Successful medical treatment of presumed Candida endocarditis in critically ill infants

Polyene Antibiotics Physical Chemistry and Their Effect on Lipid Membranes; Impacting Biological Processes and Medical Applications

This review examined a collection of studies regarding the molecular properties of some polyene antibiotic molecules as well as their properties in solution and in particular environmental conditions. We also looked into the proposed mechanism of action of polyenes, where membrane properties play a crucial role. Given the interest in polyene antibiotics as therapeutic agents, we looked into alternative ways of reducing their collateral toxicity, including semi-synthesis of derivatives and new formulations. We follow with studies on the role of membrane structure and, finally, recent developments regarding the most important clinical applications of these compounds.

Not "Much Room" in the Heart: A Rare Case of a Massive Intracardiac Candida Mass

Introduction

Coupled with the increasing use of indwelling vascular catheters and prosthetic cardiac valves is an uptrend in sepsis secondary to fungemia. An insidious onset often shrouds the initial diagnosis, contributing to poor outcomes. Candida infective endocarditis (CIE) is a feared complication of candidemia, associated with high mortality rates. It requires prolonged hospital stays for medical and, often, surgical management. We report a case of a massive intracardiac Candida mass in an adult with native valve CIE.

Case

A 51-year-old male on chronic total parenteral nutrition (TPN) because of bowel resection presented with fevers, night sweats, and unintentional weight loss. He was febrile and tachycardiac on admission, with a benign physical examination. Laboratory workup showed elevated inflammatory markers and an acute kidney injury. Extended blood cultures showed growth of Candida glabrata (C. glabrata) and Candida dubliniensis (C. dubliniensis). Transthoracic (TTE) and transesophageal echocardiography revealed a large mobile right atrial mass (4 cm × 6 cm × 2.5 cm), extending to the right ventricular outflow tract. Since he was a poor surgical candidate, management with micafungin was initiated and continued for 8 weeks. He responded well to the regimen with resolution of the fungal mass on follow-up TTE 3 months later. In anticipation of the future need for TPN, he continues on lifelong suppressive oral fluconazole.

Conclusion

CIE may be an insidious complication of indwelling central venous catheters, necessitating a high index of suspicion. Conservative management, with antifungal therapy, can yield favorable outcomes in poor surgical candidates.

Fungal Endocarditis in Neonates: A Review of Seventy-one Cases (1971-2013)

BACKGROUND

Fungal endocarditis (FE) remains an uncommon but life-threatening complication of invasive fungal infections. As data on neonatal FE are scant, we aimed to review all published experience regarding this serious infection.

METHODS

Neonatal FE cases published in PubMed (1971-2013) as single cases, or case series were identified using the terms "fungal endocarditis, neonates and cardiac vegetation." Data on predefined criteria including demographics, predisposing factors, mycology, sites of cardiac involvement, therapy and outcome were collected and analyzed.

RESULTS

The dataset comprised 71 neonates with FE. Median birth weight was 940 g [interquartile range (IQR): 609], median gestational age 27 weeks (IQR: 6) and median postnatal age at diagnosis 20 days (IQR: 20). Ninety-two percent of the patients were premature. Right atrium was the most common vegetation site (63%). Seventy-one percent of the cases reported were associated with previous central venous catheters. Candida albicans was the most predominant fungal species (59%). Amphotericin B monotherapy was used in 42.2% and fluconazole in 2.8%. Amphotericin B with flucytosine (25.3%) was the most frequent combined regimen. Surgical treatment was conducted in 28%. Overall mortality was 42.2%. Initiation with combined antifungal treatment was associated with lower mortality than monotherapy (24.2% vs. 51.7%, respectively, P = 0.036).

CONCLUSIONS

Neonatal FE most frequently occurs in very premature infants and is associated with central venous catheters. C. albicans is the predominant fungus. Although outcome has been dismal, it may be improved with combined antifungal therapy.

Tricuspid valve mycetoma in an infant successfully treated by excision and complex tricuspid valve repair followed by fluconazole therapy

BACKGROUND

Fungal valve endocarditis in children is an uncommon and lethal disease. The risk increases with use of central venous catheters (CVC), total parenteral nutrition (TPN), and use of broad-spectrum antibiotics during the neonatal period. Due to high mortality, a combination of surgery and antifungal therapy is usually recommended for treatment.

METHODS

Case report and review of the literature.

RESULTS

We present a case of an asymptomatic infant with multiple Candida tricuspid valve mycetomas. Complete cure was achieved by combined tricuspid valve repair and fluconazole therapy. We also review 26 cases of tricuspid valve Candida endocarditis in children published in the literature.

CONCLUSION

From being uniformly fatal five decades ago to a current survival rate of 64% to 100%, the prognosis of Candida endocarditis has changed dramatically with the use of antifungal therapy alone or in combination with surgery. Our case re-emphasizes the role of valve-sparing debridement with repair of the native valve using autologous pericardium in combination with long-term antifungal therapy as a feasible option in managing tricuspid valve Candida endocarditis.

Candidaendocarditis in neonates: report of five cases and review of the literature

Candidal endocarditis is an uncommon and serious complication of invasive Candida infection in neonates. The aim of this study was to further characterise candidal endocarditis in neonates. Between 1995 and 2000, 56 patients were diagnosed with Candida bloodstream infections (CBSI) in the Neonatal Intensive Care Unit of Schneider Children's Medical Center of Israel. Five of them (9%) developed mycetoma of the right atrium. None of the patients had congenital heart disease or a central venous catheter in the right heart at the time of diagnosis. All were treated with amphotericin B alone or in combination with other antifungals, without surgical intervention. One patient died of the disease and one died later of polymicrobial sepsis and necrotizing enterocolitis. A review of the literature since 1980 yielded an additional 25 cases of candidal endocarditis. For the whole sample (n = 30) survival rate was 73.1%. Six of the 10 patients treated with antifungal agents and surgery survived (60%), compared with 13 of the 20 patients treated only medically (65%) (P = 1.0). Candida endocarditis in neonates differs from fungal endocarditis in adults in risk factors, clinical presentation and outcome. As the outcome of surgical and medical treatment are comparable, antifungal therapy alone may be a valid therapeutic option in high-risk cases.

Fungal endocarditis in neonates and children

Fungal endocarditis in the neonate and pediatric population is associated with a high degree of morbidity and mortality, with diagnosis in the majority of cases made postmortem. The aim of this article is to review published literature on fungal endocarditis in children and to discuss the incidence due to a wide range of fungi, primarily Aspergillus and Candida species, as well as its diagnosis, including the importance of molecular-based approaches and various treatment regimes.

Transplantation of Yeast-Infected Cardiac Allografts: A Report of 2 Cases

For the first time in the literature to date, we report 2 cases of transplantation of yeast-infected cardiac allografts. In both cases, endocardial vegetations were observed before graft implantation. Microbiologic samples grew yeasts: Rhodotorula glutinis was found close to the left atrial appendage in the first case and Candida parapsilosis was identified in a vegetation located at the base of the tricuspid valve in the second case. We discuss the possible routes of donor organ infection and management of these 2 unusual cases.

A meta-analysis of medical versus surgical therapy for Candida endocarditis

OBJECTIVES

The optimal management of Candida infective endocarditis (IE) is unknown.

METHODS

We reviewed all 879 cases of Candida IE reported from 1966-2002 in the peer-reviewed literature to better understand the role of medical and surgical therapies. This review included 163 patients from 105 reports that met our inclusion criteria: 31 cases treated with antifungal monotherapy, 25 cases treated with medical antifungal combination therapy, and 107 cases treated with adjunctive surgical plus medical antifungal therapy. We also used meta-analytic techniques to evaluate 22 observational case-series (72 patients) of the 105 reports with two or more patients with definite Candida IE.

RESULTS

We found that in patients who underwent adjunctive surgery there was a lower reported proportion of deaths [prevalence odds ratio (POR)=0.56; 95% confidence interval (CI)=0.16, 1.99)]. Higher mortality was noted in patients treated prior to 1980 (POR=2.03; 95% CI=0.55, 7.61), treated with antifungal monotherapy (POR=1.49; 95% CI=0.39, 5.81), infected with Candida parapsilosis (POR=1.51; 95% CI=0.41, 5.52), or with left-sided endocarditis (POR=2.36; 95% CI=0.55, 10.07).

CONCLUSIONS

Medical antifungal therapy of Candida IE is poorly characterized, and recent antifungal developments lend promise for those patients who cannot undergo surgery.

Antifungals in systemic neonatal candidiasis

Fungal infections are common in the newborn period, especially among premature neonates, and are responsible for considerable morbidity and mortality. Currently, three classes of antifungals are commonly used in the treatment of systemic fungal infections in neonates: the polyene macrolides (e.g. amphotericin B [deoxycholate and lipid preparations]); the azoles (e.g. fluconazole); and the fluorinated pyrimidines (e.g. flucytosine). The echinocandins (e.g. caspofungin and micafungin) are a newer class of antifungals which shows promise in this population.The available kinetic data on amphotericin B deoxycholate in neonates are derived from very small studies and exhibit considerable variability. There are no kinetic data available for the use of lipid preparations in this population and, again, much has been inferred from adult studies. The information available for flucytosine is also limited but appears similar to what is observed in adults. Fluconazole has the most neonatal pharmacokinetic data, which show slightly less variability than the other antifungals. Genomic factors which affect the metabolism of amphotericin B and fluconazole may explain some of the observed variability. Most of the data for the efficacy of antifungal drugs in neonates are derived from retrospective studies and case reports. The data for amphotericin B deoxycholate and flucytosine are limited. There are more data for the liposomal and lipid complex preparations of amphotericin B and for fluconazole in this population. These support the use of these drugs in neonates, but because of their largely noncomparative nature they can not define the optimal dosage or duration of therapy. Amphotericin B deoxycholate is primarily nephrotoxic. It also induces electrolyte abnormalities and is to a lesser degree cardiotoxic. This toxicity in neonates appears similar to published data in older children and adults. While the lipid preparations of amphotericin B owe their existence to a presumed decrease in toxicity, the observed toxicity in neonates appears to be equal to that seen with the deoxycholate, although it should be noted that the lipid preparations are usually given at much higher dosages. Fluconazole toxicity appears to be milder and less frequent in this population than is seen with amphotericin B. In the final analysis, we do not have sufficient data to define the pharmacokinetic profiles, optimal dose or duration of therapy, or toxicity for any of these compounds in neonates. Further studies are necessary if the optimisation of antifungal therapy in this population is to continue.

Late onset Candida parapsilosis endocarditis after surviving nosocomial candidemia in an infant with structural heart disease

The incidence of nosocomial candidemia is increasing. Late onset endocarditis after surviving nosocomial fungemia is described in adults. We report a case of late onset Candida parapsilosis endocarditis of a structurally abnormal aortic valve in an infant surviving nosocomial candidemia.

Low yield of ancillary diagnostic studies in neonates infected with Candida

BACKGROUND

Fungal infection can be a significant complication for the critically ill neonate. However, the usefulness of extensive radiologic and ophthalmologic investigations in this population has not been thoroughly elucidated.

OBJECTIVE

To report the incidence of organ fungal involvement diagnosed by ancillary testing (echocardiogram, ophthalmologic examination, brain imaging, and renal ultrasound (RUS)) among neonatal intensive care unit (NICU) patients with Candida infection.

METHODS

This was a single center review of all NICU patients with Candida-positive cultures of blood, urine, peritoneal fluid, endotracheal tube aspirate, or cerebrospinal fluid from January 1, 1997 to June 1 2002. Data regarding the number of positive cultures, species isolated, and presence of specific risk factors and clinical symptoms were recorded for each case, as well as occurrence, timing and results of ancillary testing.

RESULTS

In all, 66 patients had at least one positive culture for Candida. The majority (71%) were <1500 g at birth, and mean gestational age was 29.5+/-5.6 weeks. Echocardiograms were obtained in 54/66 (82%), and ophthalmology examinations were obtained in 36/66 (55%); none of these was consistent with fungal involvement. Brain imaging was performed in 50/66 (76%), only one of which was positive, in a patient with 16 positive blood cultures for Candida albicans. RUS were performed in 58/66 (88%) of patients, with concerning findings for fungal involvement in seven of the studies. RUS findings alone did not appear to consistently influence the length of therapy.

CONCLUSIONS

Ancillary evaluations to investigate for fungal dissemination were undertaken frequently, but were of overall low yield. Although ancillary testing may be of limited additional value in centers with a low threshold for suspecting fungal infections and an aggressive approach to therapy, potentially important findings, which could impact management, may occur.

Infective endocarditis successfully treated in extremely low birth weight infants with recombinant tissue plasminogen activator

Increased survival of extremely low birth weight infants depends on the use of indwelling catheters. These catheters expose the infant to the risk of thrombus formation and line infection. When intracardiac thromboses become infected, the entity is indistinguishable from infective endocarditis and exposes the infant to prolonged sepsis and risk of disseminated infected emboli. Despite prolonged antiinfective therapy and removal of the infected line, resolution of the sepsis and dissolution of the vegetations is frequently not achieved. We describe 2 cases of infective endocarditis in extremely low birth weight infants successfully treated with recombinant tissue plasminogen activator in addition to prolonged antiinfective therapy. Blood cultures became sterile and vegetations disappeared within days of commencing treatment, and there were no systemic complications. A literature search detailed in the article confirms the poor outcome associated with infectious endocarditis in preterm infants. Tissue plasminogen activator may play an important role when standard care has failed.

Ophthalmologic, visceral, and cardiac involvement in neonates with candidemia

A retrospective review of 86 neonates with candidemia hospitalized from January 1989 through June 1999 was conducted to determine the frequency of ophthalmologic, visceral, or cardiac involvement. Retinal abnormalities were observed in 4 (6%) of the 67 infants in whom indirect ophthalmoscopy examination was performed. Abdominal ultrasound abnormalities were detected in 5 (7.7%) of 65 infants. Echocardiogram revealed thrombi or vegetations in 11 (15.2%) of 72 infants. Age at onset, presence of central venous catheters, and species of Candida were not predictors for involvement at these sites. Infants with candidemia that lasted > or =5 days were more likely to demonstrate ophthalmologic, renal, or cardiac abnormalities than those with a shorter duration. Infants with involvement of these organs received larger cumulative doses of amphotericin B than those without detectable abnormalities. Because complication of disseminated candidiasis by eye, renal, or cardiac involvement has therapeutic implications, and because risk factors for candidemia inadequately predict these complications, evaluations are indicated for all neonates with candidemia.

Candida endocarditis in a premature infant

Endocarditis is an uncommon complication of invasive candidiasis. We present a fatal case of endocarditis caused by Candida albicans in a very low birth weight infant. The 780-g male infant did not have any structural heart disease and a central venous catheter was not placed. Endocarditis developed in spite of parenteral fluconazole treatment. Echocardiography was a valuable tool in making the diagnosis. The infant died on the 40th day of life. The development of Candida endocarditis in a premature infant who was treated with fluconazole had not been previously reported. In the case of systemic candidiasis, premature infants require very careful monitoring for the progression of the disease, even if antifungal therapy is administered.

Administration of fluconazole in children below 1 year of age

For this review, 78 studies regarding the use of fluconazole in a total of 726 children below 1 year of age were evaluated. The range of fluconazole dosage was 2-50 mg kg-1 day-1, with 162 days being the maximum duration of treatment. According to current experience, fluconazole seems to be well tolerated and efficacious against systemic candidosis and candidaemia in children below 1 year of age, including neonates and very low-birthweight infants (VLBWIs). The recommended daily dosage is 6 mg kg-1. (In Germany, fluconazole is approved for children between 1 and 16 years in cases in which there is no therapeutic alternative for treatment of systemic infections caused by Candida spp. and Cryptococcus neoformans in a dosage of 3-6 mg kg-1 day-1 and for superficial Candida infections in a dosage of 1-2 mg kg-1 day-1.) In patients with impaired renal function, the daily dose should be reduced in accordance with the guidelines given for adults. In neonates during the first 2 weeks of life, this dosage should be administered only every 72 h. In weeks 2-4 of life, the same dose should be given every 48 h, following which daily dosing is appropriate. This posology is derived from the age-related pharmacokinetics of fluconazole, with a higher volume of distribution and a prolonged plasma elimination half-life, especially during the first month of life. Drug monitoring during treatment should be performed to ensure therapeutic plasma concentrations of fluconazole within a range between 4 and 20 micrograms ml-1. The benefit of fluconazole should be investigated in prospective studies for treatment of systemic candidosis with administration of higher dosages as well as for early empiric therapy in VLBWIs.

[Use of fluconazole in children less than 1 year old: review]

For this review, 78 publications for use of fluconazole in children below 1 year of age were evaluated with a total of 726 patients. The range of fluconazole dosage was 2-50 mg/kg/day with 162 days as maximum duration of treatment. According to the present experience, fluconazole seems to be an efficacious and well tolerated therapy against systemic candidosis and candidemia in children below 1 year of age, including neonates and very low birth-weight infants (VLBWI). The recommended daily dosage is 6 mg/kg. In patients with impaired renal function, the daily dose should be reduced in accordance with the guidelines given for adults. In neonates during the first two weeks of life, this dosage should be administered only every 72 hours. In weeks two to four of life, the same dose should be given every 48 hours. After that daily dosing is appropriate. This posology is derived from the age-related pharmacokinetics of fluconazole with a higher volume of distribution and a prolonged plasma elimination half life especially during the first month of life. Drug monitoring during treatment should be performed to ensure therapeutic plasma concentrations of fluconazole within a range between 4 and 20 micrograms/ml. The benefit of fluconazole should be investigated in prospective studies for treatment of systemic candidosis with administration of higher dosages as well as for early empiric therapy in VLBWI.

Fungal endocarditis--a report on seven cases and a brief review

Candida endocarditis is an unusual but severe complication of systemic infection caused by Candida albicans and occasionally by other fungal species. We describe seven cases that occurred during a period of 20 years in western Sweden. In four cases infections were located on prosthetic valves and in three cases native valves were involved. Three patients died of the disease in the acute phase. A definite diagnosis was established in one of four survivors. This patient had an aortic valve endocarditis and a saddle embolisation and was treated with immediate surgery, followed by intensive treatment with liposomal amphotericin B+ flucytosine. Fungal endocarditis is still a serious disease with a high mortality and whenever the diagnosis is suspected, antifungal therapy must be started and transesophageal sonography should be performed to visualize vegetations. Immediate surgery should be considered.

Infective endocarditis in neonates

We studied retrospectively the predisposing factors and signs of infective endocarditis (IE) in neonates and infants younger than 3 months of age, and we suggest diagnostic criteria. The charts of 16 infants less than 3 months of age, diagnosed with IE during a 5-year period, were reviewed for possible maternal and infant risk factors and for pathognomonic clinical and laboratory features. No apparent maternal risk factors were noted. Infant risk factors were congenital heart disease (4), patent ductus arteriosus (PDA) (5), and the use of central venous catheters (14). The main clinical findings were cardiac murmurs (12), petechiae (2), skin abscesses (7), arthritis (2), hepatomegaly (9), and splenomegaly (2). Echocardiography revealed a mass or vegetation in nine patients. Of the 27 microorganisms isolated from blood, the most common were staphylococci (15) and Candida sp. (6). Urine cultures were positive in six patients and cerebrospinal fluid cultures were positive in one. Other laboratory findings were not of diagnostic value. We conclude that the main risk factors for neonatal IE are central venous catheters and congenital heart disease, including PDA. The main causative microorganisms are staphylococci and Candida sp. The main investigations of diagnostic value are blood and urine cultures and echocardiography. We propose the diagnostic categories of definite, probable, and possible cases of neonatal IE, based primarily on clinical, blood culture, and echocardiographic data.

Medical treatment of recurrent candidemia in a patient with probable Candida parapsilosis prosthetic valve endocarditis

Fungal endocarditis is considered an absolute indication for valve replacement surgery. We describe the successful medical treatment of recurrent Candida parapsilosis candidemia with sequential treatment with amphotericin B and fluconazole in a patient with probable prosthetic valve endocarditis. Because of the presumed effectiveness of amphotericin B and fluconazole in the treatment of this patient, medical therapy should be considered as potentially useful in the treatment of recurrent C parapsilosis fungemia or endocarditis or both.