutrition and Candida albicans was associated with CE, with pooled odds ratios (95% CI) of 6.92 (3.58-13.36) and 3.02 (1.67-5.46), respectively. CONCLUSIONS Prevalence of concordant CE overall and among Asian countries was 2 and 4 times higher than the prevalence previously reported by the American Academy of Ophthalmology (AAO) of <0.9%, respectively. There is an urgent need to study optimal screening protocols and to establish joint recommendations by the Infectious Diseases Society of America and AAO.
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Affiliation(s)
- Kasidis Phongkhun
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Thananop Pothikamjorn
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Kasama Manothummetha
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Anawin Sanguankeo
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Achitpol Thongkam
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nipat Chuleerarux
- Department of Medicine, Jackson Memorial Hospital/University of Miami, Miami, Florida, USA
| | - Surachai Leksuwankun
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Tanaporn Meejun
- Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Morgan Walker
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland, USA
| | - Shilpa Gopinath
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pattama Torvorapanit
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nattapong Langsiri
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Chatphatai Moonla
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rongpong Plongla
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Olivia S Kates
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Saman Nematollahi
- Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Nitipong Permpalung
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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5
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Vena A, Bovis F, Tutino S, Santagostino Barbone A, Mezzogori L, Ponzano M, Taramasso L, Baldi F, Dettori S, Labate L, Russo C, Giacobbe DR, Mikulska M, Dentone C, Magnasco L, Marchese A, Robba C, Ball L, Battaglini D, Pelosi P, Crea F, Di Pilato V, Di Biagio A, Bouza E, Muñoz P, Bassetti M. Short Course of Antifungal Therapy in Patients With Uncomplicated Candida Bloodstream Infection: Another Case of Less Is More in the Clinical Setting? Open Forum Infect Dis 2022; 10:ofac656. [PMID: 36655192 PMCID: PMC9835756 DOI: 10.1093/ofid/ofac656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Background The objective of this study was to compare the clinical outcomes of patients receiving a short course (SC) vs a prolonged course (PC) of antifungal therapy for uncomplicated Candida bloodstream infections (BSIs). Methods All episodes of uncomplicated Candida BSI from September 1, 2018, to August 31, 2020, were reviewed. We compared the primary (all-cause 90-day mortality) and secondary study end points (1-year recurrent Candida BSI and all-cause 1-year mortality) among patients who underwent SC (5-11 days) or PC (12-24 days) therapy using propensity score analysis with the inverse probability of treatment weighting (IPTW) method. Results A total of 114 patients with uncomplicated Candida BSI were included: 35 (30.7%) were classified into the SC group (median [interquartile range {IQR}], 9 [7-11] days) and 79 (69.3%) into the PC group (median [IQR], 14 [14-16] days). Patients in the SC group compared with the PC group had a higher rate of hospitalization in the surgical ward (40.0% vs 19.0%; P = .02) or septic shock at the time of Candida BSI onset (11.4% vs 1.3%; P = .03). The risk of 90-day mortality was not different between the SC and PC groups (n = 8 [22.9%] vs 17 [21.5%], respectively; IPTW-adjusted subdistribution hazard ratio [sHR], 0.67; 95% CI, 0.31-1.47; P = .20). The risk for recurrent Candida BSI within 1 year of completing therapy (IPTW-adjusted sHR, 1.07; 95% CI, 0.20-5.80; P = .94) or for all-cause 1-year mortality (IPTW-adjusted HR, 0.72; 95% CI, 0.35-1.50; P = .38) did not differ between groups. Conclusions Receiving a short vs prolonged course of antifungal therapy did not affect mortality or BSI recurrence in patients with uncomplicated candidemia.
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Affiliation(s)
- Antonio Vena
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Francesca Bovis
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Biostatistics Unit, University of Genoa, Genoa, Italy
| | - Stefania Tutino
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | | | - Laura Mezzogori
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Marta Ponzano
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Biostatistics Unit, University of Genoa, Genoa, Italy
| | - Lucia Taramasso
- Correspondence: Lucia Taramasso, MD, PhD, Infectious Diseases Unit, Ospedale Policlinico San Martino—IRCCS, University of Genoa, L.go R. Benzi, 10–16132 Genoa, Italy ()
| | - Federico Baldi
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Silvia Dettori
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Laura Labate
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Chiara Russo
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Malgorzata Mikulska
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Chiara Dentone
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Laura Magnasco
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Anna Marchese
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Microbiology Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Denise Battaglini
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Francesca Crea
- Microbiology Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Vincenzo Di Pilato
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Microbiology Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Antonio Di Biagio
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Hospital Gregorio Marañón, Madrid, Spain,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Hospital Gregorio Marañón, Madrid, Spain,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Seagle EE, Jackson BR, Lockhart SR, Jenkins EN, Revis A, Farley MM, Harrison LH, Schaffner W, Markus TM, Pierce RA, Zhang AY, Lyman MM. Recurrent Candidemia: Trends and Risk Factors Among Persons Residing in 4 US States, 2011-2018. Open Forum Infect Dis 2022; 9:ofac545. [PMID: 36324324 PMCID: PMC9620433 DOI: 10.1093/ofid/ofac545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Background Candidemia is a common healthcare-associated infection with high mortality. Estimates of recurrence range from 1% to 17%. Few studies have focused on those with recurrent candidemia, who often experience more severe illness and greater treatment failure. We describe recurrent candidemia trends and risk factors. Methods We analyzed population-based candidemia surveillance data collected during 2011-2018. Persons with >1 episode (defined as the 30-day period after a positive Candida species) were classified as having recurrent candidemia. We compared factors during the initial episode between those who developed recurrent candidemia and those who did not. Results Of the 5428 persons identified with candidemia, 326 (6%) had recurrent infection. Recurrent episodes occurred 1.0 month to 7.6 years after any previous episode. In multivariable logistic regression controlling for surveillance site and year, recurrent candidemia was associated with being 19-44 years old (vs ≥65 years; adjusted odds ratio [aOR], 3.05 [95% confidence interval {CI}, 2.10-4.44]), being discharged to a private residence (vs medical facility; aOR, 1.53 [95% CI, 1.12-2.08]), hospitalization in the 90 days prior to initial episode (aOR, 1.66 [95% CI, 1.27-2.18]), receipt of total parenteral nutrition (aOR, 2.08 [95% CI, 1.58-2.73]), and hepatitis C infection (aOR, 1.65 [95% CI, 1.12-2.43]). Conclusions Candidemia recurrence >30 days after initial infection occurred in >1 in 20 persons with candidemia. Associations with younger age and hepatitis C suggest injection drug use may play a modifiable role. Prevention efforts targeting central line care and total parenteral nutrition use may help reduce the risk of recurrent candidemia.
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Affiliation(s)
- Emma E Seagle
- ASRT, Inc, Atlanta, Georgia, USA,Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brendan R Jackson
- Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Shawn R Lockhart
- Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Emily N Jenkins
- Correspondence: Emily N. Jenkins, MPH, ASRT, Inc, Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS H24-9, Atlanta, GA, 30329 ()
| | - Andrew Revis
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA,Foundation for Atlanta Veterans Education and Research, Atlanta, Georgia, USA,Georgia Emerging Infections Program, Atlanta, Georgia, USA
| | - Monica M Farley
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA,Georgia Emerging Infections Program, Atlanta, Georgia, USA,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lee H Harrison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Rebecca A Pierce
- Oregon Public Health Division, Oregon Health Authority, Portland, Oregon, USA
| | - Alexia Y Zhang
- Oregon Public Health Division, Oregon Health Authority, Portland, Oregon, USA
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7
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Chen YN, Hsu JF, Chu SM, Lai MY, Lin C, Huang HR, Yang PH, Chiang MC, Tsai MH. Clinical and Microbiological Characteristics of Neonates with Candidemia and Impacts of Therapeutic Strategies on the Outcomes. J Fungi (Basel) 2022; 8:jof8050465. [PMID: 35628721 PMCID: PMC9148079 DOI: 10.3390/jof8050465] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022] Open
Abstract
Neonatal candidemia is associated with significant morbidities and a high mortality rate. We aimed to investigate the clinical characteristics of Candida bloodstream infections in neonates and the impact of therapeutic strategies on the outcomes. We identified all the neonates with candidemia from a medical center in Taiwan over an 18-year period (2003−2021) and analyzed them. Clinical isolates were confirmed by DNA sequencing, and antifungal susceptibility testing was performed. The prognostic factors associated with clinical treatment failure (30-day, all-cause mortality and persistent candidemia > 72 h after antifungal agents) and in-hospital mortality were analyzed using logistic regression modeling. A total of 123 neonates with 139 episodes of candidemia were included in the study. The median (IQR) gestational age and birth weight of the neonates with candidemia were 29.0 (26.0−35.0) weeks and 1104.0 (762.0−2055) g, respectively. The most common Candida spp. was Candida albicans (n = 57, 41.0%), followed by C. parapsilosis (n = 44, 31.7%), Candida guilliermondii (n = 12, 8.6%), and C. glabrata (n = 11, 7.9%). The overall susceptibility to fluconazole was 81.3%, and the resistant rates against other antifungal agents were less than 3%. The cumulative mortality rate at 7 and 30 days after the first episode of candidemia was 11.3% and 32.3%, respectively. The overall in-hospital mortality rate was 42.3%. The treatment outcomes did not change over the study period and were not affected by delayed initiation of antifungal agents. Multivariate analysis showed that delayed catheter removal (odds ratio [OR], 5.54; 95% confidence interval [CI]: 1.93−15.86, p = 0.001), septic shock (OR, 7.88; 95% CI: 2.83−21.93, p < 0.001), and multiple chronic comorbidities (OR, 8.71; 95% CI: 1.82−41.81, p = 0.007) were independently associated with the final in-hospital mortality. We concluded that the overall mortality of neonatal candidemia has remained consistently high over the past decade. Prompt early catheter removal and an aggressive treatment strategy for neonatal candidemia with septic shock would be critical to improving patient outcomes.
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Affiliation(s)
- Yu-Ning Chen
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-N.C.); (J.-F.H.); (S.-M.C.); (M.-Y.L.); (H.-R.H.); (M.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.L.); (P.-H.Y.)
| | - Jen-Fu Hsu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-N.C.); (J.-F.H.); (S.-M.C.); (M.-Y.L.); (H.-R.H.); (M.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.L.); (P.-H.Y.)
| | - Shih-Ming Chu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-N.C.); (J.-F.H.); (S.-M.C.); (M.-Y.L.); (H.-R.H.); (M.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.L.); (P.-H.Y.)
| | - Mei-Yin Lai
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-N.C.); (J.-F.H.); (S.-M.C.); (M.-Y.L.); (H.-R.H.); (M.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.L.); (P.-H.Y.)
| | - Chih Lin
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.L.); (P.-H.Y.)
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Hsuan-Rong Huang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-N.C.); (J.-F.H.); (S.-M.C.); (M.-Y.L.); (H.-R.H.); (M.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.L.); (P.-H.Y.)
| | - Peng-Hong Yang
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.L.); (P.-H.Y.)
- Department of Pediatrics, Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Ming-Chou Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-N.C.); (J.-F.H.); (S.-M.C.); (M.-Y.L.); (H.-R.H.); (M.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.L.); (P.-H.Y.)
| | - Ming-Horng Tsai
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.L.); (P.-H.Y.)
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin 638, Taiwan
- Correspondence: ; Tel.: +886-5-691-5151 (ext. 2879); Fax: +886-5-691-3222
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8
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Machado M, Estévez A, Sánchez-Carrillo C, Guinea J, Escribano P, Alonso R, Valerio M, Padilla B, Bouza E, Muñoz P. Incidence of Candidemia Is Higher in COVID-19 versus Non-COVID-19 Patients, but Not Driven by Intrahospital Transmission. J Fungi (Basel) 2022; 8:jof8030305. [PMID: 35330307 PMCID: PMC8950429 DOI: 10.3390/jof8030305] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 01/27/2023] Open
Abstract
There is scarce information on the actual incidence of candidemia in COVID-19 patients. In addition, comparative studies of candidemia episodes in COVID-19 and non-COVID-19 patients are heterogeneous. Here, we assessed the real incidence, epidemiology, and etiology of candidemia in COVID-19 patients, and compared them with those without COVID-19 (2020 vs. 2019 and 2020, respectively). We also genotyped all C. albicans, C. parapsilosis, and C. tropicalis isolates (n = 88), causing candidemia in both groups, providing for the first time a genotypic characterization of isolates gathered in patients with either COVID-19 or non-COVID-19. Incidence of candidemia was higher in patients with COVID-19 than non-COVID-19 (4.73 vs. 0.85 per 1000 admissions; 3.22 vs. 1.14 per 10,000 days of stay). No substantial intergroup differences were found, including mortality. Genotyping proved the presence of a low number of patients involved in clusters, allowing us to rule out rampant patient-to-patient Candida transmission. The four patients, involved in two clusters, had catheter-related candidemia diagnosed in the first COVID-19 wave, which demonstrates breaches in catheter management policies occurring in such an overwhelming situation. In conclusion, the incidence of candidemia in patients with COVID-19 is significantly higher than in those without COVID-19. However, genotyping shows that this increase is not due to uncontrolled intrahospital transmission.
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Affiliation(s)
- Marina Machado
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (C.S.-C.); (J.G.); (P.E.); (R.A.); (M.V.); (B.P.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
- Correspondence: (M.M.); (A.E.)
| | - Agustín Estévez
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (C.S.-C.); (J.G.); (P.E.); (R.A.); (M.V.); (B.P.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
- Correspondence: (M.M.); (A.E.)
| | - Carlos Sánchez-Carrillo
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (C.S.-C.); (J.G.); (P.E.); (R.A.); (M.V.); (B.P.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias-CIBERES (CB06/06/0058), 28029 Madrid, Spain
| | - Jesús Guinea
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (C.S.-C.); (J.G.); (P.E.); (R.A.); (M.V.); (B.P.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias-CIBERES (CB06/06/0058), 28029 Madrid, Spain
| | - Pilar Escribano
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (C.S.-C.); (J.G.); (P.E.); (R.A.); (M.V.); (B.P.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
| | - Roberto Alonso
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (C.S.-C.); (J.G.); (P.E.); (R.A.); (M.V.); (B.P.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias-CIBERES (CB06/06/0058), 28029 Madrid, Spain
- Medicine Department, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Maricela Valerio
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (C.S.-C.); (J.G.); (P.E.); (R.A.); (M.V.); (B.P.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
| | - Belén Padilla
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (C.S.-C.); (J.G.); (P.E.); (R.A.); (M.V.); (B.P.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (C.S.-C.); (J.G.); (P.E.); (R.A.); (M.V.); (B.P.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias-CIBERES (CB06/06/0058), 28029 Madrid, Spain
- Medicine Department, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (C.S.-C.); (J.G.); (P.E.); (R.A.); (M.V.); (B.P.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias-CIBERES (CB06/06/0058), 28029 Madrid, Spain
- Medicine Department, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
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Aldossary S, Shah A. Healthcare Utilization and Impact of Antifungal Stewardships Within Respiratory Care Settings: A Systematic Literature Review. Mycopathologia 2021; 186:673-684. [PMID: 33991279 PMCID: PMC8536614 DOI: 10.1007/s11046-021-00547-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/17/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Fungal infection and sensitization are common in chronic respiratory patient populations such as bronchiectasis, chronic obstructive pulmonary disease (COPD), and cystic fibrosis (CF) and are often associated with prolonged antifungal therapy (Hohmann et al. in Clin Infect Dis 15:939-940, 2010; Vissichelli et al. in Infect Prev Pract 1:100029, 2019), morbidity, and mortality. Although the use of antifungal stewardship (AFS) is increasing within an invasive fungal disease setting, its use and impact within a chronic respiratory setting have not been defined. METHODS A systematic literature review was conducted using PRISMA guidelines to evaluate the use of antifungal stewardship within a chronic respiratory care setting. Three databases have been searched, Medline via Ovid, Embase and GlobalHealth, for papers published between 1949 and 2020. RESULTS The initial search identified 987 papers from Medline, 1761 papers from Embase, and 481 papers from GlobalHealth. Only 28 papers met the criteria for inclusion in this systematic literature review. The included studies were subjected to CASP and GRADE assessments to rank their quality and applicability. Only two studies were focussed on Aspergillus species infection. CONCLUSION Although antifungal stewardship is increasing, its applications are still limited in chronic respiratory care settings despite the prolonged requirement for antifungal therapy and high antimicrobial resistance.
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Affiliation(s)
- Salma Aldossary
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anand Shah
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
- MRC Centre of Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK.
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10
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Mind the gaps: challenges in the clinical management of invasive candidiasis in critically ill patients. Curr Opin Infect Dis 2021; 33:441-448. [PMID: 33044240 DOI: 10.1097/qco.0000000000000684] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Strict adherence to clinical practice guidelines is recognized to improve outcomes but the inconvenient truth is that only a small subset of what is done in medicine has been tested in appropriate, well designed studies. In this article, we aim to review controversial aspects of the clinical management of invasive candidiasis recommended by guidelines. RECENT FINDINGS Despite still being recommended by guidelines, we fail to identify a single randomized clinical trial documenting that the use of antifungal drugs in high-risk critically ill patients without microbiologic documentation of Candida infection decreases mortality. Regarding deep-seated Candida infections, most cohort studies of patients with candidemia found less than 5% of patients developed endophthalmitis and endocarditis. In this scenario, it is reasonable to reconsider routine universal screening of both complications in candidemic patients. Finally, a large number of studies have shown that critically ill patients usually have lower echinocandin exposure when compared with other populations. We need more data on the clinical relevance of this finding. SUMMARY We need robust studies to validate new strategies for the clinical management of candidemia in ICU, including: the use of fungal biomarkers in the early initiation or interruption of antifungal therapy in high-risk patients to replace the conventional empirical antifungal therapy driven by predictive rules; validation of targeted screening of eye infection and endocarditis with the aid of fungal biomarkers only in high-risk patients; we should clarify if higher doses of candins are necessary to treat invasive candidiasis in critically ill patients, especially in the case of intra-abdominal infections where drug penetration is suboptimal.
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11
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Prevalence and Impact of Biofilms on Bloodstream and Urinary Tract Infections: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2021; 10:antibiotics10070825. [PMID: 34356749 PMCID: PMC8300799 DOI: 10.3390/antibiotics10070825] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/29/2021] [Accepted: 07/02/2021] [Indexed: 02/07/2023] Open
Abstract
This study sought to assess the prevalence and impact of biofilms on two commonly biofilm-related infections, bloodstream and urinary tract infections (BSI and UTI). Separated systematic reviews and meta-analyses of observational studies were carried out in PubMed and Web of Sciences databases from January 2005 to May 2020, following PRISMA protocols. Studies were selected according to specific and defined inclusion/exclusion criteria. The obtained outcomes were grouped into biofilm production (BFP) prevalence, BFP in resistant vs. susceptible strains, persistent vs. non-persistent BSI, survivor vs. non-survivor patients with BSI, and catheter-associated UTI (CAUTI) vs. non-CAUTI. Single-arm and two-arm analyses were conducted for data analysis. In vitro BFP in BSI was highly related to resistant strains (odds ratio-OR: 2.68; 95% confidence intervals-CI: 1.60–4.47; p < 0.01), especially for methicillin-resistant Staphylococci. BFP was also highly linked to BSI persistence (OR: 2.65; 95% CI: 1.28–5.48; p < 0.01) and even to mortality (OR: 2.05; 95% CI: 1.53–2.74; p < 0.01). Candida spp. was the microorganism group where the highest associations were observed. Biofilms seem to impact Candida BSI independently from clinical differences, including treatment interventions. Regarding UTI, multi-drug resistant and extended-spectrum β-lactamase-producing strains of Escherichia coli, were linked to a great BFP prevalence (OR: 2.92; 95% CI: 1.30–6.54; p < 0.01 and OR: 2.80; 95% CI: 1.33–5.86; p < 0.01). More in vitro BFP was shown in CAUTI compared to non-CAUTI, but with less statistical confidence (OR: 2.61; 95% CI: 0.67–10.17; p < 0.17). This study highlights that biofilms must be recognized as a BSI and UTI resistance factor as well as a BSI virulence factor.
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12
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Adequate duration of therapy in severe fungal infections. Curr Opin Crit Care 2021; 26:466-472. [PMID: 32773617 DOI: 10.1097/mcc.0000000000000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To highlight recent findings on the adequate duration of antifungal therapy in patients with invasive fungal disease (IFD). RECENT FINDINGS Plenty of published data available suggest that there is no additional clinical benefit at a certain point after initiation of antifungal treatment in patients with confirmed IFD. Moreover, the prolonged antifungal exposure can be associated with an increased risk of side effects and toxicity as well as striking risk for developing antifungal resistance or rising unnecessary healthcare costs. Recent data suggest that, in the presence of an adequate initial antifungal therapy and adequate source control of the infection, new stratified approaches integrating clinical judgment, biomarkers and microbiological eradication, should be considered as an alternative to the 'one-size-fits-all' treatment duration currently used worldwide. SUMMARY The optimal duration of antifungal therapy is still an unresolved issue that depends by many key elements including the host; the pathogen and its microbiological eradication, the adequateness of initial antifungal therapy and the promptness of source control of the infection. In general, many patients with invasive candidiasis can be treated with a 2 weeks course of antifungal therapy. Longer antifungal course (6 weeks or more) is generally required for patients with invasive aspergilosis.
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Ala-Houhala M, Anttila VJ. Characteristics of late recurrent candidemia in adult patients. Mycoses 2021; 64:503-510. [PMID: 33377571 DOI: 10.1111/myc.13236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Candida species are one of the most common causes of health care-associated bloodstream infections. However, recurrent candidemia is rare, and the characteristics of late recurrent (LR) candidemia are partly unclear. Our aim was to evaluate the characteristics of LR candidemia in adult patients. PATIENTS AND METHODS A retrospective cohort study was performed in the hospital district of Helsinki and Uusimaa in Finland (2007-2016). All candidemia cases were searched in an electronic database during the study period. Patients with LR candidemia were compared with patients with a single candidemia episode to evaluate the characteristics of LR candidemia. LR candidemia was defined as having at least two episodes of candidemia more than 30 days apart. RESULTS We identified 24 episodes of LR candidemia in 20 patients. Patients with LR candidemia represented 6% of all patients with candidemia during the study period, and most of these cases were nosocomial. The median time between the first and the recurrent episode was 5.1 months. One-year mortality in LR candidemia was 45%. Underlying gastrointestinal disease (OR 7.21, 95% CI 2.52-20.61) and history of intra-venous drug use (IVDU) (OR 3.62, 95% CI 1.03-12.69) were independent risk factors for LR candidemia in the multivariable analysis. CONCLUSION Our study indicates that the gastrointestinal tract may be a continuous source of infection in patients with chronic gastrointestinal diseases. Gastrointestinal diseases and IVDU should be regarded as risk factors for LR candidemia.
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Affiliation(s)
- Mari Ala-Houhala
- Inflammation Center, Division of Infectious Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Veli-Jukka Anttila
- Inflammation Center, Division of Infectious Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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14
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Esteves P, Lopes Lima S, Salles de Azevedo Melo A, Maria Beirão E, Nucci M, Colombo AL. (1,3)-β-D-glucan is able to predict therapeutic failure of patients with candidemia and not only mortality. Mycoses 2020; 64:264-271. [PMID: 33274533 DOI: 10.1111/myc.13224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Candidemia is a major cause of bloodstream infection in tertiary hospitals worldwide and fungal biomarkers may provide early diagnosis. OBJECTIVES To evaluate the performance of (1-3)-β-D-glucan (BDG) in the diagnosis of candidemia and its ability to predict therapeutic failure. PATIENTS AND METHODS This was a prospective, multi-centre study conducted in 3 Brazilian hospitals. Clinical outcome was evaluated along 2 weeks of treatment, and therapeutic failure was defined as the occurrence of persistent candidemia, Candida deep-seated infection or death. Baseline BDG detection was performed with the Fungitell® assay (Associates of Cape Cod, Falmouth-USA). RESULTS We enrolled a total of 71 patients with candidemia and a control group with 110 healthy volunteers. The sensitivity and specificity of BDG for diagnosing candidemia were as follows: 71.8% (95% confidence interval [95% CI] 59.7% - 81.5%) and 98.2% (95% CI 92.9% - 99.7%), respectively. The only predictor of therapeutic failure was a higher BDG value at diagnosis of candidemia; a value > 226 pg/mL predicted failure with sensitivity and specificity of 75% and 78%, respectively. CONCLUSIONS A high baseline serum BDG value was associated with therapeutic failure.
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Affiliation(s)
- Patrícia Esteves
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Soraia Lopes Lima
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Analy Salles de Azevedo Melo
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Elisa Maria Beirão
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcio Nucci
- Department of Internal Medicine, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Arnaldo L Colombo
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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15
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Dalla Lana DF, Falci DR, Sanha V, Jaskulski Filho SD, Schuch F, Pasqualotto AC. Candidaemia Mortality Has not Changed Over the Last 2 Decades in Brazil. Mycopathologia 2020; 185:685-690. [PMID: 32524348 DOI: 10.1007/s11046-020-00466-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/30/2020] [Indexed: 12/19/2022]
Abstract
Despite advances in fungal diagnostics and antifungal therapy, mortality associated with candidaemia remains very high, particularly in developing countries. In this study, we reviewed the Brazilian literature on candidaemia over the last 20 years (1999-2019), with the aim to document if mortality rates changed over the years in Brazil. Variables studied included number of patients with candidaemia per study, age, most prevalent Candida species and use of antifungals. Selected manuscripts evaluated a median of 114 patients, the majority being men (54.4%). Median age was 45 year-old. The most prevalent species in all studies was C. albicans (37.3%), followed by C. parapsilosis (23.0%). An increase in use of echinocandins occurred in recent years, with a proportional decrease in the use of fluconazole and amphotericin B. Surprisingly, mortality of candidaemia has remained unchanged over the years in the largest Latin American country, regardless of treatment with echinocandins. Potential explanations for these findings are discussed.
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Affiliation(s)
- Daiane F Dalla Lana
- Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Diego R Falci
- Infectious Diseases Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Valberto Sanha
- Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | | | - Felipe Schuch
- Department of Sports Methods and Techniques, Federal University of Santa Maria, Santa Maria, Brazil
| | - Alessandro C Pasqualotto
- Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil. .,Molecular Biology Laboratory, Santa Casa de Misericórdia de Porto Alegre, Av Independência 155, Hospital Dom Vicente Scherer, heliponto, Porto Alegre, RS, 90020-090, Brazil.
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16
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Ala‐Houhala M, Anttila V. Persistent vs non‐persistent candidaemia in adult patients in 2007‐2016: A retrospective cohort study. Mycoses 2020; 63:617-624. [DOI: 10.1111/myc.13085] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/29/2020] [Accepted: 03/31/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Mari Ala‐Houhala
- Division of Infectious Diseases Inflammation Center Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Veli‐Jukka Anttila
- Division of Infectious Diseases Inflammation Center Helsinki University Hospital and University of Helsinki Helsinki Finland
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17
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Bassetti M, Vena A, Meroi M, Cardozo C, Cuervo G, Giacobbe DR, Salavert M, Merino P, Gioia F, Fernández-Ruiz M, López-Cortés LE, Almirante B, Escolà-Vergé L, Montejo M, Aguilar-Guisado M, Puerta-Alcalde P, Tasias M, Ruiz-Gaitán A, González F, Puig-Asensio M, Marco F, Pemán J, Fortún J, Aguado JM, Soriano A, Carratalá J, Garcia-Vidal C, Valerio M, Sartor A, Bouza E, Muñoz P. Factors associated with the development of septic shock in patients with candidemia: a post hoc analysis from two prospective cohorts. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:117. [PMID: 32216822 PMCID: PMC7099832 DOI: 10.1186/s13054-020-2793-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 02/17/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Almost one third of the patients with candidemia develop septic shock. The understanding why some patients do and others do not develop septic shock is very limited. The objective of this study was to identify variables associated with septic shock development in a large population of patients with candidemia. METHODS A post hoc analysis was performed on two prospective, multicenter cohort of patients with candidemia from 12 hospitals in Spain and Italy. All episodes occurring from September 2016 to February 2018 were analyzed to assess variables associated with septic shock development defined according to The Third International Consensus Definition for Sepsis and Septic Shock (Sepsis-3). RESULTS Of 317 candidemic patients, 99 (31.2%) presented septic shock attributable to candidemia. Multivariate logistic regression analysis identifies the following factors associated with septic shock development: age > 50 years (OR 2.57, 95% CI 1.03-6.41, p = 0.04), abdominal source of the infection (OR 2.18, 95% CI 1.04-4.55, p = 0.04), and admission to a general ward at the time of candidemia onset (OR 0.21, 95% CI, 0.12-0.44, p = 0.001). Septic shock development was independently associated with a greater risk of 30-day mortality (OR 2.14, 95% CI 1.08-4.24, p = 0.02). CONCLUSIONS Age and abdominal source of the infection are the most important factors significantly associated with the development of septic shock in patients with candidemia. Our findings suggest that host factors and source of the infection may be more important for development of septic shock than intrinsic virulence factors of organisms.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata, Piazzale Santa Maria della Misericordia 15, 33010, Udine, Italy. .,Department of Health Sciences, University of Genoa, Genoa, Italy. .,Clinica Malattie Infettive, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy.
| | - Antonio Vena
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata, Piazzale Santa Maria della Misericordia 15, 33010, Udine, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Marco Meroi
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata, Piazzale Santa Maria della Misericordia 15, 33010, Udine, Italy
| | - Celia Cardozo
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Guillermo Cuervo
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | - Daniele Roberto Giacobbe
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | | | - Paloma Merino
- Hospital Universitario Clínico "San Carlos", Madrid, Spain
| | | | - Mario Fernández-Ruiz
- Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología Clínica, Hospital Universitario Virgen Macarena/Instituto de Biomedicina de Sevilla (IBiS)/Universidad de Sevilla/Centro Superior de Investigaciones Científicas, Seville, Spain
| | - Benito Almirante
- Hospital Universitari Vall d'Hebron, VHIR (Vall d'Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Escolà-Vergé
- Hospital Universitari Vall d'Hebron, VHIR (Vall d'Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Pedro Puerta-Alcalde
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Mariona Tasias
- Hospital Universitari I Politecnic "La Fe", Valencia, Spain
| | | | | | - Mireia Puig-Asensio
- Hospital Universitari Vall d'Hebron, VHIR (Vall d'Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesc Marco
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Javier Pemán
- Hospital Universitari I Politecnic "La Fe", Valencia, Spain
| | - Jesus Fortún
- Hospital Universitario "Ramón y Cajal", Madrid, Spain
| | - Jose Maria Aguado
- Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | - Alejandro Soriano
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Jordi Carratalá
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | - Carolina Garcia-Vidal
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Maricela Valerio
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, Spain
| | - Assunta Sartor
- Microbiology Unit, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, Spain.,Medicine Department School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Udine, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, Spain.,Medicine Department School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Udine, Spain
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