Candidemia in a Portuguese tertiary care hospital: Analysis of a 2-year period

Impact of Fluconazole Resistance on the Outcomes of Patients With Candida parapsilosis Bloodstream Infections: A Retrospective Multicenter Study

BACKGROUND

This study assesses the impact of fluconazole resistance on 30-day all-cause mortality and 1-year recurrence in patients with Candida parapsilosis bloodstream infections (BSI).

METHODS

A multicenter retrospective study was performed at 3 hospitals in Italy and Spain between 2018 and 2022. Adult patients with positive blood cultures for C. parapsilosis who received appropriate targeted therapy with either echinocandins or fluconazole were included.

RESULTS

Among 457 patients, 196 (42.9%) had fluconazole-resistant C. parapsilosis (FLZR-CP) BSI and 261 (57.1%) had fluconazole-susceptible C. parapsilosis (FLZS-CP) BSI. All FLZR-CP patients received targeted echinocandins, while FLZS-CP patients received either echinocandins (60.5%) or fluconazole (39.5%). Unadjusted 30-day all-cause mortality rates were 28.6% for FLZR-CP and 28.4% for FLZS-CP (log-rank test, P = .998). In multivariable analysis, increased mortality was associated with age (adjusted hazard ratio [aHR] 1.03 per year; 95% confidence interval [CI], 1.01-1.05; P = .0005), solid tumor (aHR 1.91; 95% CI, 1.06-3.46; P = .0302), previous antifungal treatment (aHR 1.84; 95% CI, 1.12-3.10; P = .0192), and septic shock (aHR 2.39; 95% CI, 1.42-4.06; P = .0010), but not fluconazole resistance (aHR 1.00; 95% CI, .62-1.63; P = .9864) nor the type of initial antifungal therapy (aHR 1.46; 95% CI, .69-3.06; P = .3202). Propensity score-matched analysis showed no 30-day all-cause mortality difference between echinocandin-treated FLZR-CP and fluconazole-treated FLZS-CP patients (HR 0.81; 95% CI, .37-1.75; P = .5915). However, a higher 1-year recurrence risk was observed in FLZR-CP patients (odds ratio, 7.37; 95% CI, 2.11-25.80; P = .0018).

CONCLUSIONS

Our results suggest that fluconazole resistance is not associated with a higher mortality risk in patients with C. parapsilosis BSI, though 1-year recurrence rates were higher in the FLZR-CP group.

Enhancing ICU Candida spp. surveillance: a cost-effective approach focused on Candida auris detection

Introduction

Candida auris is an emerging pathogen that represents a worldwide health problem due to its global expansion, multidrug resistance, and difficult laboratory identification. Among the risk factors for colonization/infection by C. auris, a stay in an intensive care unit (ICU) stands out. This prospective multicenter study aimed to monitor the trend of the local epidemiology of Candida spp. and unveil the prevalence of C. auris.

Methods

From 2020 to 2022, axillar/inguinal swabs were collected from adult patients at three points: upon admission (D1) and on the fifth (D5) and eighth (D8) days of their ICU stay. We employed culture-based screening methods combined with molecular techniques to identify Candida spp. down to the species level. Specific screening for Candida auris was conducted using a real-time PCR assay in combination with an improved selective culture medium, mannitol salt agar auris (MSAA). To validate the effectiveness of MSAA, a collection of reference C. auris strains representing the four major geographical clades was used.

Results

We enrolled 675 patients, and 355 Candida isolates were retrieved from the 988 swab samples collected. From those, 185/355 (52.1%) were identified as C. albicans and 170/355 (47.9%) as non-albicans Candida (NAC). MSAA medium showed a specificity of 94.8%, albeit C. auris was not detected in this cohort. The dynamics of Candida spp. colonization by ICU were significant at the three collection points. Upon admission, C. albicans was associated with the Beatriz Ângelo Hospital ICU (p=0.003) and C. tropicalis with the general Hospital Professor Doutor Fernando Fonseca (FFH) ICU (p=0.006). C. parapsilosis and C. lusitaniae were associated with FFH ICUs, with the general ICU at D5 (p=0.047) and surgical ICU at D8 (p=0.012). The dynamics of NAC colonization by ICU were significantly different at D1 (p=0.011), D5 (p=0.047), and D8 (p=0.012).

Conclusion

We developed and implemented a screening protocol for C. auris while uncovering the colonization patterns of Candida in the ICU. Our findings contribute to the optimization of overall patient management, ensuring that ICU protocols are resilient and adaptive to emerging fungal threats.

Insights into Candida Colonization in Intensive Care Unit Patients: A Prospective Multicenter Study

The skin mycobiota plays a significant role in infection risk, pathogen transmission, and personalized medicine approaches in intensive care settings. This prospective multicenter study aimed to enhance our understanding of intensive care units' (ICUs') Candida colonization dynamics, identify modifiable risk factors, and assess their impact on survival risk. Specimens were taken from 675, 203, and 110 patients at the admission (D1), 5th (D5), and 8th (D8) days of ICU stay, respectively. The patient's demographic and clinical data were collected. Candida isolates were identified by conventional culture-based microbiology combined with molecular approaches. Overall, colonization was 184/675 (27.3%), 87/203 (42.8%), and 58/110 (52.7%) on D1, D5, and D8, respectively. Candida colonization dynamics were significantly associated with ICU type (odds ratio (OR) = 2.03, 95% CI 1.22-3.39, p = 0.007), respiratory infection (OR = 1.74, 95% CI 1.17-2.58, p = 0.006), hemodialysis (OR = 2.19, 95% CI 1.17-4.10, p = 0.014), COVID-19 (OR = 0.37, 95% CI 0.14-0.99, p = 0.048), and with a poor 3-month outcome (p = 0.008). Skin Candida spp. colonization can be an early warning tool to generate valuable insights into the epidemiology, risk factors, and survival rates of critically ill patients, and should be considered for epidemiological surveillance.

Comparison of Candida colonization in intensive care unit patients with and without COVID-19: First prospective cohort study from Turkey

Candida species are the primary cause of fungal infections in intensive care units (ICUs). Despite the increasing prevalence of Candida-related infections, monitoring the progression of these infections from colonization in COVID-19 ICU patients lacks sufficient information. This study aims prospectively to compare 62 COVID-19 and 60 non-COVID-19 ICU patients from admission to discharge in terms of colonization development, rates, isolated Candida species, risk factors, and Candida infections during hospitalization. A total of 1464 samples were collected at specific time intervals from various body sites [mouth, skin (axilla), rectal, and urine]. All samples were inoculated onto CHROMagar Candida and CHROMagar Candida Plus media, and isolates identified using MALDI-TOF MS. COVID-19 patients exhibited significantly higher colonization rates in oral, rectal, and urine samples compared to non-COVID-19 patients, (p < 0.05). Among the Candida species, non-albicans Candida was more frequently detected in COVID-19 patients, particularly in oral (75.8%-25%; p < 0.001) and rectal regions (74.19% - 46.66%; p < 0.05). Colonization with mixed Candida species was also more prevalent in the oropharyngeal region (p < 0.05). Mechanical ventilation and corticosteroid use emerged as elevated risk factors among COVID-19 patients (p < 0.05). Despite the colonization prevalence, both COVID-19-positive and negative patients exhibited low incidences of Candida infections, with rates of 9.67% (n = 6/62) and 6.67% (n = 3/60), respectively. Consequently, although Candida colonization rates were higher in COVID-19 ICU patients, there was no significant difference in Candida infection development compared to the non-COVID-19 group. However, the elevated rate of non-albicans Candida isolates highlights potential future infections, particularly given their intrinsic resistance in prophylactic or empirical treatments if needed. Additionally, the high rate of mixed colonization emphasizes the importance of using chromogenic media for routine evaluation.

Effect of Cinnamaldehyde on Systemic Candida albicans Infection in Mice

OBJECTIVE

To investigate the therapeutic efficacy of cinnamaldehyde (CA) on systemic Candida albicans infection in mice and to provide supportive data for the development of novel antifungal drugs.

METHODS

Ninety BALB/c mice were randomly divided into 3 groups according to a random number table: CA treatment group, fluconazole (positive control) group, and Tween saline (negative control) group, with 30 mice in each group. Initially, all groups of mice received consecutive intraperitoneal injections of cyclophosphamide at 200 mg/kg for 2 days, followed by intraperitoneal injection of 0.25 mL C. albicans fungal suspension (concentration of 1.0 × 107 CFU/mL) on the 4th day, to establish an immunosuppressed systemic Candida albicans infection animal model. Subsequently, the mice were orally administered CA, fluconazole and Tween saline, at 240, 240 mg/kg and 0.25 mL/kg respectively for 14 days. After a 48-h discontinuation of treatment, the liver, small intestine, and kidney tissues of mice were collected for fungal direct microscopic examination, culture, and histopathological examination. Additionally, renal tissues from each group of mice were collected for (1,3)- β -D-glucan detection. The survival status of mice in all groups was monitored for 14 days of drug administration.

RESULTS

The CA group exhibited a fungal clearance rate of C. albicans above 86.7% (26/30), significantly higher than the fluconazole group (60.0%, 18/30, P<0.01) and the Tween saline group (30.0%, 9/30, P<0.01). Furthermore, histopathological examination in the CA group revealed the disappearance of inflammatory cells and near-normal restoration of tissue structure. The (1,3)-β-D-glucan detection value in the CA group (860.55 ± 126.73 pg/mL) was significantly lower than that in the fluconazole group (1985.13 ± 203.56 pg/mL, P<0.01) and the Tween saline group (5910.20 ± 320.56 pg/mL, P<0.01). The mouse survival rate reached 90.0% (27/30), higher than the fluconazole group (60.0%, 18/30) and the Tween saline group (30.0%, 9/30), with a significant difference between the two groups (both P<0.01).

CONCLUSIONS

CA treatment exhibited significant therapeutic efficacy in mice with systemic C. albicans infection. Therefore, CA holds potential as a novel antifungal agent for targeted treatment of C. albicans infection.

Computer-made peptide RQ18 acts as a dual antifungal and antibiofilm peptide though membrane-associated mechanisms of action

The spread of fungi resistant to conventional drugs has become a threatening problem. In this context, antimicrobial peptides (AMPs) have been considered as one of the main alternatives for controlling fungal infections. Here, we report the antifungal and antibiofilm activity and some clues about peptide RQ18's mechanism of action against Candida and Cryptococcus. This peptide inhibited yeast growth from 2.5 μM and killed all Candida tropicalis cells within 2 h incubation. Moreover, it showed a synergistic effect with antifungal agent the amphotericin b. RQ18 reduced biofilm formation and promoted C. tropicalis mature biofilms eradication. RQ18's mechanism of action involves fungal cell membrane damage, which was confirmed by the results of RQ18 in the presence of free ergosterol in the medium and fluorescence microscopy by Sytox green. No toxic effects were observed in murine macrophage cell lines and Galleria mellonella larvae, suggesting fungal target selectivity. Therefore, peptide RQ18 represents a promising strategy as a dual antifungal and antibiofilm agent that contributes to infection control without damaging mammalian cells.

Study of Candidemia and its Antifungal Susceptibility Profile at the University Hospital of Montevideo, Uruguay

Systemic candidiasis are high mortality infections caused by yeasts of the genus Candida, affecting patients with numerous risk factors. Nowadays, candidemia produced by "non-albicans" species has increased considerably. Timely diagnosis and subsequent treatment substantially improve patients' survival. Our objectives are to study the frequency, distribution, and antifungal susceptibility profiles of candidemia isolates in our hospital. We conducted a descriptive, cross-sectional study. Positive blood cultures were recorded from January 2018 to December 2021. Positive Candida genus blood cultures were selected, classified, and analyzed on their susceptibility profile for amphotericin B, fluconazole and caspofungin using AST-YS08® card for VITEK 2 Compact® to determine minimum inhibitory concentration (MIC) and CLSI M60 2020 2nd Edition to determine breakpoints. 3862 positive blood cultures were obtained, 113 (2.93%) presented growth of Candida spp., corresponding to 58 patients. 55.2% came from the Hospitalization Ward and Emergency Services and 44.8% from the Intensive Care Unit. The species were distributed as follows: Nakaseomyces glabratus (Candida glabrata) (32.74%), Candida albicans (27.43%), Candida parapsilosis (23.01%), Candida tropicalis (7.08%) and others (9.73%). Most species were found to be susceptible to most antifungals, except for C. parapsilosis, presenting 4 isolates with resistance to fluconazole and N. glabratus (C. glabrata), whose clinical susceptibility data remains insufficient to provide accurate breakpoints. The percentage of recorded positive blood cultures of Candida spp. was 2.93%, these results were consistent with those reported at a regional level. A predominance of "non-albicans" species was observed. It is essential to know the prevalence, epidemiology, and susceptibility profiles of candidemia in our country, as well as being updated on its subsequent changes, maintaining epidemiological surveillance. This allows professionals to map out early and effective therapeutic strategies, staying alert of possible multi-resistant strains.

The interplay of infectious diseases consultation and antimicrobial stewardship in candidemia outcomes: A retrospective cohort study from 2016 to 2019

OBJECTIVE

To evaluate the need for mandatory infectious diseases consultation (IDC) for candidemia in the setting of antimicrobial stewardship guidance.

DESIGN

Retrospective cohort study from January 2016 to December 2019.

SETTING

Academic quaternary-care referral center.

PATIENTS

All episodes of candidemia in adults (n = 92), excluding concurrent bacterial infection or death or hospice care within 48 hours.

METHODS

Primary outcome was all-cause 30-day mortality. Secondary outcomes included guideline-adherence and treatment choice. Guideline-adherence was assessed with the EQUAL Candida score.

RESULTS

Of 186 episodes of candidemia, 92 episodes in 88 patients were included. Central venous catheters (CVCs) were present in 66 episodes (71.7%) and were the most common infection source (N = 38, 41.3%). The most frequently isolated species was Candida glabrata (40 of 94, 42.6%). IDC was performed in 84 (91.3%) of 92 candidemia episodes. Mortality rates were 20.8% (16 of 77) in the IDC group versus 25% (2 of 8) in the no-IDC group (P = .67). Other comparisons were numerically different but not significant: repeat blood culture (98.8% vs 87.5%; P = .17), echocardiography (70.2% vs 50%; P = .26), CVC removal (91.7% vs 83.3%; P = .45), and initial echinocandin treatment (67.9% vs 50%; P = .44). IDC resulted in more ophthalmology examinations (67.9% vs 12.5%; P = .0035). All patients received antifungal therapy. Antimicrobial stewardship recommendations were performed in 19 episodes (20.7%). The median EQUAL Candida score with CVC was higher with IDC (16 vs 11; P = .001) but not in episodes without CVC (12 vs 11.5; P = .81).

CONCLUSIONS

In the setting of an active antimicrobial stewardship program and high consultation rates, mandatory IDC may not be warranted for candidemia.

Relationships between Secreted Aspartyl Proteinase 2 and General Control Nonderepressible 4 gene in the Candida albicans resistant to itraconazole under planktonic and biofilm conditions

This study aimed to explore the roles of SAP2 and GCN4 in itraconazole (ITR) resistance of C. albicans under different conditions, and their correlations. A total of 20 clinical strains of C. albicans, including 10 ITR resistant strains and 10 sensitive strains, were used. Then, SAP2 sequencing and GCN4 sequencing were performed, and the biofilm formation ability of different C. albicans strains was determined. Finally, real-time quantitative PCR was used to measure the expression of SAP2 and GCN4 in C. albicans under planktonic and biofilm conditions, as well as their correlation was also analyzed. No missense mutations and three synonymous mutation sites, including T276A, G543A, and A675C, were found in SAP2 sequencing. GCN4 sequencing showed one missense mutation site (A106T (T36S)) and six synonymous mutation sites (A147C, C426T, T513C, T576A, G624A and C732T). The biofilm formation ability of drug-resistant C. albicans strains was significantly higher than that of sensitive strains (P < 0.05). Additionally, SAP2 and GCN4 were up-regulated in the ITR-resistant strains, and were both significantly higher in C. albicans under biofilm condition. The mRNA expression levels of SAP2 and GCN4 had significantly positive correlation. The higher expression levels of SAP2 and GCN4 were observed in the ITR-resistant strains of C. albicans under planktonic and biofilm conditions, as well as there was a positive correlation between SAP2 and GCN4 mRNA expression.

Antifungal Activity of Mycogenic Silver Nanoparticles on Clinical Yeasts and Phytopathogens

In this study, seven different silver nanoparticles (AgNPs) were obtained using the fungi species from the phylum Ascomycota, Aspergillus tubingensis, Aspergillus spp., Cladosporium pini-ponderosae, Fusarium proliferatum, Epicoccum nigrum, Exserohilum rostratum, and Bionectria ochroleuca, isolated from the Brazilian biodiversity, particularly from the mangrove and Caatinga biomes. The nanoparticles were coded as AgNP-AT, AgNP-Asp, AgNP-CPP, AgNP-FP, AgNP-EN, AgNP-ER, and AgNP-BO and characterized using spectrophotometry (UV-Vis), dynamic light scattering (DLS), zeta potential, transmission electron microcopy (TEM), and Fourier-transform infrared (FTIR) spectroscopy. All the AgNPs presented homogeneous size in the range from 43.4 to 120.6 nm (DLS) and from 21.8 to 35.8 nm (TEM), pH from 4.5 to 7.5, negative charge, and presence of protein coating on their surface. The antifungal activity of the AgNPs was evaluated on clinical strains of Candida albicans, and on the non-albicans species, Candida krusei, Candida glabrata, Candida parapsilosis, Candida tropicalis, and Candida guilliermondii, common in hospital infections, and against the phytopathogens Fusarium oxysporum, Fusarium phaseoli, Fusarium sacchari, Fusarium subglutinans, Fusarium verticillioides, and Curvularia lunata, which are species responsible for serious damage to agriculture production. The AgNPs were effective against the yeasts with MICs ranging from 1.25 to 40 µM and on the phytopathogens with MICs from 4 to 250 µM, indicating the promising possibility of application of these AgNPs as antifungal agents. The results indicated that the physicochemical parameters of the AgNPs, including the functional groups present on their surface, interfered with their antifungal activity. Overall, the results indicate that there is no specificity of the AgNPs for the yeasts or for the phytopathogens, which can be an advantage, increasing the possibility of application in different areas.

Epidemiology, management and outcome of candidaemia in patients with diabetes

BACKGROUND

Candidaemia is the commonest fungal bloodstream infection in hospitalised patients. Diabetes is one of the risk factors for mortality from candidaemia.

METHODS

We compared the epidemiology, clinical characteristics and management of candidaemia in patients with and without diabetes.

RESULTS

Over a 10-year period, 200 episodes of Candida bloodstream infection were documented. Patients with diabetes were younger (58.7 vs 65.5 years), less likely to be suffering from cancer (21.8% vs 36%), and had significantly lower 30-day and 90-day crude mortality (17.2% vs 35.6% and 28.4% vs 48.6%, respectively). Candida glabrata was more common in patients with diabetes (39.3% vs 29.7%). Based on European Confederation of Medical Mycology (ECMM) quality indicators, the management of patients with and without diabetes was similar.

DISCUSSION

Our study highlights the importance of epidemiological data in relation to candidaemia in patients with diabetes and the growing threat of invasive C. glabrata infection in this subset of patients.

Survival Outcome of Empirical Antifungal Therapy and the Value of Early Initiation: A Review of the Last Decade

AIM

This rapid systematic review aimed to collect the evidence published over the last decade on the effect of empirical antifungal therapy and its early initiation on survival rates.

METHODS

A systematic search was conducted in PubMed, Cochrane, Medline, Scopus, and Embase, in addition to a hand search and experts' suggestions.

RESULTS

Fourteen cohort studies and two randomized clinical trials reporting the survival outcome of empirical antifungal therapy were included in this review. Two studies reported the association between early empirical antifungal therapy (EAFT) and survival rates in a hematological cancer setting, and fourteen studies reported the outcome in patients in intensive care units (ICU). Six studies reported that appropriate EAFT decreases hospital mortality significantly; ten studies could not demonstrate a statistically significant association with mortality rates.

DISCUSSION

The inconsistency of the results in the literature can be attributed to the studies' small sample size and their heterogeneity. Many patients who may potentially benefit from such strategies were excluded from these studies.

CONCLUSION

While EAFT is practiced in many settings, current evidence is conflicting, and high-quality studies are needed to demonstrate the true value of this approach. Meanwhile, insights from experts in the field can help guide clinicians to initiate EAFT when indicated.

Epidemiology of nosocomial candidemia, mortality and antifungal resistance, 7-year experience, in Turkey

Candidemia is an important clinical condition that prolongs the period of hospitalization and increases morbidity, mortality, and hospital costs. In this retrospective study, we aimed to evaluate the epidemiological and microbiological characteristics of patients with candidemia, between January 2013 and December 2019. Two hundred forty-one candidemia episodes were observed in the 230 patients, of whom 45% were female. The median age was 63 and 53.9% of the episodes were in the ICU. Frequently observed predisposing factors for candidemia included the use of antibiotics (71.3%), urinary catheterization (56.3%), Central venous catheter placement (50.3%), total parenteral nutrition (47.9%), solid-organ malignancy (46%), a surgical intervention (48.6%), chemotherapy (37%), steroid treatment (25.5%). The crude mortality rate was 52.7%. A significant difference was found between survivors and non-survivors (p = 0.007) with the Charlson comorbidity index. However, no statistically significant association was found between mortality and age, sex, surgical intervention, catheter-related candidemia, or Candida spp. The most frequently isolated Candida spp. was C. albicans (51%). Overall resistance to fluconazole, voriconazole, caspofungin, micafungin and flucytosine was 3.7%, 0%, 2.5%, 1.8%,1.8%, respectively. Consequently, there is a need for tests that yield higher success rates and rapid in diagnosis candidemia and local epidemiological data for antifungal resistance.

Association between Following the ESCMID Guidelines for the Management of Candidemia and Mortality: A Retrospective Cohort Study

Objectives: The objective of this study was to evaluate the association between ESCMID adherence and 30-day mortality in candidemia. Methods: We performed a retrospective cohort study in two French tertiary-care hospitals. All patients with at least one positive blood culture (BC) for Candida spp. between January 2013 and December 2019 were included. An adherent case was defined as a candidemia case for which the treatment fulfilled a bundle of defined criteria based on the latest ESCMID recommendations. We explored factors associated with adherence to ESCMID recommendations in an unadjusted model, and we used a propensity score method to address potential channeling biases with regard to 30-day mortality. Results: During the study period, 165 cases of candidemia were included. Among the ESCMID criteria, funduscopic examination was not performed in 45% and neither was echocardiography in 31%, while the ESCMID criteria were fully implemented in 44 cases (27%). In the propensity score analysis, the all-cause 30-day mortality rate was significantly lower among adherent cases (3.4/36.6, 9%) than among nonadherent cases (42.4/119.5, 36%) (OR = 5.3 95% CI [1.6–17.1]). Conclusions: In our study, adherence to the bundle of criteria for candidemia management was associated with increased survival, supporting additional efforts to implement these recommendations.

The Utility of EQUAL Candida Score in Predicting Mortality in Patients with Candidemia

In an effort to standardize practice, the European Confederation of Medical Mycology (ECMM) developed the European Confederation of Medical Mycology Quality of Clinical Candidaemia Management (EQUAL) Candida score. This study investigated the utility of the EQUAL Candida score in predicting mortality in patients with candidemia admitted between January 2004 and July 2019. A total of 142 cases were included in the study, and 43.6% died within 30 days of candidemia diagnosis. There were no significant differences between survivors and non-survivors in terms of comorbidities predisposing to candidemia, except for malignancy (p = 0.021). The overall mean EQUAL score was 11.5 in the total population and 11.8 ± 3.82 and 11.03 ± 4.59 in survivors and non-survivors, respectively. When patients with a central venous catheter (CVC) were considered alone, survivors were found to have significantly higher scores than non-survivors (13.1 ± 3.19 vs. 11.3 ± 4.77, p = 0.025). When assessing components of the EQUAL Score separately, only candida speciation (p = 0.013), susceptibility testing (p = 0.012) and echocardiography results (p = 0.012) were significantly associated with a lower case-fatality rate. A higher EQUAL Candida score was able to predict a lower case-fatality rate in patients with a CVC.

Opportunist Coinfections by Nontuberculous Mycobacteria and Fungi in Immunocompromised Patients

Nontuberculous mycobacteria (NTM) and many fungal species (spp.) are commonly associated with opportunistic infections (OPIs) in immunocompromised individuals. Moreover, occurrence of concomitant infection by NTM (mainly spp. of Mycobacterium avium complex and Mycobacterium abscessus complex) and fungal spp. (mainly, Aspergillus fumigatus, Histoplasma capsulatum and Cryptococcus neoformans) is very challenging and is associated with poor patient prognosis. The most frequent clinical symptoms for coinfection and infection by single agents (fungi or NTM) are similar. For this reason, the accurate identification of the aetiological agent(s) is crucial to select the best treatment approach. Despite the significance of this topic it has not been sufficiently addressed in the literature. This review aims at summarizing case reports and studies on NTM and fungi coinfection during the last 20 years. In addition, it briefly characterizes OPIs and coinfection, describes key features of opportunistic pathogens (e.g., NTM and fungi) and human host predisposing conditions to OPIs onset and outcome. The review could interest a wide spectrum of audiences, including medical doctors and scientists, to improve awareness of these infections, leading to early identification in clinical settings and increasing research in the field. Improved diagnosis and availability of therapeutic options might contribute to improve the prognosis of patients' survival.

European confederation of medical mycology quality of clinical candidaemia management score: A review of the points based best practice recommendations

Candidaemia is associated with high mortality. In the last few years, several guidelines have been published on the management of Candida bloodstream infection. However, adherence to the practice guidelines has been suboptimal. In order to facilitate and objectively measure the adherence to good practice recommendations, a scoring criterion was published by the European Confederation of Medical Mycology (ECMM). The ECMM Quality (EQUAL) of Clinical Candidaemia Management is an audit tool that comprises of 10 quality indicators. Each quality indicator is allotted between 1 and 3 points. The maximum achievable score is 22 or 19 in patients with or without a central venous catheter, respectively. This paper reviews each of the 10 quality indicators and provides the context for improving quality within the individual domains. The review also suggests areas that are in need of further clarity or areas which merit attention in the future updates of the EQUAL scoring system so that clinicians are able to derive maximum benefit from the audit tool. The EQUAL scoring tool is an important milestone in the quality improvement aspect of the management of candidaemia and contributes to the various components of clinical governance in the management of Candida infection of the bloodstream.

A seven-year surveillance study of the epidemiology, antifungal susceptibility, risk factors and mortality of candidaemia among paediatric and adult inpatients in a tertiary teaching hospital in China

Background

There are no current national estimates of the candidaemia burden in China, and epidemiological candidaemia data from the underdeveloped region of China are lacking.

Methods

A 7-year retrospective study was carried out to analyse the prevalence, species distribution, antifungal susceptibility, risk factors and inpatient mortality of candidaemia among paediatric and adult patients in a regional tertiary teaching hospital in China.

Results

During the seven-year study period, a total of 201 inpatients with candidaemia were identified. The median age of the patients was 65 years (range, 1 day to 92 years), and 114 of the patients (56.7%) were male. The mean annual incidence of candidaemia was 0.26 cases per 1000 admissions (0.42 cases per 1000 paediatric admissions vs 0.24 cases per 1000 adult admissions, P < 0.05). Candida albicans was the most common fungal species (81/201, 40.3%) in all patients, Candida glabrata was the most common fungal species (18/35, 51.4%) in paediatric patients. Most isolates were susceptible to flucytosine (99.0%) and amphotericin B (99.0%), and the activity of antifungal agents against Candida species was no significant difference in satisfaction between paediatric and adult patients (P > 0.05). The all-cause mortality rate was 20.4% (paediatric patients: 11.4% vs adult patients:22.3%, P > 0.05). Fewer univariate predictors of poor outcomes were identified for paediatric patients than for adult patients (4 vs 11 predictors). Respiratory dysfunction and septic shock were independent predictors of 30-day mortality for all patients.

Conclusions

The epidemiological data of candidaemia in paediatric and adult patients are only different in the distributions of Candida species and the mean annual incidence of candidaemia. Flucytosine and amphotericin B can be used as first-choice agents when no antifungal susceptibility test results are available.

Marked virulence and azole resistance in Candida albicans isolated from patients with periodontal disease

Candida albicans is an opportunistic fungus frequently associated with periodontal diseases. The objective of this study was to determine the expression patterns of virulence genes associated with those of azole resistance among the strains of C. albicans isolated from patients with periodontal disease. We isolated 80 strains of C. albicans from patients with periodontal disease enrolled from two dental clinics and their antifungal susceptibilities were evaluated using the disc diffusion method. C. albicans and its virulence genes were identified using PCR. The expressions of the virulence genes of C. albicans were analyzed using real-time PCR post in vitro infection of the cell line A549. The phenotype for resistance against azoles such as ketoconazole and fluconazole was observed in all analyzed strains (n = 80), which coincided with the high frequency of occurrence of the genes CDR1 and MDR1 associated with resistance. The frequencies of detection and expression of the genes HWP1 (47/15), ALS1 (80/66), ALS3 (70/30), LIP1 (78/44), LIP4 (77/65), LIP5 (79/58), LIP6 (79/58), PLB1 (79/65), and PLB2 (80/66) were found to be higher in the strains of C. albicans isolated from patients with moderate periodontitis and different expression patterns associated with those for azole resistance were identified. It could be elucidated that the high expression of virulence markers associated with azole resistance in C. albicans might be contributing to the chronicity of periodontal infections.

Species distribution and antifungal susceptibilities of bloodstream Candida isolates: a nine-years single center survey

This study analyzed the epidemiology of bloodstream infections due to Candida spp. in a tertiary referral hospital of Ancona, Italy, and their susceptibility to antifungals. The retrospective observational study from January 2010 to December 2018 identified 504 episodes of candidemia in 461 patients. Although Candida albicans remained the species most frequently isolated, Candida spp. other than C. albicans caused 49% of the overall episodes of candidemia. According to CLSI interpretation, most of the isolates resulted susceptible to antifungals. Azoles vs Candida tropicalis represented an exception. Echinocandin non-susceptibility was rare across the species. In conclusion, with the exception of C. tropicalis, the isolation of a non-susceptible Candida strains against azoles, echinocandins and amphotericin B was a rare event.