Candida Infections in the Intensive Care Unit

Drug Repurposing of Haloperidol: Discovery of New Benzocyclane Derivatives as Potent Antifungal Agents against Cryptococcosis and Candidiasis

Despite the high morbidity and mortality of invasive fungal infections (IFIs), effective and safe antifungal agents are rather limited. Starting from antifungal lead compound haloperidol that was identified by drug repurposing, a series of novel benzocyclane derivatives were designed, synthesized, and assayed. Several compounds showed improved antifungal potency and broader antifungal spectra. Particularly, compound B10 showed good inhibitory activities against a variety of fungal pathogens and was proven to be an inhibitor of several virulence factors important for drug resistance. In the in vivo cryptococcosis and candidiasis models, compound B10 could effectively reduce the brain fungal burden of Cryptococcus neoformans and synergize with fluconazole to treat resistant Candida albicans infections. Preliminary antifungal mechanism studies revealed that compound B10 regained cell membrane damage and down-regulated the overexpression of ERG11 and MDR1 genes when used in combination with fluconazole. Taken together, haloperidol derivative B10 represents a promising lead compound for the development of a new generation of antifungal agents.

Toll-like receptor 9-dependent activation of myeloid dendritic cells by Deoxynucleic acids from Candida albicans

The innate immune system of humans recognizes the human pathogenic fungus Candida albicans via sugar polymers present in the cell wall, such as mannan and beta-glucan. Here, we examined whether nucleic acids from C. albicans activate dendritic cells. C. albicans DNA induced interleukin-12p40 (IL-12p40) production and CD40 expression by murine bone marrow-derived myeloid dendritic cells (BM-DCs) in a dose-dependent manner. BM-DCs that lacked Toll-like receptor 4 (TLR4), TLR2, and dectin-1, which are pattern recognition receptors for fungal cell wall components, produced IL-12p40 at levels comparable to the levels produced by BM-DCs from wild-type mice, and DNA from a C. albicans pmr1Delta null mutant, which has a gross defect in mannosylation, retained the ability to activate BM-DCs. This stimulatory effect disappeared completely after DNase treatment. In contrast, RNase treatment increased production of the cytokine. A similar reduction in cytokine production was observed when BM-DCs from TLR9(-/-) and MyD88(-/-) mice were used. In a luciferase reporter assay, NF-kappaB activation was detected in TLR9-expressing HEK293T cells stimulated with C. albicans DNA. Confocal microscopic analysis showed similar localization of C. albicans DNA and CpG-oligodeoxynucleotide (CpG-ODN) in BM-DCs. Treatment of C. albicans DNA with methylase did not affect its ability to induce IL-12p40 synthesis, whereas the same treatment completely eliminated the ability of CpG-ODN to induce IL-12p40 synthesis. Finally, impaired clearance of this fungal pathogen was not found in the kidneys of TLR9(-/-) mice. These results suggested that C. albicans DNA activated BM-DCs through a TLR9-mediated signaling pathway using a mechanism independent of the unmethylated CpG motif.

[Intra-abdominal mycoses]

The incidence of invasive mycoses in patients undergoing abdominal surgery amounts to approximately 8% and shows an upward trend in epidemiological studies. The lethality of these systemic mycoses, which are mostly based on Candida infections constitutes up to 60%. The development of a sytemic mycosis is marked by exogenic, endogenic and iatrogenic risk factors and typically displays tissue invasion after an initial fungal contamination or systemic dissemination via fungal sepsis. Fungal peritonitis is generally a monoinfection with Candida spp., where Candida albicans outweighs in 70% of cases. Aspergillus spp. are only detected abdominally in rare cases. The histological verification of a fungal invasion is regarded as proof of the existence of an invasive mycosis, but typical macroscopic findings with corresponding cultural findings can also confirm the diagnosis. Systemic mycosis requires an early initiation of a consistent antimycotic therapy as well as definitive surgical eradication of the focus in order to reduce high lethal rate. Resistances or incorrect dosages can be validated objectively by means of histological monitoring of the antimycotic therapy, thus affording early recognition of the need to change the substance class.

Assessment of nephrotoxicity in patients receiving amphotericin B lipid complex: a pharmacosurveillance study in Spain

This study assessed the risk of haematological, renal and hepatic toxicity associated with amphotericin B lipid complex (ABLC; Abelcet) in a multicentre, open-label, non-comparative study of 93 patients from 17 different hospitals who received ABLC because of proven or suspected systemic fungal infection or leishmaniasis. Most (66%) patients had onco-haematological diseases. Optimum treatment with ABLC comprised a slow (2-h) infusion dose of 5 mg/kg/day for a minimum period of 14 days. Biochemical and haematological parameters were measured pre-, during and post-treatment. In the overall patient group, the mean serum creatinine concentration was similar pre- and post-study (1.00 +/- 1.14 mg/dL vs. 1.20 +/- 1.19 mg/dL; p > 0.05). There were no significant changes pre- and post-treatment in concentrations of haemoglobin, potassium, transaminases and bilirubin. There was no significant correlation between the dose administered and the concentrations of serum creatinine (Spearmann 0.22). There was no greater nephrotoxicity in the patients with previous renal failure, or in those who had received amphotericin B previously. There were serious adverse events in five patients, but other alternative causes that could explain these events were present in three of these patients. Fevers or chills were experienced by 23% of the patients during the ABLC infusion, but only in one case did this necessitate the suspension of treatment. It was concluded that ABLC is a drug with low nephrotoxicity, even when administered to patients with pre-existing renal insufficiency. Adverse events were generally slight or moderate, and were managed easily with appropriate pre-medication.

Potential risk factors for infection with Candida spp. in critically ill patients

The incidence, risk factors and prognostic factors for candidal infection were determined in a prospective study of 280 infected patients. Thirty-one (11%) patients were infected with Candida spp., sub-divided into 18 (58%) with C. albicans, and 13 (42%) with non-albicans spp. (six C. glabrata, three C. parapsilosis, and one each of C. krusei, C. tropicalis, C. guilliermondii and C. lusitaniae). Infection with Candida spp. was always associated with concurrent bacterial infection. By univariate logistic regression analysis, the degree of morbidity and the duration of mechanical ventilation were independent predictive factors for death, but infection with Candida spp., was not. Factors associated with Candida spp. infection were the degree of morbidity, intensive care unit length of stay, alterations of immune response, and the number of medical devices involved. By multivariate logistic regression analysis, the only independent risk factor for candidal infection was intensive care unit length of stay.

Candida peritonitis due to peptic ulcer perforation: incidence rate, risk factors, prognosis and susceptibility to fluconazole and amphotericin B

Sixty-two cases of peritonitis due to peptic ulcer perforation were diagnosed between January 2000 and December 2000. Of these 62 cases, 23 isolates of Candida in 23 cases (CP) were cultured from peritoneal fluid. Cultures of peritoneal fluid of 10 (BP) of the remaining 39 cases was positive for bacteria only. Cultures of peritoneal fluid of the remaining 29 cases was negative. Comparison of CP, BP and culture-negative cases did not reveal any significant risk factor. Of the 23 Candida isolates, the Candida species and 48-h MICs of fluconazole and amphotericin B (mean, range ug/ml) were C. albicans 18 (0.688, 0.125-1.0; 0.297, 0.031-0.5), C. glabrata 3 (0.542, 0.125-1.0; 0.25, 0.125-0.5), C. tropicalis 1 (0.25; 0.5), C. intermedia 1 (1.0; 0.125) respectively. Mortality rates of CP, BP and culture-negative peritonitis due to infection were 5/23(21.7%), 0/10 and 1/29(3.4%) respectively. Without effective antifungal therapy, the mortality rate of CP was not low.

Candida colonization in mechanically ventilated patients

The diagnosis of pulmonary candidosis is controversial. We undertook a prospective study on 50 mechanically ventilated (>48 h) patients who were hospitalized (>72 h) in the intensive care unit (ICU) with the aim of assessing the incidence of the isolation of Candida species from endotracheal aspirates (EA). Patients were categorized as individuals already colonized with Candida spp. on admission, individuals becoming colonized during hospitalization, or patients with no colonization. Patients in the ICU were hospitalized for a mean of 23 days. The percentage of patients already colonized with Candida was low (six of 50; 12%), the incidence of Candida isolation from EA in critically ill, mechanically ventilated patients in ICU was also low (six of 50; 12%). Age, duration of hospitalization, pre-treatment with antimicrobials or immunosuppressive agents and occurrence of underlying disease were not risk factors in our study. Both antifungal usage and neutropenia were more common in already colonized patients. No risk factors were determined for patients colonized during hospitalization. As all the isolates identified were C. albicans. It appears that at present, colonization and/or infection by more resistant Candida species is not a problem in our unit.

Evaluation of DNA-based typing procedures for strain categorization of Candida spp

DNA-based procedures have replaced earlier epidemiologic methodologies that relied on nonreproducible and insensitive measurements of phenotypic characteristics to identify a specific strain as the source of infection. The reliability (interlaboratory percent agreement for strain delineation) and sensitivity (recognition of subtle strain-to-strain variation) of similar DNA-based typing systems by different laboratories were evaluated. Ten isolates (five epidemiologic-related and five unrelated strains each) of Candida albicans, C. lusitaniae, C. parapsilosis, C. tropicalis, and Candida (Torulopsis) glabrata were characterized in a blinded fashion by three laboratories. All 50 isolates were subtyped in each laboratory by electrophoretic karyotyping (EK) analysis using contour-clamped homogenous electric field (CHEF) electrophoresis protocols. In addition, two laboratories also performed restriction endonuclease analysis of genomic DNA (REAG) using the restriction endonucleases SfiI and BssHII followed by CHEF electrophoresis separation of resulting fragments. DNA strain identification of the 50 isolates by the three different laboratories using similar CHEF methodologies demonstrated the following species-dependent, interlaboratory reproducibility: C. tropicalis (82%), C. parapsilosis (83%), C. albicans (90%), C. lusitaniae (93%), and C. glabrata (100%). In addition, agreement was higher by the CHEF method (83 to 100%), when compared with the strain types identified by the REAG (60 to 100%) method. Five to seven strains of each Candida species evaluated were detected by the different methodologies used for this study. This study indicates that these procedures are relatively discriminatory and reliable tools to study strain-to-strain variations in epidemiologic evaluations of these yeasts.

Do variations in molecular structure affect the clinical efficacy and safety of lipid-based amphotericin B preparations?

While amphotericin B is the drug of choice in the treatment of most fungal infections, systemic adverse reactions and dose-dependent nephrotoxicity associated with its use frequently render the conventional preparation of amphotericin unsuitable. A number of lipid-based formulations of amphotericin have been developed to overcome the limitations of the parent compound. These preparations, amphotericin B lipid complex (ABLC), amphotericin B colloid dispersion (ABCD) and liposomal amphotericin differ from one another significantly in their molecular structure. They are also considerably more expensive than the parent compound. Clinical data on their appropriate use are limited. This review looks at the differences in molecular structure of these preparations, and at the available clinical safety and efficacy data.

A randomized study comparing fluconazole with amphotericin B/5-flucytosine for the treatment of systemic Candida infections in intensive care patients

In this prospective, randomized study fluconazole and amphotericin B/5-flucytosine were compared in the treatment of systemic candidiasis. Seventy-two non-neutropenic intensive care patients with systemic Candida infections were enrolled. Thirty-six patients were randomly assigned to receive fluconazole (400 mg on the first day then 200 mg) and 36 were randomized to amphotericin B/5-flucytosine (1.0-1.5 mg/kg body weight every other day and 3 x 2.5 g flucytosine/day) for 14 days following the diagnosis. There was no statistically significant difference in clinical outcome in regard to the treatment of pneumonia and sepsis: 18/28 of the patients were treated successfully with fluconazole and 17/27 with amphotericin B/5-flucytosine. For the treatment of peritonitis, however, amphotericin B/5-flucytosine was more effective than fluconazole (55% vs. 25%). Furthermore, amphotericin B/5-flucytosine was found to be superior to fluconazole with regard to pathogen eradication (86% vs. 50%). Fluconazole was associated with less toxicity than amphotericin B/5-flucytosine.

Fluconazole increases bactericidal activity of neutrophils

BACKGROUND

Candida infections after injury are associated with significant mortality. Death often results from gram negative sepsis. Because antifungal therapy lowers mortality seen with Candida infections, this study was undertaken to determine whether fluconazole (FCZ) augments host response against bacteria, specifically, the bactericidal activity of polymorphonuclear neutrophils (PMN).

METHODS

PMN from 23 volunteers were incubated with phosphate-buffered saline or FCZ (20 micrograms/mL or 40 micrograms/mL). Bactericidal activity of these PMN, as well as FCZ alone, was determined using Escherichia coli and a colony forming unit protocol.

RESULTS

PMN possess potent bactericidal activity while FCZ possesses minimal inherent bactericidal activity. PMN bactericidal activity is significantly augmented by preincubation with FCZ. This enhanced bactericidal state is greater than the combined individual bactericidal properties of either FCZ concentration and PMN.

CONCLUSIONS

FCZ augments PMN bactericidal activity. This augmentation may help to explain the improved survival of critically injured patients receiving FCZ.

An experimental model for study of Candida survival and transmission in human volunteers

In order to determine the potential for cross-transmission of Candida spp. between health-care workers and patients, the survival of clinical isolates of five species of Candida on the palms of human volunteers was tested. One hundred microliters of a McFarland 1.0 density suspension (5 x 10(5) cfu) from an overnight culture of Candida albicans, Candida krusei, Candida parapsilosis, Candida tropicalis and Candida glabrata was used as inoculum. The degree of hydrophobicity of the different Candida species was also tested and did not influence the survival. The half-lives were brief, being 9.5, 12.4, 7.4, 12.8, 9.6 min for Candida albicans, Candida krusei, Candida glabrata, Candida parapsilosis, and Candida tropicalis, respectively, but at 45 min 2.6 x 10(3) to 3 x 10(4) organisms remained on the hands. Survival of Candida albicans for as long as 24 h on inanimate surfaces was observed. Transmission from one hand to a second hand occurred in 69% of the experiments and from the first to a third hand in 38%. Transmission to and from inanimate surfaces was successful in most of the experiments (90%). This experimental model aids in the biological study of Candida spp. and suggests some of the potential mechanisms of transmission.

Protection against murine disseminated candidiasis mediated by a Candida albicans-specific T-cell line

The role of T lymphocytes in disseminated candidiasis in a mouse model of irradiation-induced immunosuppression was investigated. A continuously cultured Candida albicans-specific T-cell line mediated protection of sublethally irradiated mice from disseminated candidiasis as measured by both the fungal load in the kidneys and mortality. These results are the first to demonstrate directly a role for antigen-specific T cells in the protective immune response against murine disseminated candidiasis.

Selective decontamination with nystatin for control of a Candida outbreak in a neonatal intensive care unit

Selective decontamination of the digestive tract (SDD) with oral nystatin was evaluated as a measure to control an outbreak of Candida infection in a neonatal intensive care unit (NICU). Seventy-six out of 106 neonates who carried Candida spp. received the main study manoeuvre (the application of oral nystatin in the throat and stomach) during the 12-month open trial. One third of the neonates weighed < 1500 g whilst about half were being ventilated. The mean stay was 33.2 d (SD +/- 46.9). Two cases with candidaemia within a fortnight were associated with a yeast carriage rate in the NICU of about 50%; more than 80% of the isolates were Candida parapsilosis. During the implementation period there were four new neonates with fungaemia caused by C. parapsilosis. Once the carriage rate dropped below 5% (P < 0.001), no new cases of systemic infection with the outbreak strain were recognized in the following 8 months. It took 3.5 months to control the outbreak. The observation that all other clinical diagnostic samples were free from Candida suggests that translocation from throat or gut into the systemic circulation occurred. SDD with oral nystatin was effective in reducing the yeast carriage index (mean index 1.93, before SDD; 0.45, after SDD; P < 0.001). A significant reduction of carriage, both in rates and indices, is thought to have contributed to the control of this candida outbreak.

Life-threatening Candida Infections in the Intensive Care Unit

In the past decade there has been a dramatic increase in the incidence of life-threatening Candida infections in patients in intensive care units (ICUs). Once considered a minor pathogen, Candida is now among the most commonly cultured pathogens in the ICU. This phenomenon is in part attributable to greater numbers of immunocompromised patients being hospitalized and the more frequent use of surgery, instrumentation, and broadspectrum antibiotics. Serious Candida infections can present as generalized sepsis, as focal involvement of virtually any organ, or as part of the syndrome of multiple system organ failure. Once established, these infections can be difficult to detect until their late stages and consequently are responsible for significant morbidity and mortality in ICU patients. For treatment to be successful it must be instituted promptly and, on occasion, empirically. As a result, new diagnostic techniques, treatments, and prophylactic strategies to minimize the occurrence of Candida infections are the subjects of ongoing research. This article is intended to provide practitioners with an understanding of why serious Candida infections are increasing, as well as information on pathogenesis, diagnosis, treatment, and some measures that can be taken to prevent such infections in critically ill patients.

Fungal infections in cancer patients: an international autopsy survey

In an attempt to estimate the frequency of fungal infections among cancer patients, a survey of autopsy examinations was conducted in multiple institutions in Europe, Japan and Canada. Fungal infections were identified most often in leukemic patients and transplant recipients (25% each). Fifty-eight percent of fungal infections were caused by Candida spp. and 30% by Aspergillus spp. There was considerable variability in the frequency of fungal infections in different countries. Nevertheless, this study clearly demonstrates that fungal infections represent a common complication in cancer patients, especially in patients with leukemia.

[Systemic candidiasis]

Candida proliferate within the body of patients with deficient cellular immunity either by the haematogenous route or by adjacency. This condition is often found in hospital patients. It explains the increasing incidence of disseminated candidiasis. They are preferentially found in patients who have had complicated surgery, mostly of the gastrointestinal tract and the heart, or transplant surgery (except for kidney transplants), or who have had prolonged intensive care. Other patients concerned are neonates with a low birth weight, haemato-oncology patients, heroin addicts and AIDS patients. Clinical signs are usually unspecific. When there is widespread involvement, clinical signs can be defined by the secondary locations, especially within the kidneys, lung, endocardium and brain in surgical patients, and liver and spleen in haemato-oncology patients. Eye, skin, gastrointestinal tract, and indeed, muscle lesions which are easily accessible, should be looked for routinely. This helps to ascertain the diagnosis, by showing the presence of Candida in the tissues. Moreover, isolating Candida from places which are normally sterile confirms deep-seated candidiasis. However, the presence of Candida in urine, bronchi, or drainage fluids is only the witness of saprophytism. This underlines the usefulness of immunological tests, which should soon benefit from the availability of new kits for the detection of cytoplasmic antigens. Indeed, the search for antibodies or circulating metabolites do not provide, at present, significantly different results in patients who have only been colonised and in those who have a systemic candidiasis. Interesting results are only obtained by showing the presence of mannans, in research laboratories. For treatment, amphotericin B remains the standard antifungal agent, and the association of amphotericin B with flucytosine the recommended association. However, drugs such as the new triazoles, among which fluconazole is particularly well tolerated and efficient, may considerably alter the principles of treatment. Finally, combining a fungal decontamination of the gut should help reduce the very high death rate of systemic candidiasis.

Contour-clamped homogeneous electric field gel electrophoresis as a powerful epidemiologic tool in yeast infections

To examine the longitudinal and cross-sectional patterns of yeast colonization in critically ill patients using genotypic characteristics defined by contour-clamped homogeneous electric field (CHEF) gel electrophoresis, 322 clinical isolates of Candida species were prospectively collected from 29 critically ill patients under routine surveillance over a 6-month period. All isolates, recovered from multiple anatomic sites and from the same sites on different days, were characterized by several identification methods (germ tube test), phenotyping (API system), and genotyping (electrophoretic karyotyping). Electrophoretic karyotype (EK) was determined using pulsed field electrophoresis with the CHEF technique. We used a karyotyping system for Candida albicans (EK code) that facilitated intraspecies delineation. C. albicans colonized 83% of the 29 patients. Candida sp. strains isolated from an individual patient had an identical EK pattern, even when isolated from different body sites, and remained the same over a prolonged period, up to 140 days. EK delineated not only the different Candida species, but also different strains of C. albicans. Strains of C. albicans isolated from different patients were distinguished using the EK pattern, but not API system. Minor variations in EK pattern could be demonstrated in a minority of strains recovered from four patients and were interpreted as chromosomal rearrangements between parent strains. Severe candidal infections, including eight episodes of fungemia, occurred in 11 of 29 patients (38%). All patients had been previously colonized with strains with identical EK patterns. Infection occurred a mean of 25 days after initial surveillance cultures grew yeast. No horizontal transmission could be demonstrated during the study period. In conclusion, EK is a reproducible, stable marker allowing inter-, as well as, intraspecies Candida strain delineation. EK strain delineation is a useful tool in candidal epidemiologic and pathogenic studies. Yeast colonization with the same strain preceded infection in critically ill patients.

Antibiotic choices in surgical intensive care unit patients

Antibiotics have dramatically changed the care of the critically ill patient over the last 60 years. Patients with complex physiological conditions present with infectious processes requiring the effective use of antimicrobial drugs. In many situations, the inability to eradicate the infectious process is complicated by the progressive development of resistance among the causative organisms. Systemic antibiotic prophylaxis is warranted only for the prevention of wound infections. Regimens in these cases should use large doses of nontoxic antibiotics covering the spectrum of organisms likely to contaminate the wound. The duration of wound prophylaxis should be short, essentially covering only the period of active wound closure; this is usually less than 24 hours. Prevention of most other infections in the ICU depends on the recognition and correction of the various disturbances of host defenses. Topical antibiotic therapy may reduce the level of colonization for a few specific types of infection. Initial empiric antibiotic therapy should be started for clear indications. The antibiotics chosen should be those most likely to be effective against the probable organisms, those which have the lowest toxicity, and those with the smallest likelihood of inducing multiresistance. They must be adjusted promptly based on the microbiologic sensitivities observed. The realization that the physiology of critical illness may alter the normal relations between drug dosages and the tissue antibiotic levels obtained mandates a different approach to the treatment of these patients. The drug volumes of distribution are generally markedly expanded in these patients. Furthermore, these patients require high tissue antibiotic concentrations to improve the chances for successful therapy. Thus, the antibiotics selected must be capable of providing these levels without significant toxicity to the host. Therapy should be continued based on the clinical response observed. Premature cessation of effective therapy often results in relapse.

Role of candida in pathogenesis of antibiotic-associated diarrhoea in elderly inpatients

The part that candida plays in antibiotic-associated diarrhoea was investigated in 24 elderly inpatients (mean age 74 years) who tested negative for Clostridium difficile toxin and other intestinal pathogens. 7 had intestinal overgrowth of Candida species (greater than or equal to 10(5) cfu/ml). None of the 24 matched, antibiotic-treated controls without diarrhoea had candida overgrowth. All 5 patients with diarrhoea and candida overgrowth treated with oral nystatin responded with resolution of diarrhoea and lowering of faecal counts to less than 10(4) cfu/ml within 7 days of start of antifungal therapy despite continuation of antibacterial therapy. In the other 2 patients with candida overgrowth, the diarrhoea subsided spontaneously and faecal candida counts returned to normal (less than 10(4) cfu/ml) after antibacterial agents were withdrawn. In patients without candida overgrowth, diarrhoea persisted until antibiotics were withdrawn, at a mean of 16 days after study entry.

Fungal infection: a common, unrecognised complication of acute liver failure

The true incidence and clinical relevance of fungal infection was ascertained in a prospective study of 50 consecutive patients with acute liver failure. Fungal infection was present in 16 (32%) patients (15 candida, one aspergillus) and in seven was considered the major cause of death. All six untreated died, while five of ten patients treated with anti-fungal therapy survived. The diagnosis was made on positive cultures from at least one significant site or on histological evidence of tissue invasion. All 16 had concomitant bacterial infection and shared features suggestive of a clinical syndrome: deterioration in coma grade after initial improvement; pyrexia unresponsive to antibiotics; established renal failure; and a markedly elevated white cell count. Fungal infection is a common, serious complication of acute liver failure and therapy is indicated for those with positive cultures. A prophylactic trial would be justified in those surviving 5 days, especially, with established renal failure.

Characterization of the sequence of colonization and nosocomial candidemia using DNA fingerprinting and a DNA probe

The objective of this hospital-based study was to determine the relationship between colonizing and infecting strains of Candida species and Torulopsis glabrata. Surveillance cultures from high-risk patients were paired with subsequent bloodstream isolates. Organisms were typed by using restriction endonuclease digestion of chromosomal DNA with BstNI and EcoRI, followed by Southern hybridization with a DNA probe (pBD4) derived from Saccharomyces cerevisiae. Sixteen patients for whom documented colonization preceded documented bloodstream infection were identified. The mean time between obtainment of surveillance isolates and obtainment of bloodstream isolates was 8 days, with a range of 1 to 423 days. For 15 (94%) of 16 patients, the DNA fingerprint pattern (using BstNI) of the surveillance isolate was identical to that of the bloodstream isolate. Isolates from 13 (81%) of 16 patients were unique to those patients. Typing by Southern hybridization with the pBD4 probe was less discriminating. We conclude that for a well-defined subset of hospitalized patients who were colonized by Candida species before developing nosocomial candidemia, the colonizing and infecting strains were identical, suggesting endogenous acquisition of infection. Restriction endonuclease digestion of chromosomal DNA was shown to be a discriminating and reproducible typing method for Candida species and T. glabrata.

Fluconazole monitoring in Candida peritonitis based on histological control

Between May 1, 1988 and January 1, 1990, 10 patients were treated for Candida peritonitis. Origins of the infections were lesions and perforations of the gastrointestinal tract. Risk factors promoting the disease were tumours, diabetes mellitus and extensive antibiotic therapy. The mean classification by the APACHE score 2 was 19.0. All patients underwent the programmed peritoneal lavage for diffuse peritonitis. Daily relaparotomy and lavage of all quadrants of the abdomen was performed. The diagnosis of Candida peritonitis had been established by microbiological investigation, increasing serologic titres, histologic demonstration of a deep mycosis and clinical picture. All patients were treated with 300 mg fluconazole daily. Five of the ten patients died from their severe primary diseases in spite of control of fungal peritonitis. Daily relaparotomies allowed to follow up the microbiologic and histologic course of the disease. Within 2 to 4 days after administration of fluconazole, hydrous swelling and reduction of fungal elements could be demonstrated histologically. On the 4th day after onset of antifungal therapy, fungal mycelia were markedly reduced and distendedly decayed. Fluconazole clearly leads to a destruction of deeply invading Candida elements within 4 days.