Prospective study of fungaemia in a single cancer institution over a 10-y period: aetiology, risk factors, consumption of antifungals and outcome in 140 patients

Uncommon Candida Species Fungemia among Cancer Patients, Houston, Texas, USA

Many uncommon Candida species that cause bloodstream infections (BSIs) are not well-characterized. We investigated the epidemiology, antifungal use, susceptibility patterns, and factors associated with all-cause death among cancer patients in whom uncommon Candida spp. BSIs were diagnosed at a cancer treatment center during January 1998–September 2013. Of 1,395 Candida bloodstream isolates, 79 from 68 patients were uncommon Candida spp. The incidence density of uncommon Candida spp. BSIs and their proportion to all candidemia episodes substantively increased during the study period, and the rise was associated with increasing use of echinocandin antifungal drugs. Thirty-seven patients had breakthrough infections during therapy or prophylaxis with various systemic antifungal drugs for >7 consecutive days; 21 were receiving an echinocandin. C. kefyr (82%), and C. lusitaniae (21%) isolates frequently showed caspofungin MICs above the epidemiologic cutoff values. These findings support the need for institutional surveillance for uncommon Candida spp. among cancer patients.

Infections Caused byFusariumSpecies

Fusariosis, an emerging opportunistic mycosis caused by Fusarium species, carries a high mortality rate in immunocompromised patients. The dismal prognosis of patients with fusariosis is aggravated by the limited therapeutic options. Here we give an overview of the epidemiology, pathogenesis, clinical manifestations, antifungal susceptibility and management of fusariosis.

The effect of cumulative length of hospital stay on the antifungal resistance of Candida strains isolated from critically ill surgical patients

Fluconazole is the first line of therapy for the management of candidiasis. However, fluconazole-resistant strains pose an emerging challenge in everyday clinical practice. In this study, we sought to determine whether cumulative length of hospital stay (CLOS) is a predictive factor for the acquisition of non-susceptible Candida strains to fluconazole. Thirty-three critically ill emergency surgery patients with 56 Candida isolates were enrolled in this prospective study. We divided our isolates according to their minimum inhibitory concentration (MIC) to fluconazole using 8 mcg/ml as a cutoff. We then compared the two groups with respect to basic demographics, antifungal agents prescribed, number of wide-spectrum antibiotics, duration of central venous catheter placement, elapsed time to positive culture, duration of prior hospital stay, and length of hospital stay. Non-susceptible fluconazole samples belonged to patients with a significantly longer prior hospital stay and a longer CLOS (P = 0.02 and 0.01, respectively). The difference between the 2 groups regarding non-albicans strains was statistically significant (P < 0.001). By fitting a non-parametric receiver-operating characteristics (ROC) curve into our analysis, a CLOS ≥ 29 days predicted the occurrence of non-susceptible strains with 90% sensitivity and 79.6% specificity (correct classification 81.5%). A CLOS ≥ 29 days is a strong predictor for the isolation of non-susceptible Candida isolates to fluconazole among critically ill emergency surgery patients. Clinicians should consider the duration of previous hospital stay when deciding on empiric antifungal therapy.

Rhodotorula spp. isolated from blood cultures: clinical and microbiological aspects

The emergence of less common fungal pathogens has been increasingly reported in the last decade. We describe 25 cases of Rhodotorula spp. isolated from blood cultures at a large Brazilian tertiary teaching hospital from 1996-2004. We also investigated the in vitro activity of four antifungal drugs, using a standardized method. The median age of patients was 43 years. The majority of patients (88%) had a central venous catheter (CVC) and 10 (40%) were recipients of a bone marrow transplant. The episode was classified as a bloodstream infection (BSI) in 80% of the patients. Amphotericin B deoxycholate was the most common antifungal used and CVC was removed in 89.5% of the patients. Death occurred in four patients (17.4%), all classified as BSI. All strains were identified as R. mucilaginosa by conventional methods. Misidentification of the species was observed in 20% and 5% of the strains with the Vitek Yeast Biochemical Card and API 20C AUX systems, respectively. Amphotericin B demonstrated good in vitro activity (MIC50/90, 0.5 microg/ml) and the MICs for fluconazole were high for all strains (MIC50/90, >64 microg/ml).

Treatment of invasive candidiasis in immunocompromised pediatric patients

In the last 3 decades, systemic candidiasis has become increasingly recognized as a major source of morbidity and mortality in immunocompromised pediatric patients. As the number of children receiving chemotherapy and bone marrow transplantations continue to increase, clinicians should expect that invasive infections from Candida spp. will also increase in these vulnerable hosts. Fortunately, in the past 15 years, the evolution of older antifungals coupled with the discovery of new classes of antifungal agents has equipped physicians with reasonable options for treating these otherwise life-threatening infections.This review aims to familiarize the reader with the evolving epidemiology of candidiasis in immunocompromised children as well as discuss therapeutic options from each class of antifungal agents. Mechanisms of action, pharmacokinetics, toxicities, resistance patterns, chemotherapy interactions, and clinical relevance in immunocompromised children are reviewed for polyenes, flucytosine (5-fluorocytosine), azoles, and echinocandins.

A case of invasive rhinosinusitis by Fusarium verticillioides (Saccardo) Nirenberg in an apparently immunocompetent patient

A case of chronic invasive rhinosinusitis in an apparently healthy man, caused by Fusarium verticillioides, is described. The identity of the isolate as F. verticillioides was established by demonstrating characteristic morphological features and by amplification of rDNA using species-specific primers. Surgical debridement of the infected nasal tissue and therapy with amphotericin B resulted in a favorable outcome. To the best of our knowledge, F. verticillioides has not been described previously to cause this condition.

Diagnosis of fusariosis in urine cytology

Fusarium is a filamentous fungus widely distributed in plants and in the soil. Most species are more common at tropical and subtropical areas. Besides being a common contaminant and a well-known plant pathogen, Fusarium sp may cause various infections in humans. However, it has not yet been reported as being the pathogen of urinary tract infection. A 67-year-old woman had extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy for renal stones 7 and 6 years ago, respectively. She had had fever, chillness, urinary urgency and frequency for 6 days. Routine testing of urine showed numerous leucocytes. She was admitted under the impression of urinary tract infection. On admission, many spindle-shaped structures were found in the urine smears. This shows that Fusarium was identified. Fusarium may be the pathogen of the urinary tract infection, particularly when urolithiasis is present.

Candidaemia and cancer: patients are not all the same

Background

Most of the studies about invasive Candida infections in cancer patients have focused on haematological patients. The aim of this study was to provide information about risk factors for candidaemia in patients with solid tumours.

Methods

Retrospective cohort study. During a 9-year period (1995–2003) we reviewed all cases of candidaemia that affected cancer patients in Santa Casa Complexo Hospitalar, Brazil.

Results

During the period of study, 210 patients had the diagnosis of candidaemia in our medical centre, and 83 of these patients had cancer (39.5%). The majority of patients with cancer had solid tumours (77.1%), mostly in the alimentary tract. Most of solid cancers were non-metastatic (71.9%). Major diagnoses in patients with haematological neoplasia were acute leukaemia (n = 13), high grade non-Hodgkin lymphoma (n = 5) and Hodgkin's disease (n = 1). Non-Candida albicans species caused 57.8% of the episodes of candidaemia in patients with cancer, mainly in patients with haematological malignancies (p = 0.034). Neutropenia and treatment with corticosteroids were more frequent in the haematological group, in comparison with patients with solid tumours. Only 22.2% of patients with solid tumours were neutropenic before candidaemia. Nonetheless, the presence of ileus and the use of anaerobicides were independent risk factors for candidaemia in patients with solid cancers. The overall mortality in cancer patients with candidaemia was 49.4%. We then compared 2 groups of adult patients with candidaemia. The first was composed of non-neutropenic patients with solid tumours, and the second group included patients without cancer. We found that central venous catheters and gastrointestinal surgery were independently associated with candidaemia in patients with solid tumour.

Conclusion

Cancer patients with candidaemia seem to have very different predisposing factors to acquire the infection when stratified according to baseline diseases. This study provides some useful clinical information regarding risk for candidaemia in patients with solid tumours.

Fusarium fungaemia in immunocompromised patients

Fusarium spp. cause infections only rarely in immunologically competent hosts, but disseminated infection may occur in severely immunocompromised patients. Symptoms of disseminated infection are persistent fever, despite broad-spectrum antibacterial and antifungal treatment, associated with skin lesions, most commonly on the extremities, in 60-80% of patients. A mortality rate of 50-75% has been reported for patients with disseminated fusariosis. Despite treatment failures, amphotericin B remains the preferred drug, in part because of lack of alternatives. Voriconazole is a promising new agent, but more clinical experience is required.