Impaired clearance and organ localization of Candida albicans in obstructive jaundice

Clinical significance of isolated biliary candidiasis in patients with unresectable cholangiocarcinoma

BACKGROUND

The frequency of isolated biliary candidiasis is increasing in cancer patients. The clinical significance of isolated biliary candidiasis remains unclear. We analyzed the risk factors of biliary candidiasis and outcomes of the patients with unresectable cholangiocarcinoma after percutaneous transhepatic biliary drainage (PTBD).

METHODS

Among 430 patients who underwent PTBD between January 2012 and March 2015, 121 patients had unresectable cholangiocarcinoma. Bile and blood samples were collected for consecutive fungal culture.

RESULTS

The study cohort included 49 women and 72 men with a median age of 71 years. Multivariate analysis showed that cancer progression (P=0.013), concurrent presence of another microorganism (P=0.010), and previous long-term (>7 days) antibiotic use (P=0.011) were potential risk factors of biliary candidiasis. Chemotherapy was not associated with overall biliary candidiasis (P=0.196), but was significantly related to repeated biliary candidiasis (P=0.011). Patients with isolated biliary candidiasis showed remarkably reduced survival compared with those without [median overall survival (OS): 32 vs 62 days, P=0.011]. Subgroup analysis was also performed. Patients with repeated candidiasis had markedly decreased survival compared with those with transient candidiasis (median OS: 30 vs 49 days, P=0.046). Biliary candidiasis was identified as a poor prognostic factor by univariate and multivariate analyses (P=0.033). Four cases of repeated candidiasis (4/19, 21%) showed Candida species in consecutive blood culture until the end of the study, but others showed no candidemia.

CONCLUSIONS

Isolated biliary candidiasis may be associated with poor prognosis in patients with unresectable cholangiocarcinoma. Especially, repeated biliary candidiasis may have the possibility of progression to candidemia. We suggest that biliary dilatation treatment or antifungal agents might be helpful for patients with biliary candidiasis.

Risk factors and outcome in patients with primary sclerosing cholangitis with persistent biliary candidiasis

Background

Candidiasis is commonly observed in patients with primary sclerosing cholangitis (PSC), but the clinical risk factors associated with its presence have not been fully investigated. In this study, we aimed to analyse the incidence, risk factors, and transplantation-free survival in primary sclerosing cholangitis (PSC) patients with persistent biliary candidiasis.

Methods

We retrospectively analysed patients diagnosed with PSC who were admitted to our department during 2002 to 2012. One-hundred fifty patients whose bile cultures were tested for fungal species were selected, and their clinical and laboratory parameters were investigated. The results of endoscopic retrograde cholangiography (ERC) and bile cultures were analysed using chart reviews. The cases of biliary candidiasis were sub-classified as transient or persistent.

Results

Thirty out of 150 (20.0%) patients had biliary candidiasis. Although all patients demonstrated comparable baseline characteristics, those with biliary candidiasis showed significantly reduced transplantation-free survival (p < 0.0001) along with a markedly elevated frequency of cholangiocarcinoma (CCA) (p = 0.04). The patients were further sub-classified according to the transient (15/30) or persistent (15/30) nature of their biliary candidiasis. A subgroup analysis showed reduced survival with a greater necessity for orthotopic liver transplantation (OLT) only in patients with persistence of Candida (p = 0.007). The survival in the patients with transient biliary candidiasis was comparable to that in candidiasis-free patients. In a multivariate regression analysis that included Mayo risk score (MRS), sex, age, dominant stenosis, inflammatory bowel disease, autoimmune hepatitis overlap syndrome, and number of times ERC was performed, biliary candidiasis was an independent risk factor for reduced survival (p = 0.008). Risk factors associated with acquisition of biliary candidiasis were age at PSC diagnosis and number of ERCs.

Conclusions

The persistence of biliary candidiasis is associated with markedly reduced transplantation-free survival in PSC patients. By contrast, actuarial survival in patients with transient biliary candidiasis approaches that for patients without any evidence of biliary candidiasis. Further studies on the treatment of persistent biliary candidiasis in patients with PSC are warranted.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0562-8) contains supplementary material, which is available to authorized users.

Candidosis in the intensive care unit: a 20-year survey

Deep-seated candidosis is a major problem in critically ill patients. Colonization with candida has been identified as an important independent risk factor for the development of candidaemia. Since the 1980s routine surveillance cultures have been performed on patients admitted for six or more days to the 'E. Vecla' intensive care unit (ICU) of the IRCCS Ospedale Maggiore di Milano. Colonization was observed on admission to the ICU in 59 of 117 (50%) patients in 2000 and 10 others developed colonization during their stay on the unit. A similar colonization rate was found in a survey performed 16 years earlier. The incidence of non-albicans Candida species, however, increased in 2000. In particular, 24 patients were culture positive for Candida glabrata at some point during their hospital stay, whereas this species was isolated from only one patient in 1983-1984. Antifungal susceptibility testing performed by Sensititre Yeast One revealed no resistance among 19 C. albicans strains tested. In contrast, fluconazole resistance was observed in two of 39 (5%) C. glabrata isolates from 23 patients. In the period 1983-2002, 28 candida bloodstream infections were identified and 12 were considered to be ICU-acquired (2.6/1000 hospitalized patients; 0.33/1000 patient days). The low rate of ICU-acquired candidaemia despite the inclusion of severely compromised patients in this study confirms the usefulness of routine mycological surveillance in preventing deep-seated candidosis.

Alterations of tumor necrosis factor-alpha and interleukin 6 production and activity of the reticuloendothelial system in experimental obstructive jaundice in rats

BACKGROUND

Immunological changes are well recognised in obstructive jaundice. The aim of this study was to monitor plasma tumor necrosis factor alpha (TNF-alpha) and interleukin-6 (IL-6) levels in rats with obstructive jaundice.

METHODS

The ability of splenocytes and peritoneal exudate cells (PEC) to produce these cytokines both spontaneously and on induction with lipopolysaccharide (LPS), was compared in rats with and without obstructive jaundice (OJ). The activity of the reticuloendothelial system (RES) was also measured.

RESULTS

Serum cytokine levels in OJ rats were higher than in control rats. PEC cultures produced significantly more IL-6, compared with control rats, declining thereafter. TNF-alpha activity in the splenocyte cultures of OJ rats was also higher than in the control group. Pronounced differences were found in the ability to produce TNF-alpha by PEC, i.e., TNF-alpha production was much stronger on day 7 in OJ rats than in controls. On day 14 TNF-alpha production was much lower and the spontaneous response was equal to the LPS-induced one. On day 21 the cells of OJ rats partially regained the ability to produce TNF-alpha RES activity of OJ rats was significantly suppressed in the liver and spleen, whereas the phagocytic activity in the lungs was elevated.

CONCLUSION

We have demonstrated that the immune reactivity of OJ rats, initially elevated, underwent subsequent depression. The study also revealed a major effect of the operation alone on the studied parameters.

Fungal infection in the intensive care unit

Fungal infection in critically ill patients is an increasingly prevalent problem. Candida spp. cause the majority of these infections in ICU. They occur most commonly in patients with severe underlying illness, multiple courses of antibiotics and intravascular catheters. Clinical diagnosis is difficult due to nonspecific signs and the frequent occurrence of widespread superficial colonization with Candida spp. in ventilated patients. Most patients are diagnosed using inferential evidence of infection, such as persistent pyrexia despite antibiotics, raised serum C-reactive protein and the presence of individual risk factors. Amphotericin B and fluconazole are the most commonly used anti-fungals dependent on the identity of the fungus. Most of these infections are endogenous; however, a proportion may be caused via the hands of healthcare staff or contaminated medical equipment.

Obstructive jaundice causes reduced expression of polymorphonuclear leucocyte adhesion molecules and a depressed response to bacterial wall products in vitro

BACKGROUND

Obstructive jaundice is associated with an increased incidence of infection and endotoxaemia, which may result from impaired host immunity. Neutrophil adhesion to vascular endothelium is a key part of the inflammatory response.

AIMS

To investigate neutrophil adhesion molecule expression and activation in obstructive jaundice.

PATIENTS

Nine adult patients with obstructive jaundice and 11 control subjects.

METHODS

The expression of the neutrophil adhesion receptors L-selectin, CD11a, CD11b, CD11c, and CD15 was determined using flow cytometry. CD11b expression in response to stimulation with fMLP and endotoxin was measured.

RESULTS

The basal expression of L-selectin, CD11a, and CD15 was significantly decreased in jaundiced patients (p < 0.05) and the expression of CD11b in response to stimulation with fMLP and endotoxin was significantly impaired in the jaundiced group. Endotoxin stimulation without plasma did not reverse the impaired response showing that it is not caused by endotoxin inactivation by plasma proteins.

CONCLUSIONS

Neutrophils from patients with obstructive jaundice show decreased adhesion receptor expression and an impaired response to stimulation with bacterial products. This cellular dysfunction may be responsible for the high incidence of septic complications in these patients.

Blood clearance and organ localization of Candida albicans and E coli following dual infection in rats

Immunosuppressed prematures, cancer patients, and transplant recipients are susceptible to bacterial or fungal sepsis or both. This report evaluates whether the ability of the reticuloendothelial system (RES) to remove blood-borne viable radiolabeled 35S Escherichia coli and 3H-Leucine Candida albicans is adversely affected by a dual intravenous challenge of these organisms. Male Sprague Dawley rats (n = 150) weighing 175 to 180 g were placed in 5 experimental groups (n = 30). Group I received intravenous (IV) C albicans (10(7)/mL), group II received E coli (10(9)/mL), group III received a dual injection of C albicans and E coli, group IV received Candida 1 hour prior to E coli, and group V received E coli 1 hour prior to fungi. At 1, 4, and 24 hours, tissue samples (50 to 100 mg) of liver, spleen, kidneys, and lungs were processed for liquid scintillation counting. Organ distribution of bacteria and fungi was calculated and expressed as mean percent +/- SD of labeled organisms. The liver trapped 72% +/- 10% and the lungs 1.1% +/- 0.3% of E coli (group II) (P < .001). The organ distribution of Candida (group I), however, was similar in liver and lungs (42.5% +/- 10% and 41.4% +/- 6.4%, respectively). Liver localization of E coli was unaffected by simultaneous or staggered fungal injection (groups III, 4, and V). Lung distribution of E coli following dual injection (group III) was significantly higher than controls (group II) (3.6% +/- 0.7% v 1.1% +/- 0.3%; P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Fungemia observations of peripheral tissue clearance in humans

Patients with fungemia, mainly due to Candida albicans, had cultures repeated from arterial and venous sites to determine yeast cell clearance during fungemia. Of the 48 patients, 37 had repeat positive cultures (36 arterial and venous samples; one venous culture). Additionally, 24 patients had arterial and venous samples cultured quantitatively. An average of 9.1 colony forming units (CFU) ml-1 was isolated from arterial samples and 5.5 CFU ml-1 from venous samples (60% of arterial, P < 0.01). This suggest that arterial fungal densities exceed venous densities and that peripheral tissues clear 40% of yeasts.