Hospital-acquired candida and aspergillus pneumonia--diagnostic approaches and clinical findings

Severe pneumonia due to infection with Candida krusei in a case of suspected Middle East respiratory syndrome: A case report and literature review

Candida krusei (C. krusei) pneumonia is a rare infection that is frequently associated with a poor outcome. The present study reports an unusual case of C. krusei pneumonia that was initially suspected to be a Middle East respiratory syndrome (MERS) case. A 64-year-old Saudi Arabian male patient was admitted to our hospital with complaints of cough and dyspnea that persisted for 6 days. The patient presented fever (oral temperature, 38.5°C) and slight tachypnea (25 respirations/min). A chest computerized tomography demonstrated unclear lung fields, diffuse pathological changes in the two lungs and multiple lymphadenectasis in the retrocaval and para-aortic arch area. The patient received 95-98% oxygen (6 l/min) for 24 h, as well as sulbactam sodium/cefoperazone sodium (1:1) injection (3.0 g) every 12 h, oral oseltamivir capsules (75 mg/time) twice a day, medaron injection (80 mg/time) and 750 ml fluid infusion; however, he succumbed to the disease on day 2 after admission. The infection was diagnosed by sputum smear and culture subsequent to patient mortality. A sputum smear showed a large fungal infection and sputum culture revealed the presence of C. krusei infection. Serum procalcitonin concentrations were 4.73 µg/l and 7.23 µg/l on days 2 and 3 after admission, respectively. In conclusion, the diagnosis of Candida pneumonia should be strongly considered in the presence of growth of Candida from a sputum culture and based on a suggestive computed tomography image. Tumescent diaphragmatic lymph nodes may also be an important symptom of Candida pneumonia. Treatment should be initiated immediately to improve tissue oxygenation, restore cardiovascular function and improve other organ functions.

ACR appropriateness criteria(®)acute respiratory illness in immunocompromised patients

The respiratory system is often affected by complications of immunodeficiency, typically manifesting clinically as acute respiratory illness. Ongoing literature reviews regarding the appropriateness of imaging in these patients are critical, as advanced medical therapies such as stem cell transplantation, chemotherapy, and immunosuppressive therapies for autoimmune disease continue to keep high the population of immunosuppressed patients in our health care system today. This ACR Appropriateness Criteria(®) topic describes clinical scenarios of acute respiratory illness in immunocompromised patients with cough, dyspnea, chest pain, and fever; in those with negative, equivocal, or nonspecific findings on chest radiography; in those with diffuse or confluent opacities on chest radiography; and in those in whom noninfectious disease is suspected. The use of chest radiography, chest CT, transthoracic needle biopsy, and nuclear medicine imaging are all discussed in the contexts of these clinical scenarios. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Antifungal treatment strategies in patients with haematological diseases or cancer: from prophylaxis to empirical, pre-emptive and targeted therapy

Immunocompromised patients have a high risk for invasive fungal diseases (IFDs). These infections are mostly life-threatening and an early diagnosis and initiation of appropriate antifungal therapy are essential for the clinical outcome. Empirical treatment is regarded as the standard of care for granulocytopenic patients who remain febrile despite broad-spectrum antibiotics. However, this strategy can bear a risk of overtreatment and subsequently induce toxicities and unnecessary treatment costs. Pre-emptive antifungal therapy is now increasingly used to close the time gap between delayed initiation for proven disease and empirical treatment for anticipated infection without further laboratory or radiological evidence of fungal disease. Currently, some new non-invasive microbiological and laboratory methods, like the Aspergillus-galactomannan sandwich-enzyme immunoassay (Aspergillus GM-ELISA), 1,3-β-D-glucan assay or PCR techniques have been developed for a better diagnosis and determination of target patients. The current diagnostic approaches to fungal infections and the role of the revised definitions for invasive fungal infections, now IFDs, will be discussed in this review as well as old and emerging approaches to empirical, pre-emptive and targeted antifungal therapies in patients with haemato-oncological malignancies.

Could Candida dubliniensis be involved in lung fungus balls?

We describe a case of cavitary pneumonia due to Candida dubliniensis along with fungemia due to Candida kefyr in a leukemic patient. This is the first case of C. dubliniensis isolated in our laboratory. The identification was performed by phenotypic and molecular methods such as thermotolerance test, carbohydrate fermentation and polymerase chain reaction.

Candida sp. isolated from bronchoalveolar lavage: clinical significance in critically ill trauma patients

OBJECTIVE

Based on limited data, Candida sp. isolates from bronchoalveolar lavage (BAL) cultures in immunocompetent patients are thought to be contaminants rather than pathogens. The objective of this study was to determine the clinical significance of Candida sp. isolated from BAL cultures in critically ill trauma patients.

DESIGN AND SETTING

Retrospective study in a level 1 trauma intensive care unit.

PATIENTS AND PARTICIPANTS

All patients with Candida sp. isolated from BAL cultures over a 3-year period; 85 Candida positive BAL cultures from 62 patients were studied.

MEASUREMENTS AND RESULTS

The primary outcomes were the incidence of Candida sp. in BAL, antifungal use, course of the possible infection, and mortality. Of 1077 BAL cultures 85 (8%) grew Candida sp., representing 64 episodes of possible Candida sp. ventilator-associated pneumonia. No colony counts exceeded the diagnostic threshold for bacterial VAP (>or=10(5) cfu/ml). Only 2 of 64 episodes (3%) were treated with systemic antifungals. Three other episodes (5%) were treated because of concomitant therapy for Candida sp. at other sites. The majority of episodes were not treated with antifungals and were considered contaminants (59/64, 92%). No patients developed subsequent candidemia, and most follow-up BALs (74%) were negative for Candida sp. Overall mortality (17%) was similar to previous patients with similar severity of injury at the study center (18%).

CONCLUSIONS

The results of this study suggest that isolation of Candida sp. from BAL in quantities below the diagnostic threshold for VAP in this population does not require antifungal therapy.

[Candida pneumonia in patients without definitive immunodeficiency]

The occurrence of community-acquired pneumonia due to yeast-like fungi of the genus Candida in patients without manifest immunodeficiency has previously been discounted. However, such pneumonias may indeed occur in patients with chronic parenchymal lung damage, e.g. from nicotine. Candida pneumonia can be triggered in these patients for example by trivial viral infections. Three corresponding cases are discussed.

Outcome of postoperative pneumonia in the Eole study

OBJECTIVES

Prognosis factors of ventilator-associated pneumonia (VAP) have been largely investigated, while the data concerning postoperative pneumonia (POP) are scarce. The aim of this multicenter, prospective study was to evaluate the predictive factors of mortality due to POP and the impact of initial antibiotic therapy on outcome.

METHODS

Two hundred centers were included. Diagnosis of POP was assessed on clinical and laboratory criteria, chest X-ray changes and microbiological criteria, when possible. Outcomes of the patients were noted. An independent committee made a retrospective assessment of appropriateness of antimicrobial therapy.

RESULTS

The overall mortality among the 556 cases of POP was 23% (126 patients). Five parameters were independently associated with mortality: American Society of Anesthesiology (ASA) grade 3 or more ( p<0.001), age 64 years or more ( p<0.01), time to onset of pneumonia more than 3 days ( p<0.01), mottling ( p<0.05) and hypotension ( p<0.05). Among the 322 microbiologically confirmed cases of pneumonia, 92 received inappropriate antibiotic (AB) therapy (29%). No difference in mortality was observed between the patients receiving inappropriate and appropriate AB therapy (22.8 vs 16.9%). In this subgroup, three parameters remained independently associated with mortality: ASA grade 3 or higher ( p<0.001), time to onset of pneumonia more than 3 days ( p<0.05) and hypotension ( p<0.05). Inappropriate initial AB did not modify the model ( p=0.22).

CONCLUSIONS

Five independent predictive factors for mortality of POP were identified. Despite a trend toward decreased mortality with appropriate initial antimicrobial therapy, no difference was observed between the groups. Polymicrobial pneumonia or non-fermenting Gram-negative bacilli appeared to be a risk factor for inappropriate AB.

Aspergillus detection in bronchoscopically acquired material. Significance and interpretation

Pulmonary invasive aspergillosis is frequently difficult to diagnose. In particular, the value of the cultivation of Aspergillus and the Aspergillus galactomannan antigen detection (Pastorex) in bronchoscopically acquired material (bronchoalveolar lavage = BAL, bronchial lavage = BL) in the course of diagnosing this mycosis is viewed controversially. Between January 1996 and September 1999, we obtained 114 positive results in 100 bronchoscopically aquired specimens from a total of 69 patients. 59 of the 69 patients were immunosuppressed, 42 suffered from pulmonary aspergillosis and 38 suffered from invasive pulmonary aspergillosis. The positive prediction rate for a positive result with regard to pulmonary aspergillosis in bronchoscopically acquired material was approximately 61%. Cultivation of Aspergillus was more successful in BAL, and the Aspergillus antigen detection was more successful in BL.

The role of Candida sp isolated from bronchoscopic samples in nonneutropenic patients

STUDY OBJECTIVES

To determine the clinical significance of Candida sp isolated from bronchoscopic samples in patients with suspected pneumonia.

DESIGN

A retrospective chart review was performed in all nonneutropenic adult patients with Candida sp isolates from respiratory secretions obtained by bronchoscopy over a 5-year period (1991 to 1995). Potential risk factors, therapeutic decisions, and outcome were recorded. Microbiological findings, chest radiograph reports, and pathologic material were reviewed. Isolates were classified as definite, probable, or indeterminate contamination, or as definite pulmonary candidiasis, on the basis of histologic findings, therapeutic decisions, and outcome.

SETTING

A 600-bed teaching hospital with 16 beds in a medical-surgical ICU.

PATIENTS

Thirty-seven consecutive patients with positive cultures for Candida sp from respiratory samples obtained by bronchoscopy were evaluated. Thirty-two of these 37 patients (86.5%) received antibiotic therapy prior to sampling, and 23 (62.2%) were intubated.

RESULTS

Contamination was classified as definite in 3 patients (8.1%) and probable in 30 others (81.0%). Contamination was indeterminate in two cases (5.4%). Two additional patients (5.4%) received antifungal agents for systemic candidiasis. No cases of pulmonary candidiasis could be demonstrated, although 24 of 28 patients showed protected specimen brush cultures > or = 10(3) cfu/mL.

CONCLUSIONS

Nonneutropenic patients with isolation of Candida sp from bronchoscopic samples, even in high concentrations, are unlikely to have invasive candidiasis. Indication for initiation of antifungal therapy should be based on histologic evidence or identification from sterile specimens.

Role of quantitative cultures and microscopic examinations of endotracheal aspirates in the diagnosis of pulmonary infections in ventilated patients

Endotracheal aspirates (EA) from 20 intubated patients in a surgical intensive care unit (mean ventilation time/patient = 16.5 days) were investigated serially by performing quantitative cultures using growth of 10(5) cfu/mL as a cut-off point. Microscopic examinations were made using Giemsa's stain for polymorphonuclear neutrophils (PMN). The spectrum of pathogens encountered was determined and compared with clinical data to distinguish colonization from infection of the lower respiratory tract. Out of 301 EA cultures, 156 (51.8%) were positive and 145 (48.2%) were below the cut-off point. Counts of PMN were significantly higher in samples which gave positive cultures. Seventy-five different bacterial strains were isolated (64% were Gram-negative bacilli). Seventeen patients (85%) were colonized with Gram-negative bacteria. Nine patients (45%) developed nosocomial pneumonia (NP), five (25%) had no signs of pneumonia, and six (30%) had an uncertain status. Main causative agents for NP were Pseudomonas aeruginosa, Enterobacteriaceae and Staphylococcus aureus. Quantitative EA cultures had a sensitivity of 81.5%, a specificity of 64.8%, a positive predictive value of 55% and a negative predictive value of 87%. Our results suggest that EA quantitative cultures (cut-off value 10(5) cfu/mL), species identification and microscopic examination of EA may help to differentiate tracheobronchial colonization and infection, especially when bronchoscopic techniques are not available.