Successful treatment of Candida osteomyelitis with fluconazole. A noncomparative study of two patients

Vertebral Candidiasis, the State of the Art: A Systematic Literature Review

OBJECTIVE

In recent years, Candida spondylodiscitis has represented an increasingly emerging disease in clinical practice. This condition requires long-term antibiotic therapy and sometimes surgical treatments. The main purpose of this study is to investigate the epidemiology, clinical and radiological aspects, treatment protocols, and outcomes of Candida-mediated vertebral osteomyelitis.

METHODS

A systematic review of the English literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.The research was conducted on Medline, Cochrane library, PubMed, and Scopus using as search terms "vertebral"; "spinal"; "infection"; "spondylodiscitis"; "discitis"; "osteomyelitis"; "Candida"; and "Candidosis." A case of vertebral candidiasis that was surgically managed was also reported.

RESULTS

In total, 88 articles were included in our systematic review. Including the reported case, our analysis covered 113 cases of vertebral candidiasis. Candida albicans was isolated in 64 cases (56.1%), Candida tropicalis in 21 (18.4%), Candida glabrata in 14 (12.3%), and Candida parapsilosis in five (4.4%). The mean duration of the follow-up was 395 days. Finally, 87 (82%) patients completely recovered, ten (9.4%) died, and nine (8.5%) reported sequelae.

CONCLUSION

This systematic review summarized the state of the art on vertebral candidiasis, describing data on its clinical features, diagnostic criteria and current limitations, and treatment alternatives and their outcomes.

Osteoarticular Mycoses

Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.

One-stage oblique lateral corridor antibiotic-cement reconstruction for Candida spondylodiscitis in patients with major comorbidities: Preliminary experience

Fungal spondylodiscitis is rare (0.5%-1.6% of spondylodiscitis) and mainly caused by Candida albicans. Surgical intervention in spondylodiscitis patients is indicated for compression of neural elements, spinal instability, severe kyphosis, failure of conservative management and intractable pain. However, there is no evidence-based optimal surgical approach for spondylodiscitis. There have been only case reports of surgical treatment for Candida spondylodiscitis. We evaluated the preliminary results of the efficacy and safety of one-stage debridement via oblique lateral corridor with interbody fusion (OLIF) using stand-alone cement reconstruction after debridement for the treatment of Candida spondylodiscitis in patients with major co-morbidities. Five patients (4 males, 1 female, mean age: 64.2 years) suffering from Candida albicans lumbar spondylodiscitis who underwent this procedure were studied. Their predominant symptoms were unremitting back and leg pain and all had pre and postoperative anti-fungal therapy under microbiologist supervision. The operative time ranged from 137minutes to 260minutes (mean: 213.4minutes). The mean blood loss was 160mL (range: 100-200mL). There were no perioperative complications. At follow-up all showed major improvement in pain and ambulatory status. CT scan showed radiological stability for all patients at 6-12 months. Our preliminary results showed stand-alone anterior debridement and spinal re-construction with cement through mini-open OLIF approach might be a safe and effective option for patients with spinal fungal infection and major comorbidities.

Fungal spondylodiscitis in a patient recovered from H7N9 virus infection: a case study and a literature review of the differences between Candida and Aspergillus spondylodiscitis

To report a rare case of fungal spondylodiscitis in a patient recovered from H7N9 virus infection and perform a literature review of the different characteristics of Candida and Aspergillus spondylodiscitis, we reviewed cases of spondylodiscitis caused by Candida and Aspergillus species. Data, including patients' information, pathogenic species, treatment strategy, outcomes, and relapses, were collected and summarized. The characteristics of Candida and Aspergillus spondylodiscitis were compared to see if any differences in clinical features, management, or consequences could be detected. The subject of the case study was first misdiagnosed as having a vertebral tumor, and then, following open biopsy, was diagnosed as having fungal spondylodiscitis. The patient made a good recovery following radical debridement. Seventy-seven additional cases of Candida spondylodiscitis and 94 cases of Aspergillus spondylodiscitis were identified in the literature. Patients with Candida spondylodiscitis tended to have a better outcome than patients with Aspergillus spondylodiscitis (cure rate 92.3% vs. 70.2%). Candida was found more frequently (47.8%) than Aspergillus (26.7%) in blood cultures, while neurological deficits were observed more often in patients with Aspergillus spondylodiscitis (43.6% vs. 25.6%). Candida spinal infections were more often treated by radical debridement (60.5% vs. 39.6%). Patients with Candida spondylodiscitis have better outcomes, which may be associated with prompt recognition, radical surgical debridement, and azoles therapy. A good outcome can be expected in fungal spondylodiscitis with appropriate operations and anti-fungal drugs.

Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Fungal Infections of the Spine

STUDY DESIGN

Review of the literature.

OBJECTIVE

To retrospectively examine the frequency of published fungal infections by species and the treatment algorithms used to eradicate the disease.

SUMMARY OF BACKGROUND DATA

Fungal infections of the spine present unique challenges to the modern multispecialty treatment team. Although rare in comparison with bacterial infections, fungal infections have been increasing in incidence over the past several decades. Evidences-based practice is limited to referencing smaller case series.

METHODS

MEDLINE, Scopus, and EMBASE searches were carried out by one of the authors as well as by the research desk at the University of Miami/Calder Memorial Library. We included peer-reviewed articles published between 1948 and September 2010; case reports, series, and reviews were all examined and compiled into a database.

RESULTS

A total of 130 articles, representing 157 cases, were included in the review. Aspergillus (60 cases, 38.2% of the total) and Candida species (36 cases, 22.9% of the total) were the 2 most common organisms. Surgery was associated with a greater survival rate than medical management alone in patients with Aspergillus (26.9% mortality in surgical patients; 60% in medically treated patients) and Candida (0% vs. 28.6%). Overall mortality was 19.3%. The overall recurrence rate was 7.4%. Amphotericin use was associated with a higher mortality rate than azoles.

CONCLUSION

Aspergillus is the most common published pathogen in fungal infections of the spine. Recent publications depicting the use of newer antifungal medications such as azoles report higher survival rates. Surgically treated patients in combination with antifungal therapy showed highest frequencies of patient survival in Aspergillus and Candida infections.

LEVEL OF EVIDENCE

3.

ESCMID* guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients

This part of the EFISG guidelines focuses on non-neutropenic adult patients. Only a few of the numerous recommendations can be summarized in the abstract. Prophylactic usage of fluconazole is supported in patients with recent abdominal surgery and recurrent gastrointestinal perforations or anastomotic leakages. Candida isolation from respiratory secretions alone should never prompt treatment. For the targeted initial treatment of candidaemia, echinocandins are strongly recommended while liposomal amphotericin B and voriconazole are supported with moderate, and fluconazole with marginal strength. Treatment duration for candidaemia should be a minimum of 14 days after the end of candidaemia, which can be determined by one blood culture per day until negativity. Switching to oral treatment after 10 days of intravenous therapy has been safe in stable patients with susceptible Candida species. In candidaemia, removal of indwelling catheters is strongly recommended. If catheters cannot be removed, lipid-based amphotericin B or echinocandins should be preferred over azoles. Transoesophageal echocardiography and fundoscopy should be performed to detect organ involvement. Native valve endocarditis requires surgery within a week, while in prosthetic valve endocarditis, earlier surgery may be beneficial. The antifungal regimen of choice is liposomal amphotericin B +/- flucytosine. In ocular candidiasis, liposomal amphotericin B +/- flucytosine is recommended when the susceptibility of the isolate is unknown, and in susceptible isolates, fluconazole and voriconazole are alternatives. Amphotericin B deoxycholate is not recommended for any indication due to severe side effects.

Candida osteomyelitis: analysis of 207 pediatric and adult cases (1970-2011)

BACKGROUND

The epidemiology, pathogenesis, clinical manifestations, management, and outcome of Candida osteomyelitis are not well understood.

METHODS

Cases of Candida osteomyelitis from 1970 through 2011 were reviewed. Underlying conditions, microbiology, mechanisms of infection, clinical manifestations, antifungal therapy, and outcome were studied in 207 evaluable cases.

RESULTS

Median age was 30 years (range, ≤ 1 month to 88 years) with a >2:1 male:female ratio. Most patients (90%) were not neutropenic. Localizing pain, tenderness, and/or edema were present in 90% of patients. Mechanisms of bone infection followed a pattern of hematogenous dissemination (67%), direct inoculation (25%), and contiguous infection (9%). Coinciding with hematogenous infection, most patients had ≥2 infected bones. When analyzed by age, the most common distribution of infected sites for adults was vertebra (odds ratio [OR], 0.09; 95% confidence interval [CI], .04-.25), rib, and sternum; for pediatric patients (≤18 years) the pattern was femur (OR, 20.6; 95% CI, 8.4-48.1), humerus, then vertebra/ribs. Non-albicans Candida species caused 35% of cases. Bacteria were recovered concomitantly from 12% of cases, underscoring the need for biopsy and/or culture. Candida septic arthritis occurred concomitantly in 21%. Combined surgery and antifungal therapy were used in 48% of cases. The overall complete response rate of Candida osteomyelitis of 32% reflects the difficulty in treating this infection. Relapsed infection, possibly related to inadequate duration of therapy, occurred among 32% who ultimately achieved complete response.

CONCLUSIONS

Candida osteomyelitis is being reported with increasing frequency. Localizing symptoms are usually present. Vertebrae are the most common sites in adults vs femora in children. Timely diagnosis of Candida osteomyelitis with extended courses of 6-12 months of antifungal therapy, and surgical intervention, when indicated, may improve outcome.

Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America

Guidelines for the management of patients with invasive candidiasis and mucosal candidiasis were prepared by an Expert Panel of the Infectious Diseases Society of America. These updated guidelines replace the previous guidelines published in the 15 January 2004 issue of Clinical Infectious Diseases and are intended for use by health care providers who care for patients who either have or are at risk of these infections. Since 2004, several new antifungal agents have become available, and several new studies have been published relating to the treatment of candidemia, other forms of invasive candidiasis, and mucosal disease, including oropharyngeal and esophageal candidiasis. There are also recent prospective data on the prevention of invasive candidiasis in high-risk neonates and adults and on the empiric treatment of suspected invasive candidiasis in adults. This new information is incorporated into this revised document.

Fluconazole for the management of invasive candidiasis: where do we stand after 15 years?

Candida spp. are responsible for most of the fungal infections in humans. Available since 1990, fluconazole is well established as a leading drug in the setting of prevention and treatment of mucosal and invasive candidiasis. Fluconazole displays predictable pharmacokinetics and an excellent tolerance profile in all groups, including the elderly and children. Fluconazole is a fungistatic drug against yeasts and lacks activity against moulds. Candida krusei is intrinsically resistant to fluconazole, and other species, notably Candida glabrata, often manifest reduced susceptibility. Emergence of azole-resistant strains as well as discovery of new antifungal drugs (new triazoles and echinocandins) have raised important questions about its use as a first line drug. The aim of this review is to summarize the main available data on the position of fluconazole in the prophylaxis or curative treatment of invasive Candida spp. infections. Fluconazole is still a major drug for antifungal prophylaxis in the setting of transplantation (solid organ and bone marrow), intensive care unit, and in neutropenic patients. Prophylactic fluconazole still has a place in HIV-positive patients in viro-immunological failure with recurrent mucosal candidiasis. Fluconazole can be used in adult neutropenic patients with systemic candidiasis, as long as the species identified is a priori susceptible. Among non-neutropenic patients with candidaemia fluconazole is one of the first line drugs for susceptible species. Cases reports and uncontrolled studies have also reported its efficacy in the setting of osteoarthritis, endophthalmitis, meningitis, endocarditis and peritonitis caused by Candida spp. among immunocompetent adults. In paediatrics, fluconazole is a well tolerated and major prophylactic drug for high-risk neonates, as well as an alternative treatment for neonatal candidiasis. Importantly 15 years after its introduction in the antifungal armamentarium, fluconazole is still a first line treatment option in several cases of invasive candidiasis. Its prophylactic use should however be limited to selected high-risk patients to limit the risk of emergence of azole-resistant strains.

Candida spondylodiscitis and epidural abscess: management with shorter courses of anti-fungal therapy in combination with surgical debridement

Epidural abscess associated with candidal spondylodiscitis is rarely seen, particularly when it involves the cervical and thoracic spine. We report two such cases that were successfully managed with early surgical debridement, as well as medical therapy with intravenous amphotericin followed by oral fluconazole. The literature related to candidal spinal infection is reviewed, and a rational approach to the management of this uncommon condition is proposed. A good outcome may generally be expected with early diagnosis as well as appropriate surgical and pharmacological treatment. Oral fluconazole appears to be useful in the management of candida spondylodiscitis complicated by epidural abscess formation. Treatment until a normal ESR is attained is ideal, and this may be as short as 3 months when surgical drainage has been adequately performed.

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

BACKGROUND

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

CASE DESCRIPTION

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

CONCLUSION

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

Candida albicans osteomyelitis: case report and literature review

OBJECTIVE

Osteomyelitis due to Candida species is an unusual but recognized entity. However, with the increasing occurrence of factors predisposing to candidemia and invasive candidiasis, candidal osteomyelitis is being diagnosed more frequently. An unusual case of Candida albicans osteomyelitis is reported here, along with a review of the published literature on previously reported cases of this disease.

METHODS

Report of the case and literature review.

RESULTS

In this case, Candida albicans was isolated from the talus; however, the diagnosis was made after several cultures were performed. Only one other case of Candida osteomyelitis located in foot bones was found in the review.

CONCLUSIONS

It is thought that this is the first case reported in Venezuela, and only the second in international literature.

Oral versus intravenous therapy in the treatment of systemic mycosis

The great majority of systemic fungal infections require long-term therapy that often extends 6-12 months, particularly in immunosuppressed patients. It can be difficult to comply with this requirement when the drug to be used is only available for intravenous administration, because problems related to maintaining a permeable venous pathway for long periods arise. The availability of an intravenously (IV) and orally (PO) administered drug can solve this problem by making sequential therapy possible. Voriconazole is a new antifungal agent that, apart from satisfying this requirement because it has a high oral bioavailability, presents a broad spectrum of antifungal activity that makes its use possible, a priori, in the initial and/or sequential IV/PO treatment of any systemic mycotic infection. Based on current costs there is potential for savings compared with liposomal amphotericin B.

Successful treatment of Candida albicans osteomyelitis of the spine with fluconazole and surgical debridement: case report

A 65-year old diabetic male presented with progressive bone destruction of thoracic spine (T-11&12) with cord compression. Candida albicans was isolated from aspirated materials pre-and intra-operative. Two weeks of fluconazole was given prior to surgical debridement, and fixation of the lesion. C. albicans isolated pre-and 2-weeks after fluconazole treatment were DNA-typed using AP-PCR. MIC was 2-4 mg/l in all isolates tested. The pre-and post treatment isolates had two DNA patterns, indicating the existence of two different strains. Surgical treatment was necessary for patient recovery.

Candida albicans sternal wound infections: a chronic and recurrent complication of median sternotomy

Eleven patients developed deep sternal wound infections due to Candida albicans after undergoing coronary artery bypass grafting (CABG) and were assessed. Six had sternal osteomyelitis, 1 had osteomyelitis and mediastinitis, and 4 had deep wound infections that probably involved bone. Seven patients experienced onset of infection within 28 days of CABG, but 4 experienced onset 48-150 days after CABG. Infections were characterized by a chronic, indolent course requiring prolonged treatment with an antifungal agent. Delay in initiating antifungal therapy was common. All patients were treated with fluconazole, and 1 also received amphotericin B. Six patients underwent incision and drainage, with or without wire removal, and 3 underwent sternectomy with placement of a muscle flap. Of 10 patients for whom follow-up data were available, 7 were cured after initial therapy (median duration of treatment, 6 months), and 3 experienced a relapse and required a second course of fluconazole.

Effects of macrophage colony-stimulating factor on antifungal activity of neonatal monocytes against Candida albicans

The effects of recombinant macrophage-colony stimulating factor (M-CSF) on antifungal activities of monocytes (MNC) from healthy neonates and adults against Candida albicans were compared. Pretreatment of adult and neonatal MNC with 15 ng/ml of M-CSF for 4 days significantly increased superoxide anion (O(-2)) production in response to phorbol myristate acetate. While M-CSF-treated MNC from adults produced significantly higher O(-2) in response to Candida blastoconidia, M-CSF-treated neonatal MNC did not show a similar response. Further, M-CSF significantly enhanced phagocytosis of C. albicans by adult MNC but not by neonatal MNC. While M-CSF enhances antifungal activities of adult MNC against C. albicans, it does not appear to affect anticandidal function of neonatal MNC.

Case report. Successful treatment of two cases of post-surgical sternal osteomyelitis, due to Candida krusei and Candida albicans, respectively, with high doses of triazoles (fluconazole, itraconazole)

Two female patients, aged 75 and 59 years, respectively, with candidal sternal osteomyelitis were successfully treated by the administration of triazoles. Both had developed post-operative wound infection after sternotomy for coronary artery by-pass grafting. Sternal osteomyelitis was confirmed by bone scans with technetium 99Tc and gallium 67Ga. The cultures, from the pus draining at the site of the sternotomy scar, grew Candida krusei in the first case. The fistula closed after a 9-week course of itraconazole therapy (800 mg daily, followed by 600 mg daily) and the patient completed a 6-month period of therapy. The second patient had underlying diabetes mellitus. Post-operatively she developed two fistulae draining pus on the sternum. The pus cultures grew C. albicans. Initial treatment with oral fluconazole (400 mg daily) failed. Subsequent treatment with liposomal amphotericin B also failed. A dramatic improvement was noted when the patient received high doses of fluconazole (800 mg daily). The fistulae gradually closed after 1 month. Oral fluconazole was continued for 6 months. The cure was confirmed by bone scans. Three years later, both patients remained well.

Vertebral osteomyelitis due to Candida species: case report and literature review

Candida species uncommonly cause vertebral osteomyelitis. We present a case of lumbar vertebral osteomyelitis caused by Candida albicans and review 59 cases of candidal vertebral osteomyelitis reported in the literature. The mean age was 50 years, and the lower thoracic or lumbar spine was involved in 95% of patients. Eighty-three percent of patients had back pain for >1 month, 32% presented with fever, and 19% had neurological deficits. The erythrocyte sedimentation rate was elevated in 87% of patients, and blood culture yielded Candida species for 51%. C. albicans was responsible for 62% of cases, Candida tropicalis for 19%, and Candida glabrata for 14%. Risk factors for candidal vertebral osteomyelitis were the presence of a central venous catheter, antibiotic use, immunosuppression, and injection drug use. Medical and surgical therapies were both used, and amphotericin B was the primary antifungal agent. Prognosis was good, with an overall clinical cure rate of 85%.

Candidal vertebral osteomyelitis: report of 6 patients, and a review

The incidence of deep-seated candidal infection is increasing, but candidal vertebral osteomyelitis is still rare. We describe 6 patients recently treated in our hospital. Conservative treatment failed in all. We reviewed the literature and identified 59 additional cases of candidal vertebral osteomyelitis. Candidemia was documented in 61.5% of them. The interval between the diagnosis of candidemia and the onset of symptoms of vertebral osteomyelitis varied widely, from days to >1 year. In patients without documented candidemia, there was a similar interval between the occurrence of risk factors for candidemia (present in 72% of the patients) and the onset of symptoms of vertebral osteomyelitis. Clinical, laboratory, and radiological findings are not specific for candidal spondylodiskitis. Final diagnosis is determined by means of culture of a biopsy specimen from the infected vertebra or disk. Treatment consisted of prolonged antifungal treatment, and it often included surgery. On the basis of our experience (for all 6 patients, initial conservative treatment with only antifungals failed), we recommend consideration of early surgical debridement in combination with prolonged antifungal therapy.

Practice guidelines for the treatment of candidiasis. Infectious Diseases Society of America

Infections due to Candida species are the most common of the fungal infections. Candida species produce a broad range of infections, ranging from nonlife-threatening mucocutaneous illnesses to invasive process that may involve virtually any organ. Such a broad range of infections requires an equally broad range of diagnostic and therapeutic strategies. This document summarizes current knowledge about treatment of multiple forms of candidiasis and is the guideline of the Infectious Diseases Society of America (IDSA) for the treatment of candidiasis. Throughout this document, treatment recommendations are scored according to the standard scoring scheme used in other IDSA guidelines to illustrate the strength of the underlying data. The document covers 4 major topical areas. The role of the microbiology laboratory. To a greater extent than for other fungi, treatment of candidiasis can now be guided by in vitro susceptibility testing. The guidelines review the available information supporting current testing procedures and interpretive breakpoints and place these data into clinical context. Susceptibility testing is most helpful in dealing with infection due to non-albicans species of Candida. In this setting, especially if the patient has been treated previously with an azole antifungal agent, the possibility of microbiological resistance must be considered. Treatment of invasive candidiasis. In addition to acute hematogenous candidiasis, the guidelines review strategies for treatment of 15 other forms of invasive candidiasis. Extensive data from randomized trials are really available only for therapy of acute hematogenous candidiasis in the nonneutropenic adult. Choice of therapy for other forms of candidiasis is based on case series and anecdotal reports. In general, both amphotericin B and the azoles have a role to play in treatment. Choice of therapy is guided by weighing the greater activity of amphotericin B for some non-albicans species (e.g., Candida krusei) against the lesser toxicity and ease of administration of the azole antifungal agents. Flucytosine has activity against many isolates of Candida but is not often used. Treatment of mucocutaneous candidiasis. Therapy for mucosal infections is dominated by the azole antifungal agents. These drugs may be used topically or systemically and have been proven safe and efficacious. A significant problem with mucosal disease is the propensity for a small proportion of patients to suffer repeated relapses. In some situations, the explanation for such a relapse is obvious (e.g., relapsing oropharyngeal candidiasis in an individual with advanced and uncontrolled HIV infection), but in other patients the cause is cryptic (e.g., relapsing vaginitis in a healthy woman). Rational strategies for these situations are discussed in the guidelines and must consider the possibility of induction of resistance over time. Prevention of invasive candidiasis. Prophylactic strategies are useful if the risk of a target disease is sharply elevated in a readily identified group of patients. Selected patient groups undergoing therapy that produces prolonged neutropenia (e.g., some bone-marrow transplant recipients) or who receive a solid-organ transplant (e.g., some liver transplant recipients) have a sufficient risk of invasive candidiasis to warrant prophylaxis.

Successful treatment of candidal osteomyelitis with fluconazole following failure with liposomal amphotericin B

A case of multiple relapses of Candida albicans infection of deep tissues is described. Treatment was complicated by renal impairment, but therapy with a liposomal amphotericin product failed to eradicate the third recurrence which subsequently resolved after protracted exposure to oral fluconazole.

Large-scale multicentre study of fluconazole in the treatment of hospitalised patients with fungal infections. Multicentre European Study Group

The purpose of this prospective, open-label, noncomparative, multicentre study was to evaluate the efficacy and safety of fluconazole in the treatment of hospitalised patients with mycoses. A total of 587 patients with diagnosed fungal infections were enrolled. Fluconazole was given orally or intravenously in a 200 or 400 mg loading dose, followed by 100 or 200 mg once daily. The most common candidal infections were fungemia, esophageal candidiasis, bronchopulmonary candidiasis, peritonitis, oropharyngeal candidiasis, urinary tract infection and deep wound infection. Meningitis was the most common cryptococcal infection. Of the 291 evaluable patients with candidiasis, 96% (70/73) of AIDS patients and 79% (171/218) of non-AIDS patients were clinically cured or improved. Of the 36 evaluable patients with cryptococcosis, 69% (20/29) of AIDS patients and 100% (7/7) of non-AIDS patients responded clinically. The overall mycological eradication rate was 85%; eradication was similar in patients with and without AIDS. Most adverse events during fluconazole therapy were mild to moderate in severity. This investigation confirms the results of previous studies demonstrating high response rates to fluconazole therapy in AIDS and non-AIDS patients with fungal infections. Even during long-term therapy treatment-limiting adverse events were uncommon with fluconazole.

Candida albicans osteomyelitis of the zygomatic bone. A distinctive case with a possible peculiar mechanism of infection and therapeutic failure with fluconazole

This report describes a distinctive case of zygomatic candidiasic osteomyelitis in a diabetic patient with oral candidiasis and malar ulceration secondary to topic 5-fluoroacil toxicity that eventually exposed part of the underlying bone. The mechanism of infection may have been self-inoculation of spores from muguet plaques on the oral mucosa to the exposed bone tissue by hand contact. Such a mechanism of bone infection probably should be considered in patients who frequently have oral candidiasis (diabetes, malignancies, and HIV infection) and open lesions of the skin and soft tissues. Treatment with fluconazole was ineffective, but amphotericin B was curative.

Candida parapsilosis vertebral osteomyelitis

A case of culture verified Candida parapsilosis lumbar spondylodiscitis, with infectious involvement of an aortic prosthetic graft, presented with a lumbar radicular pain syndrome. Only 33 Candida infections of the spine are described in the literature. Candida parapsilosis was cultured in three cases. Considering the poor general condition of the patient, a conservative treatment with bedrest, casting and amphotericin B, hydrocortisone and itraconazol was given. The patient died 28 months after onset from intercurrent pneumonia.