Fluconazole therapy in Candida albicans spondylodiscitis

Candida spondylodiscitis: a systematic review and meta-analysis of seventy two studies

OBJECTIVES

Knowledge of Candida spondylodiscitis is limited to case reports and smaller case series. Controversy remains on the most effective diagnostical and therapeutical steps once Candida is suspected. This systematic review summarized all cases of Candida spondylodiscitis reported to date concerning baseline demographics, symptoms, treatment, and prognostic factors.

METHODS

A PRISMA-based search of PubMed, Web of Science, Embase, Scopus, and OVID Medline was performed from database inception to November 30, 2022. Reported cases of Candida spondylodiscitis were included regardless of Candida strain or spinal levels involved. Based on these criteria, 656 studies were analyzed and 72 included for analysis. Kaplan-Meier curves, Fisher's exact, and Wilcoxon's rank sum tests were performed.

RESULTS

In total, 89 patients (67% males) treated for Candida spondylodiscitis were included. Median age was 61 years, 23% were immunocompromised, and 15% IV drug users. Median length of antifungal treatment was six months, and fluconazole (68%) most commonly used. Thirteen percent underwent debridement, 34% discectomy with and 21% without additional instrumentation. Median follow-up was 12 months. The two year survivorship free of death was 80%. The two year survivorship free of revision was 94%. Younger age (p = 0.042) and longer length of antifungal treatment (p = 0.061) were predictive of survival.

CONCLUSION

Most patients affected by Candida spondylodiscitis were males in their sixties, with one in four being immunocompromised. While one in five patients died within two years of diagnosis, younger age and prolonged antifungal treatment might play a protective role.

Les spondylodiscites à Candida; à propos de deux cas

In recent years, the incidence of systemic infections due to Candida increased, but the incidence of spondylodiscitis remained low, and epidural involvement during such infection was seldom reported. The purpose of this study was to report the cases of 2 young male heroin addicts who developed spondylodiscitis due to Candida sp., with epidural involvement. In one case, a microbiological diagnosis was obtained after biopsy. In the other case, the diagnosis was based on serological data and Candida antigenemia. In both cases, an oral fluconazole based therapy was administered at first (because of a poor peripheral venous system), but proved to be inefficient. A secondary therapy by liposomal amphotericin B proved efficient allowing a favourable evolution. This pathology raised a number of problems concerning diagnosis and treatment. The clinical data was non-specific the paraclinical diagnosis required MRI, and biopsy. When microbiological assessment is negative, serology and the antigenemia can be useful. The treatment pattern suggested for the management of bone and joint infections is: intravenous amphotericine B for 2-3 weeks, followed by oral administration of fluconazole or voriconazole for 6-12 month. Surgical treatment is recommended only to patients ay risk of neurological disorders or severe epidural abscess.

Fluconazole for the management of invasive candidiasis: where do we stand after 15 years?

Candida spp. are responsible for most of the fungal infections in humans. Available since 1990, fluconazole is well established as a leading drug in the setting of prevention and treatment of mucosal and invasive candidiasis. Fluconazole displays predictable pharmacokinetics and an excellent tolerance profile in all groups, including the elderly and children. Fluconazole is a fungistatic drug against yeasts and lacks activity against moulds. Candida krusei is intrinsically resistant to fluconazole, and other species, notably Candida glabrata, often manifest reduced susceptibility. Emergence of azole-resistant strains as well as discovery of new antifungal drugs (new triazoles and echinocandins) have raised important questions about its use as a first line drug. The aim of this review is to summarize the main available data on the position of fluconazole in the prophylaxis or curative treatment of invasive Candida spp. infections. Fluconazole is still a major drug for antifungal prophylaxis in the setting of transplantation (solid organ and bone marrow), intensive care unit, and in neutropenic patients. Prophylactic fluconazole still has a place in HIV-positive patients in viro-immunological failure with recurrent mucosal candidiasis. Fluconazole can be used in adult neutropenic patients with systemic candidiasis, as long as the species identified is a priori susceptible. Among non-neutropenic patients with candidaemia fluconazole is one of the first line drugs for susceptible species. Cases reports and uncontrolled studies have also reported its efficacy in the setting of osteoarthritis, endophthalmitis, meningitis, endocarditis and peritonitis caused by Candida spp. among immunocompetent adults. In paediatrics, fluconazole is a well tolerated and major prophylactic drug for high-risk neonates, as well as an alternative treatment for neonatal candidiasis. Importantly 15 years after its introduction in the antifungal armamentarium, fluconazole is still a first line treatment option in several cases of invasive candidiasis. Its prophylactic use should however be limited to selected high-risk patients to limit the risk of emergence of azole-resistant strains.

Antifungal therapy--state of the art at the beginning of the 21st century

The most relevant information on the present state of the art of antifungal chemotherapy is reviewed in this chapter. For dermatomycoses a variety of topical antifungals are available, and safe and efficacious systemic treatment, especially with the fungicidal drug terbinafine, is possible. The duration of treatment can be drastically reduced. Substantial progress in the armamentarium of drugs for invasive fungal infections has been made, and a new class of antifungals, echinocandins, is now in clinical use. The following drugs in oral and/or intravenous formulations are available: the broad spectrum polyene amphotericin B with its new "clothes"; the sterol biosynthesis inhibitors fluconazole, itraconazole, and voriconazole; the glucan synthase inhibitor caspofungin; and the combination partner flucytosine. New therapy schedules have been studied; combination therapy has found a significant place in the treatment of severely compromised patients, and the field of prevention and empiric therapy is fast moving. Guidelines exist nowadays for the treatment of various fungal diseases and maintenance therapy. New approaches interfering with host defenses or pathogenicity of fungal cells are being investigated, and molecular biologists are looking for new targets studying the genomics of pathogenic fungi.

Candida albicans sternal wound infections: a chronic and recurrent complication of median sternotomy

Eleven patients developed deep sternal wound infections due to Candida albicans after undergoing coronary artery bypass grafting (CABG) and were assessed. Six had sternal osteomyelitis, 1 had osteomyelitis and mediastinitis, and 4 had deep wound infections that probably involved bone. Seven patients experienced onset of infection within 28 days of CABG, but 4 experienced onset 48-150 days after CABG. Infections were characterized by a chronic, indolent course requiring prolonged treatment with an antifungal agent. Delay in initiating antifungal therapy was common. All patients were treated with fluconazole, and 1 also received amphotericin B. Six patients underwent incision and drainage, with or without wire removal, and 3 underwent sternectomy with placement of a muscle flap. Of 10 patients for whom follow-up data were available, 7 were cured after initial therapy (median duration of treatment, 6 months), and 3 experienced a relapse and required a second course of fluconazole.

Surgical strategy for spondylodiscitis due to Candida albicans in an immunocompromised host

A 44-year-old woman receiving systemic chemotherapy for cerebellar medulloblastoma developed thoracolumbar spondylodiscitis due to Candida albicans associated with abscesses in the bilateral psoas muscles. As long-term medical therapy with fluconazole was not effective, radical removal of the affected lesions and anterior bone grafting were performed. Corpectomy of the infected vertebra with autologous bone grafting and removal of the psoas muscle were performed via the right transthoracic retroperitoneal approach. Additional posterior instrumentation was not used. Two years after the operation, the patient was doing well, and systemic chemotherapy for medulloblastoma has restarted. Corpectomy with radical resection of surrounding infectious tissues for C. albicans spondylodiscitis in an immunocompromised host should be performed when conservative medical treatment is not successful. Further instrumentation surgery might be necessary to prevent further deformity of the spine as the second surgery.

Candidal vertebral osteomyelitis: report of 6 patients, and a review

The incidence of deep-seated candidal infection is increasing, but candidal vertebral osteomyelitis is still rare. We describe 6 patients recently treated in our hospital. Conservative treatment failed in all. We reviewed the literature and identified 59 additional cases of candidal vertebral osteomyelitis. Candidemia was documented in 61.5% of them. The interval between the diagnosis of candidemia and the onset of symptoms of vertebral osteomyelitis varied widely, from days to >1 year. In patients without documented candidemia, there was a similar interval between the occurrence of risk factors for candidemia (present in 72% of the patients) and the onset of symptoms of vertebral osteomyelitis. Clinical, laboratory, and radiological findings are not specific for candidal spondylodiskitis. Final diagnosis is determined by means of culture of a biopsy specimen from the infected vertebra or disk. Treatment consisted of prolonged antifungal treatment, and it often included surgery. On the basis of our experience (for all 6 patients, initial conservative treatment with only antifungals failed), we recommend consideration of early surgical debridement in combination with prolonged antifungal therapy.