Tuboovarian abscess caused by Candida glabrata in a febrile neutropenic patient

Antifungal Combinations against Candida Species: From Bench to Bedside

Candida spp. is the major causative agent of fungal infections in hospitalized patients and the fourth most common cause of nosocomial bloodstream infection (BSI). The availability of standardized methods for testing the in vitro activity of antifungals along with the expanding of antifungal armamentarium, the rising of drug-resistance and the persistence of a high mortality rate in systemic candidiasis have led to an increased interest in combination therapy. Therefore, we aimed to review the scientific literature concerning the antifungal combinations against Candida. A literature search performed in PubMed yielded 92 studies published from 2000 to 2021: 29 articles referring to in vitro studies, six articles referring to either in vitro and in vivo (i.e., animal models) studies and 57 clinical articles. Pre-clinical studies involved 735 isolates of Candida species and 12 unique types of antifungal combination approaches including azoles plus echinocandins (19%), polyenes plus echinocandins (16%), polyenes plus azoles (13%), polyenes plus 5-flucytosine ([5-FC], 13%), azoles plus 5-FC (11%) and other types of combinations (28%). Results varied greatly, often being species-, drug- and methodology-dependent. Some combinatorial regimens exerted a synergistic effect against difficult-to-treat Candida species (i.e., azoles plus echinocandins; polyenes plus 5-FC) or they were more effective than monotherapy in prevent or reducing biofilm formation and in speeding the clearance of infected tissues (i.e., polyenes plus echinocandins). In 283 patients with documented Candida infections (>90% systemic candidiasis/BSI), an antifungal combination approach could be evaluated. Combinations included: azoles plus echinocandins (36%), 5-FC-combination therapies (24%), polyenes plus azoles (18%), polyenes plus echinocandins (16%) and other types of combination therapy (6%). Case reports describing combination therapies yielded favorable response in most cases, including difficult-to-treat fungal infections (i.e., endocarditis, osteoarticular infections, CNS infections) or difficult-to-treat fungal pathogens. The only randomized trial comparing amphotericin-B deoxycholate (AMB) plus FLU vs. AMB alone for treatment of BSI in nonneutropenic patients showed that the combination trended toward improved success and more-rapid clearance from the bloodstream. In summary, antifungal combinations against Candida have produced great interest in the past two decades. To establish whether this approach can become a reliable treatment option, additional in vitro and clinical data are warranted.

Case Report of a Tubo-ovarian Abscess Caused by Candida kefyr

BACKGROUND

Candida species are harmless commensals of hosts, including humans, but they can cause infection when the immune system is compromised. Infections with non-albicans species can occur, ranging from urinary tract infections to sepsis, especially among patients in intensive care units.

CASE

The patient, a 37-year-old woman, presented with severe abdominal pain, fever, and vomiting. The patient's symptoms and fever continued in spite of treatment with antibiotics, and she underwent exploratory laparotomy. Cyst content culture results showed that Candida kefyr was present in the cyst.

CONCLUSION

To the best of our knowledge, this is the first case report of a tubo-ovarian abscess caused by C. kefyr. Rare pathogens can be found in patients with a tubo-ovarian abscess, so culture of the abscess material is important for determining subsequent treatment, particularly in women who require an operation for tubo-ovarian abscess.

Tubo-Ovarian Abscess Caused by Candida Albicans in an Obese Patient

BACKGROUND

Tubo-ovarian abscess (TOA) arises in most cases from pelvic infection. Appropriate treatment includes use of antimicrobials and, especially in patients with increased BMI, drainage of the contents.

CASE

A 44-year-old morbidly obese woman (BMI 72) had a persistent TOA despite receiving antibiotic treatment for four months. She had no history of diabetes, and denied being sexually active. Imaging demonstrated a pelvic abscess of 14.9 × 8.9 × 11.1 cm. Successful percutaneous drainage was performed yielding purulent material which grew Candida albicans. The patient recovered after drainage of the abscess and the addition of fluconazole to her antimicrobials. She had no apparent risk factor for acquiring such an opportunistic infection, other than her morbid obesity.

CONCLUSION

Because morbid obesity may confer a relative immunodeficiency, morbidly obese patients may develop unusual infections such as opportunistic fungal abscesses.

Efficacy of micafungin against deep-seated candidiasis in cyclophosphamide-induced immunosuppressed mice

OBJECTIVES

We investigated the effects of fluconazole and micafungin for the therapy of deep-seated candidiasis in a cyclophosphamide-induced immunosuppressed mouse model.

METHODS

We used the experimental model of intraperitoneal fungal abscess caused by Candida albicans, as described previously.

RESULTS AND CONCLUSIONS

Micafungin efficacy was equal to that of fluconazole in one-tenth dosage even in peritonitis. We also assessed the short-term (24 h) and long-term (8 days) therapeutic effects after the end of therapy. Although the therapeutic effect of fluconazole was similar to that of micafungin at 24 h after the end of therapy, the effect of micafungin was superior to that of fluconazole at 8 days after the end of therapy.