Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America

Indian National Association for the Study of Liver (INASL) Guidance Statements for Determining Futility in Liver Transplantation

Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease; however, with the growing shortage of organ donors, the need to identify futile transplants has become increasingly urgent. Futility in liver transplantation refers to situations where the expected post-transplant survival or quality of life is poor, making the procedure unlikely to yield a meaningful benefit. Various definitions of futility are used across different countries and transplant centers, with criteria often based on clinical factors such as age, comorbidities, MELD score, and functional status. For hepatologists and transplant surgeons, clearer guidelines are essential to make informed decisions and avoid unnecessary transplants that may place patients at risk without improving their prognosis. While some studies have proposed futility scores, there is currently no universal consensus on a standardized definition or set of criteria. This highlights the need for further prospective trials to evaluate the predictors of futility in liver transplantation, aiming to refine decision-making processes, optimize organ allocation, and improve patient outcomes. Future research should focus on the development of universally accepted futility criteria and explore interventions to mitigate the factors contributing to transplant futility.

Treatment of fungal urinary tract disease in dogs and cats: a scoping review

Fungal urinary tract disease has been poorly studied in veterinary medicine. While it is an uncommon condition, identification of fungal cystitis or pyelonephritis raises many clinical questions about optimal management practices. To better understand optimal management approaches and inform guideline development, a scoping review was to identify available evidence pertaining to treatment of fungal urinary tract disease in dogs and cats. After de-duplication and relevance screening, 28 studies were included in the synthesis). Twenty-six (93 %) were single case reports and 2 (7.1 %) were case series' describing fungal infections in 16 (62 %) dogs and 10 (38 %) cats. Antifungal treatment of cystitis, pyelonephritis, funguria and fungal balls was described, with variable drugs and regimens. Varied treatment approaches and outcomes have been reported, but controlled trials are lacking. In lieu of that, larger and more structured multicentre observational studies are needed to better understand treatment approaches and inform evidence-based guidelines.

A "three-in-one" thermosensitive gel system that enhances mucus and biofilm penetration for the treatment of vulvovaginal candidiasis

The special physiological barriers of women, such as vaginal mucus and self-cleaning behavior, pose great challenges for the treatment of vulvovaginal candidiasis (VVC), and the drug resistance caused by fungal biofilms limits the application of existing antifungal drugs. Based on this, we designed a "three-in-one" thermosensitive gel system (AF/BP Gel) loaded with antibiofilm nanoparticles (AF NPs) and mucus penetration-assisting nanoparticles (BP NPs) to achieve vaginal adhesion while enhancing mucus and biofilm penetration. AF NPs were loaded with farnesol (FAR) and amphotericin B (AMB), and FAR is one of quorum sensing molecules which can interfere with biofilm-related genes such as ALS3, HWP1, RAS1, CPH1, EFG1, NRG1, TUP1, UME6, and disperse mature biofilm, thus playing a synergic antibiofilm role with AMB. BP NPs was loaded with bromelain (BRO), which cleared the mucus barrier for AF NPs and help it penetrate deep into the infection. These two kinds of nanoparticles use the thermosensitive gel matrix to reach the surface of the vaginal mucosa uniformly and persistently to overcome the obstacle of vaginal self-cleaning. AF/BP Gel showed great anti-candida albicans activity in vitro and in vivo, and greatly improved the inflammatory conditions in VVC mice. Overall, this "three-in-one" thermosensitive gel system can overcome multiple physiological barriers and resist different periods of biofilm, providing a new platform for treating vagina-associated infections.

Invasive candida in the abdomen: how to differentiate infection from colonization

INTRODUCTION

Intra-abdominal candidiasis (IAC) is a serious complication in critically ill patients, particularly after abdominal surgery or trauma. Differentiating Candida colonization from invasive infection is crucial, as misdiagnosis can lead to inappropriate antifungal use, increased resistance, and worse outcomes. However, IAC remains underrecognized due to the limitations of conventional culture-based diagnostics. Relevant literature was identified through a non-systematic search of the PubMed database.

AREAS COVERED

This review highlights the challenges in diagnosing and managing IAC, focusing on the limitations of traditional culture methods and the potential of non-culture-based diagnostics. Biomarkers such as 1-3-β-D-glucan (BDG) and Candida albicans germ tube antibody (CAGTA), along with molecular assays, improve diagnostic accuracy but have varying sensitivity and specificity, requiring a multimodal approach. Management involves early diagnosis, source control, and targeted antifungal therapy. Current guidelines, largely based on candidemia, recommend echinocandins as first-line therapy, with fluconazole for stable patients and amphotericin B for resistant strains.

EXPERT OPINION

Despite advances, IAC-specific research is lacking, necessitating improved diagnostic tools and tailored therapies. There is a need for more targeted studies to refine diagnostic algorithms and therapeutic strategies. Future efforts should focus on developing rapid, high-sensitivity and specific diagnostic tools, optimizing antifungal stewardship, and individualizing treatment approaches.

Species-specific risk of ophthalmic involvement in candidemia: a propensity-matched competing risk analysis

OBJECTIVES

Given the limited data on species-specific ocular involvement in candidemia, we aimed to assess the differential risk of ocular involvement according to Candida species in patients with candidemia.

METHODS

A retrospective review was conducted of candidemia patients who underwent funduscopic examination at a tertiary center in Seoul, Korea between January 2014 and December 2023. Ocular involvement, defined as endophthalmitis, was determined by two retinal specialists. Propensity score matching and competing risk analyses were performed to adjust for pre-specified risk factors and mitigate competing-risk bias.

RESULTS

A total of 674 candidemia patients were included. Endophthalmitis was identified in 5% (32/674), and probable chorioretinitis in 10% (67/674). The prevalence of endophthalmitis was relatively high in Candida albicans (16/245, 7%) and Candida tropicalis (13/126, 10%), but low in Candida glabrata (0/193), Candida parapsilosis (2/68, 3%), and Candida krusei (0/19). Competing risk analysis identified C. albicans or C. tropicalis infection (subdistribution hazard ratio [sHR] 7.90, 95% confidence interval [CI] 2.42-25.75) as an independent risk factor for endophthalmitis. In propensity score-matched analyses, C. albicans (sHR 5.85, 95% CI 1.71-19.95) and C. tropicalis (sHR 6.97, 95% CI 1.58-29.85) were each significantly more associated with ocular involvement than non-albicans and non-tropicalis species.

CONCLUSION

While ophthalmic examinations are already recommended in all candidemia cases, our findings underscore their particular importance in C. albicans and C. tropicalis infections, where ocular involvement is significantly more common than in those involving other Candida species.

Candida Endocarditis: current perspectives on diagnosis and therapy

BACKGROUND

Candida infective endocarditis (CIE) is a rare but potentially devastating condition. Although it accounts for only 1-1.5% of infective endocarditis cases, CIE carries a high mortality rate (36-49%) and a substantial risk of relapse. Despite advances in diagnostic and therapeutic strategies, significant uncertainties persist regarding the role and selection of imaging modalities and the most effective medical and surgical management. Furthermore, the best follow-up strategy to promptly detect recurrences in patients with a confirmed diagnosis remains inadequately defined.

OBJECTIVES

This review explores the diagnosis and management of CIE with a particular focus on: i) optimal use of cardiac imaging studies; ii) challenges associated with antifungal therapy iii) the limitations and real-world impact of surgical intervention, and (iv) strategies for long-term follow-up.

SOURCES

A comprehensive literature search was conducted in PubMed using the terms Candida endocarditis, fungal biomarkers, echocardiography, antifungal therapy, and surgical management. Additional studies were identified through reference screening. Only clinically relevant articles, as judged by the authors, were included.

CONTENT

Diagnosis remains difficult due to intermittently negative blood cultures and limitations of standard endocarditis criteria. Echocardiography is the mainstay diagnostic modality for patients with candidemia, and risk-stratification to guide its use remains exploratory. Novel diagnostic methods, including fungal biomarkers (1,3-β-D-glucan), molecular assays, and PET/CT, may improve detection, but robust clinical data are lacking. Management requires a multimodal approach, combining prolonged antifungal therapy and, when feasible, surgical intervention. Echinocandins or liposomal amphotericin B plus flucytosine are first-line treatments, with fluconazole as a step-down option. Prosthetic valve infections often require lifelong suppressive therapy due to high relapse rates.

IMPLICATIONS

Given the high mortality and recurrence rates, early multidisciplinary involvement is crucial. With emerging antifungal resistance, anti-biofilm strategies and next-generation antifungals are needed to improve outcomes.

Duration of systemic antifungal therapy for patients with invasive fungal diseases: A reassessment

Invasive fungal diseases are associated with significant morbidity and mortality, especially among immunocompromised patients, and often prompt for rapid and aggressive treatment aiming cure. Due to the expanding magnitude of patients burdened by chronic immunosuppression and affected by fungal diseases, the diversity of clinical settings has risen. This often results in prolonged therapy (induction, consolidation and maintenance) associated with potentially severe side effects, and clinicians face the challenging decisions of when and how to stop anti-fungal therapy. Adequate duration of therapy is poorly defined, hampered by the lack of dedicated trials to the question, the heterogeneity of cases (type of fungal pathogen, localization of infection, underlying host conditions) and various confounding factors that may influence the clinical response (e.g. persistence vs recovery of immunosuppression, impact of surgery). In this review, we aim to evaluate the existing data underlying the guidelines and recommendations of treatment duration for the most frequent invasive fungal diseases (cryptococcal meningitis, Pneumocystis pneumonia, invasive aspergillosis, invasive candidiasis and mucormycosis), as well as specific localizations of deep-seated diseases (osteo-articular or central nervous system diseases and endocarditis) and emerging considerations and strategies.

Epidemiology of Candidemia, Candiduria and Emerging Candidozyma (Candida) auris Across Gulf Cooperative Council Countries and Yemen in the Arabian Peninsula

Candida infections represent a major component of invasive and non-invasive mycoses globally, including the countries in the Arabian Peninsula. In this review, we present epidemiological features and trends, clinical manifestations, species distribution, antifungal susceptibility, and outcomes available for candidemia and candiduria in six countries of the Gulf Cooperation Council (GCC) and Yemen, all located in the Arabian Peninsula. We discuss gaps in knowledge and provide recommendations for improving various aspects for better management of infections by these fungal pathogens. Candida species prevail, with Candida albicans being the most isolated organism, though its prevalence varies over time. The second most frequently isolated species varies from country to country within the region. Generally, invasive infections by non-albicans Candida species are increasing. Candidozyma auris, formerly known as Candida auris, is causing serious health risks in all GCC countries, including those with appropriate diagnostic capacity and awareness.

Anidulafungin exposure and population pharmacokinetics in critically ill patients with invasive candidiasis

PURPOSE

Anidulafungin is recommended as a first-line treatment for invasive Candida infections in critically ill patients. Pharmacokinetic (PK) variability is large in critically ill patients, potentially compromising pharmacokinetic-pharmacodynamic (PKPD) target attainment under standard dosing. We aimed to assess anidulafungin exposure, PKPD target attainment, and population (pop)PK in critically ill patients.

METHODS

Adult ICU patients receiving standard anidulafungin dosing [200 mg on day 1, then 100 mg daily] were included (NCT04045366). We performed rich blood sampling on an early (day 2 ± 1) and/or late (day 5 ± 1) treatment day. Using total anidulafungin plasma concentrations, we developed a popPK model (NONMEM7.5) and conducted Monte Carlo simulations (n = 1,000 per virtual patient) to evaluate the impact of patient factors on PKPD target attainment (AUC24h target 83.5 mg×h/L).

RESULTS

Twenty patients contributed 188 anidulafungin concentrations. PKPD target attainment was 45% and 65% on early and late sampling days, respectively. A two-compartment popPK model with first-order elimination described the data. Anidulafungin clearance increased with bodyweight and central volume of distribution increased as serum albumin decreased. Both bodyweight and serum albumin had a clinically relevant impact on PKPD target attainment at day 1 (area under the ROC curve; AUROC 0.82 and 0.62, respectively), and bodyweight on PKPD target attainment at day 14 (AUROC 0.94). Standard anidulafungin dosing regimen fails to achieve adequate target attainment throughout the treatment period.

CONCLUSION

Standard anidulafungin dosing is insufficient for achieving adequate exposure in critically ill patients. An interactive simulation tool is provided to aid dose-finding research and explore different dosing strategies and targets.

The tell-tale hearts: Donor-derived invasive fungal infections among orthotopic heart transplant recipients

Donor-derived invasive fungal infections among solid organ transplant recipients are rare but sometimes devastating events associated with notable morbidity and mortality. Here we describe two donor-derived fungal infections - one Candida parapsilosis complex infection and one Aspergillus fumigatus infection - that occurred among heart transplant recipients at a quaternary care center. Both recipients survived their infections, though with substantial morbidity despite aggressive surgical intervention and antifungal therapy.

Fungal biofilms in human health and disease

Increased use of implanted medical devices, use of immunosuppressants and an ageing population have driven the rising frequency of fungal biofilm-related diseases. Fungi are now recognized by the World Health Organization (WHO) as an emergent threat to human health, with most medically important species defined as critical or high-priority organisms capable of forming biofilms. Although we strive for a better understanding of diagnostic and therapeutic approaches to detect and treat these fungal diseases more generally, the issue of hard-to-treat biofilms is an ever-increasing problem. These are communities of interspersed cells that are attached to one another on a surface, such as a catheter, or trapped into a cavity such as a paranasal sinus. Biofilms are difficult to detect, difficult to remove and intrinsically tolerant to most antifungal agents. These factors can lead to devastating consequences for the patient, including unnecessary morbidity and mortality, need for reoperations and prolonged hospital stay. This Review describes the breadth and growing impact fungal biofilms have on patient management and explains the mechanisms promoting biofilm formation, focusing on how targeting these can improve therapeutic options.

Changing trends in the sources and volumes of clinical cultures with Candida auris at an integrated health system in Miami, Florida, United States, 2019-2023

BACKGROUND

Candida auris (C auris) has rapidly spread in the United States. We aimed to characterize the trends in volumes and sources of clinical cultures with C auris at a large health care system.

METHODS

We conducted a retrospective observational study including clinical cultures with C auris collected between April 1, 2019, and December 31, 2023. Surveillance cultures were excluded. Clinical specimens were processed through routine methods, and identification was performed using mass spectrometry. Whole-genome sequencing was performed on select specimens.

RESULTS

We identified 327 clinical cultures belonging to 231 unique patients. The number of clinical cultures increased each year, from 5 in 2019 to 29 in 2020 (580%), 71 in 2021 (251% relative to 2020), 107 in 2022 (46% relative to 2021), and 115 in 2023 (7% relative to 2022). Blood cultures were the most common source, but specimens originating from soft tissue/bone infections had a large increase in 2022 and 2023. All sequenced isolates belong to clade III (South African clade) and were resistant to fluconazole and susceptible to echinocandins and amphotericin B.

CONCLUSIONS

The volumes of clinical cultures with C auris have rapidly increased, accompanied by an expansion in the sources of infection.

Development of a tri-species wound model for studying fungal-bacterial interactions and antimicrobial therapies

Chronic wounds are increasing in numbers and biofilm-producing bacteria are highly prevalent in these wounds and often create resilient polymicrobial infections. Moreover, estimates suggest that up to 23 % of wounds contain fungi, particularly Candida albicans. Currently, inter-kingdom chronic wound models are scarce; thus, this study presents one of the few in vitro models that incorporate both bacterial and fungal species in a wound-relevant environment, addressing a critical gap in current biofilm research. The newly developed model contained the commonly isolated wound bacteria Pseudomonas aeruginosa and Staphylococcus aureus, and the fungus Candida albicans. Inter-species interactions were investigated through selective plate counting and pH and oxygen measurements, as well as confocal microscopy. Investigations were carried out before and after exposure to commonly used clinical antimicrobial treatments, including silver-infused bandages. When grown in a tri-species consortium, P. aeruginosa and S. aureus exhibited a higher tolerance towards silver-infused bandages than when they were grown individually. This suggests that C. albicans plays a protective role for the bacteria. In addition, the treatment also caused a shift in species ratios, moving from a P. aeruginosa-dominated consortium to a S. aureus-dominated consortium. Moreover, confocal microscopy revealed a change in biofilm architecture when comparing single-species models to tri-species models. Finally, we observed that silver-infused bandages increased the pH in the tri-species model as well as partially restoring the oxygenation within the wound model. In conclusion, our novel model exemplifies how inter-kingdom interactions in fungal-bacterial infections can complicate both the microenvironment and treatment efficacy.

Insights into the antifungal properties and modes of action of a recombinant hepcidin, rAd-Hep from the shrimp scad, Alepes djedaba (Forsskål, 1775)

Antimicrobial peptides are short, mostly cationic and amphipathic molecules crucial for host defence. Among these, hepcidins are a family of cysteine rich peptides, with HAMP1 hepcidins playing a dual role in iron metabolism and antimicrobial defense. Recently, recombinantly produced Alepes djedaba hepcidin, rAd-Hep was characterized and its antibacterial potential against various pathogens have been discerned. Herein, we investigated the antifungal nature and modes of action of rAd-Hep against some fungal pathogens. The peptide was found to be active against both filamentous fungi and yeasts viz., Aspergillus flavus, Aspergillus sydowii, Fusarium solani, Penicillium citrinum, Candida albicans and Saccharomyces cerevisiae. The peptide acted via membrane permeabilization creating pores of ∼0.7-1.4 nm radii, ROS generation, chromatin condensation and DNA binding. The recombinant hepcidin, rAd-Hep can be considered as a promising candidate for future endeavors in antifungal therapies.

Population-Based Active Surveillance for Culture-Confirmed Candidemia - 10 Sites, United States, 2017-2021

Problem/Condition

Candidemia, a bloodstream infection caused by Candida spp., is a common cause of health care-associated bloodstream infections in the United States. Candidemia is associated with substantial health care costs, morbidity, and mortality.

Period Covered

2017-2021.

Description of System

CDC's Emerging Infections Program (EIP), a collaboration among CDC, state health departments, and academic partners, was used to conduct active, population-based laboratory surveillance for candidemia at city or county sites located in 10 states (California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee), representing a combined population of approximately 21.5 million persons, or 7% of the U.S. population in 2019. Connecticut began reporting cases on January 1, 2019, and conducts statewide surveillance. Although candidemia is not a nationally notifiable condition, cases of Candida auris infection are nationally notifiable, and cases of candidemia caused by C. auris could be included in both national case counts and EIP surveillance. A culture-confirmed candidemia case is defined as a positive blood culture for any Candida sp. from a resident in the surveillance catchment area. Subsequent positive blood cultures for Candida within 30 days of the initial positive culture (index date) in the same patient are considered part of the same case. Clinical laboratories serving each catchment area report candidemia cases, and trained surveillance officers abstract information from medical charts for all cases. Corresponding isolates are sent to CDC for species confirmation and antifungal susceptibility testing.

Results

A total of 7,381 candidemia cases were identified during the surveillance period (2017-2021). The overall incidence was 7.4 cases per 100,000 population. Across age groups, sexes, racial and ethnic groups, and surveillance sites, incidence was generally stable or increased slightly from 2017 to 2021, with the lowest overall incidence in 2019 (6.8) and the highest in 2021 (7.9). In 2021, candidemia incidence was highest in patients aged ≥65 years (22.7) and infants (aged <1 year) (8.0). Incidence was higher in males (8.7) compared with females (7.0) and higher in non-Hispanic Black or African American (Black) patients (12.8) compared with non-Black patients (5.6). Incidence was highest in Maryland (14.5), followed by Tennessee (10.1) and Georgia (10.0); incidence was lowest in Oregon (4.8). Increases occurred in the percentage of cases classified as health care onset (52.2% in 2017 to 58.0% in 2021). Overall, among 7,381 cases (in 6,235 patients), 63.7% occurred in patients who had a central venous catheter, 80.7% involved recent systemic antibiotic receipt, and 9.0% occurred in patients who had a history of injection drug use. The percentage of cases with a positive SARS-CoV-2 test during the 90 days before or after the index date increased from 10.4% in 2020 to 17.7% in 2021. From 2017 to 2021, the percentage of cases involving an intensive care unit stay before the index date increased from 38.3% to 44.9%. Echinocandins (e.g., micafungin) were used as treatment in 49.8% of cases, and azoles were used in 47.7%. The all-cause in-hospital mortality rate was 32.6%; this increased from 26.8% in 2019 to 36.1% in 2021. Overall, Candida albicans accounted for 37.1% of cases, followed by Candida glabrata (30.4%) and Candida parapsilosis (13.5%); however, C. glabrata was the most frequent species in California (38.4%) and Maryland (32.9%). Candida auris infections accounted for 0.4% of cases. Among 6,576 Candida isolates for which interpretive breakpoints exist and isolates were available for testing, 5.6% were fluconazole resistant, and <1% were echinocandin resistant. Antifungal resistance was stable for all antifungals tested across years.

Interpretation

Candidemia remains an important health care-associated infection. The disproportionate incidence among older adults, males, and Black patients is consistent with previous reports, and the overall incidence of candidemia has not changed substantially compared with previous EIP findings based on data collected during 2012-2016 (8.7 per 100,000 population). The higher mortality rate associated with candidemia during 2020-2021 likely reflects consequences of the COVID-19 pandemic, including strained health care systems and an increased population of patients who were susceptible to candidemia because of COVID-19-related critical illness.

Public Health Action

Strict implementation of measures to prevent health care-associated bloodstream infections is important to help prevent candidemia cases. Health care officials and providers should be vigilant for candidemia as a complication of critical illness. Continued surveillance is needed to monitor for emerging populations at risk for candidemia and changes in antifungal resistance patterns, which can help guide antifungal treatment selection.

Uveitis in Adults: A Review

Importance

Uveitis is characterized by inflammation of the uvea-the middle portion of the eye composed of the iris, ciliary body, and choroid-causing eye redness, pain, photophobia, floaters, and blurred vision. Untreated uveitis may cause cataracts, glaucoma, macular edema, retinal detachment, optic nerve damage, and vision loss.

Observations

Uveitis predominantly affects individuals aged 20 to 50 years. Anterior uveitis affects the iris and ciliary body (41%-60% of cases); intermediate uveitis affects the pars plana (attachment point of vitreous humor) and peripheral retina (9%-15%); posterior uveitis involves the choroid and/or retina (17%-23%); and panuveitis involves all uveal layers (7%-32%). Uveitis is classified as noninfectious or infectious, with toxoplasmosis, herpes, tuberculosis, and HIV comprising 11% to 21% of infectious cases in high-income countries and 50% in low- and middle-income countries. Incidence and prevalence of uveitis are influenced by genetic factors (eg, human leukocyte antigen-B27), environmental factors (eg, air pollution), and infection rates. In the US and Europe, 27% to 51% of uveitis cases are idiopathic, and 37% to 49% are associated with systemic disease, such as axial spondyloarthritis. Treatment goals are to induce and maintain remission while minimizing corticosteroid use to reduce corticosteroid-related adverse effects. Infectious uveitis requires systemic antimicrobial treatment. Active inflammatory disorders associated with uveitis should be treated by the appropriate specialist (eg, rheumatologist). Treatment for uveitis depends on subtype; anterior uveitis is treated with topical corticosteroids, and mild intermediate uveitis may be monitored without initial treatment. Patients with moderate to severe intermediate uveitis, posterior uveitis, and panuveitis are at high risk of sight-threatening complications and require systemic and/or intravitreal corticosteroids and immunosuppressive agents. For posterior uveitis, first-line therapy with disease-modifying antirheumatic drugs such as methotrexate achieved remission of inflammation in 52.1% (95% CI, 38.6%-67.1%) of patients, and mycophenolate mofetil controlled inflammation in 70.9% (95% CI, 57.1%-83.5%). In patients who do not improve or worsen with first-line therapy, adalimumab extended time to treatment failure to 24 weeks vs 13 weeks with placebo and reduced frequency of treatment failure from 78.5% to 54.5% (P < .001).

Conclusions and Relevance

Uveitis is characterized by inflammation of the uvea and primarily affects adults aged 20 to 50 years. For noninfectious anterior uveitis, corticosteroid eyedrops are first-line treatment. For posterior noninfectious uveitis, disease-modifying antirheumatic drugs are first-line therapy; biologics such as adalimumab are second-line treatment for patients with inflammation refractory to treatment. Uveitis caused by systemic infection should be treated with antimicrobials, and local or systemic steroids may be used depending on the severity of uveitis and the specific microorganism.

Genital cutaneous candidiasis versus chronic recurrent vulvovaginal candidiasis: distinct diseases, different populations

SUMMARYVulvovaginal candidiasis (VVC) affects over half of women during their lifetime. There are two categorization systems for VVC: uncomplicated versus complicated and acute versus recurrent. Most uncomplicated or acute cases occur in postpubertal premenopausal girls and women as sporadic vaginitis due to Candida albicans. Complicated VVC includes recurrent, chronic, or severe cases, presence of non-albicans species, and/or disease occurring in people with diabetes, immunosuppression, or pregnancy. These classification systems fail to distinguish the two distinct clinical categories of genital candidiasis: estrogen-dependent VVC and estrogen-independent cutaneous candidiasis. These entities are characterized by different pathogenesis, patient demographics, predisposing conditions, symptoms, signs, investigations, differential diagnosis, treatment, and ancillary measures. The current international and national guidelines on VVC are inadequate in their description of the clinical presentation, role and limitations of culture, biopsy findings, and management of cutaneous candidiasis. Progress toward improved patient outcomes will require the interdisciplinary collaboration of researchers and guideline authors to separate these two entities, unify terminology for each, explore the roles of medications and comorbid dermatoses, detail pragmatic and accessible diagnostic processes, define treatment goals, and discuss the long-term management strategies pertinent to each condition.

Deletion of RAP1 affects iron homeostasis, azole resistance, and virulence in Candida albicans

Rap1 is a DNA-binding protein conserved from yeast to mammals for its role in telomeric maintenance. Here, to explore additional functions of Candida albicans Rap1, we performed RNA sequencing analysis. Experimental validations further showed that Rap1 plays a role in iron regulation, especially under low-iron conditions. Moreover, Rap1 was involved in iron acquisition and modulation of iron-related genes. Rap1 was found to be associated with fluconazole resistance in a low-iron condition. Finally, we demonstrated that the deletion of RAP1 leads to reduced C. albicans virulence in a mouse model of infection. Together, this study reveals new functions of C. albicans Rap1, particularly in iron homeostasis, azole resistance, and virulence.

IMPORTANCE

Candida albicans is an important pathogenic fungus that can cause superficial to life-threatening infections. Iron is essential for almost all organisms, yet it is highly restricted within the human host to defend against pathogens. To grow and survive in the iron-limited host environment, C. albicans has evolved multiple iron acquisition mechanisms. Understanding the regulation of iron homeostasis is, therefore, critical for elucidating C. albicans pathogenesis and virulence. This study explores the novel functions of C. albicans Rap1, with a focus on its contribution to iron acquisition and utilization. Our findings further highlight how iron availability impacts antifungal resistance and virulence through Rap1, providing insight into the complex iron regulatory machinery of C. albicans.

Management of invasive candidiasis in French ICUs: insights from a 2024 nationwide survey

PURPOSE

Invasive candidiasis (IC) is a major challenge in intensive care units (ICUs) given its high prevalence, mortality rate, and diagnostic complexity. This national survey aimed to evaluate the knowledge of French intensive care specialists, assess the available resources for IC management, and analyze current bedside practices in ICUs.

METHODS

A cross-sectional survey was conducted among senior ICU physicians from 221 French ICUs. A structured questionnaire addressing organizational, diagnostic, and therapeutic approaches to IC management, including clinical cases, was distributed, achieving a participation rate of 54.7%.

RESULTS

Of the 121 respondents, 75 provided complete data. Most respondents were experienced intensivists working in public centers and managing hematological oncology patients. Although 65 (74%) respondents reported organizing multidisciplinary staff meeting, mycologists were rarely involved. Despite the availability of rapid diagnostic tools such as serum (1,3)-β-D-glucan (BDG), which was accessible to 63 (75%) respondents, integrating them into patient management at the bedside remains challenging. Additionally, 55 (67%) respondents had access to antifungal therapeutic drug monitoring (TDM), with voriconazole being the most frequently monitored antifungal drug. However, only 5 (9.1%) respondents had access to TDM every day of the week.

CONCLUSION

This survey highlights the strengths of multidisciplinary teams, TDM and rapid diagnostic tools for managing IC. However, significant gaps remain in their practical application, particularly the integration of diagnostic tools into clinical algorithms to guide bedside decision-making. Optimizing antifungal stewardship through coordinated interventions is essential for accelerating the diagnosis of IC, improving clinical outcomes, reducing resistance and adverse events.

Designing Lignin-Based Nanophotocomposites as Reactive Oxygen Species Generators for Inactivating Candida Strains

A combination of sustainable resources and precision biotherapeutics is a game changer for affordable healthcare. A natural biopolymer, lignin, present in agri-biomass, can serve as a nanodrug carrier for targeted delivery. Photodynamic therapy (PDT) is a noninvasive tool to accomplish targeted delivery. Photosensitizers, which are frequently used macrocycles in PDT, lack sufficient hydrophilicity for biological applications. In this regard, lignin-derived nanocarriers provide a sustainable solution, imparting bioavailability to the photosensitizers. In this study, a series of metalloporphyrins were designed and converted into lignin-based nanophotocomposites to augment their photostability and biological efficacy. Such nanophotocomposites played a significant role in eradicating candida infection via PDT by generating reactive oxygen species upon light irradiation. Computational studies (time-dependent density functional theory) established good photosensitizing properties of the metalloporphyrins. These nanophotocomposites demonstrated a pH-triggered release of photosensitizer drugs. The lignin-based nanophotocomposites could be used as low-cost, light-assisted treatment probes for curing candida infections.

The Impact of Epidemiological Trends and Guideline Adherence on Candidemia-Associated Mortality: A 14-Year Study in Northeastern Italy

Invasive candidiasis represents a major global health concern, with incidence and mortality rates expected to rise due to medical advancements and unavoidable risk factors. This retrospective, multicentric study was conducted in eight hospitals in a northeastern Italian region, enrolling adult patients diagnosed with candidemia from 1 January 2018 to 31 December 2022. Epidemiological trends and clinical characteristics were analyzed and compared to those from a prior regional study (2009-2011), allowing a fourteen-year comparative evaluation. A shift in species distribution was observed, with a decline in Candida albicans (from 65.7% to 57.8%) and a rise in non-albicans species, particularly the Candida parapsilosis complex (from 16.1% to 18.2%). Guideline adherence was assessed applying the EQUAL Candida score; scores ≥ than 11.5 were independently associated with improved in-hospital survival (HR 3.51, p < 0.001). Among individual score components, empiric echinocandin therapy and central venous catheter removal correlated with better outcomes. Centers with routine infectious disease (ID) consultations showed higher survival and adherence, reinforcing the value of specialist involvement. These findings support local epidemiological and management practice surveillance program adoption to address context-specific gaps, promote the adoption of best practices in Candida BSI management-as expanded ID specialist consultations and education programs-and, ultimately, reduce candidemia-related mortality rates.

Diagnostic and clinical management of Candida auris infections in immunocompromised patients

INTRODUCTION

Candida (Candidozyma) auris is an emerging fungal pathogen that poses a significant threat to immunocompromised patients. Its high mortality rates, resistance to multiple antifungal classes, and ability to spread rapidly in healthcare settings underscore the need for timely and accurate diagnosis to guide effective clinical management.

AREAS COVERED

This special report provides an updated overview of C. auris infections in immunocompromised hosts. It discusses current phenotypic and molecular diagnostic tools, antifungal susceptibility testing methods, and infection control strategies. Emerging therapies, including investigational antifungals and combination regimens, are also examined in light of evolving resistance patterns and clinical challenges.

EXPERT OPINION

Despite notable advances in diagnostics and treatment, major obstacles remain in the clinical management of C. auris, particularly in vulnerable populations. Barriers to guideline implementation, lack of standardized screening protocols, and limited access to novel antifungal agents continue to hinder effective response. Future efforts should focus on expanding diagnostic capacity, developing innovative therapies, and implementing targeted surveillance strategies to reduce the global burden of C. auris.

Retrospective Analysis of Fungal Isolations in Patients on Veno-Venous Extracorporeal Membrane Oxygenation: The Multicenter RANGER STUDY 2.0

Background: Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a progressively adopted life-sustaining intervention worldwide, particularly in the management of acute respiratory distress syndrome. Nevertheless, data concerning the prognostic significance of fungal isolation in this setting remain unclear. This study aims (i) to assess the incidence of fungal infection and colonization in a homogeneous cohort of V-V ECMO patients, and (ii) to evaluate the association between fungal infection or colonization and 1-year mortality, with a focus on the impact of specific fungal species. Methods: All consecutive adults admitted to the Intensive Care Units of five Italian university-affiliated hospitals and requiring V-V ECMO were screened. Exclusion criteria were age < 18 years, pregnancy, veno-arterial or mixed ECMO-configuration, incomplete records and survival < 24 h after V-V ECMO placement. A standard protocol of microbiological surveillance was applied and the distinction between different fungal species were made through in vivo and vitro tests. Cox-proportional hazards models, Kaplan-Meier curves and linear logistic regressions were applied for investigating mortality. Results: Two-hundred and seventy-nine V-V ECMO patients (72% male) were enrolled. The overall fungal isolation was 41% (n. 114): 23% infections and 18% colonizations. The overall 1-year mortality, among fungal isolations, was 40%, with no different risk in case of fungal infection (26 out of 63, 41%) (aHR 0.85, 95% CI [0.53-1.37], p-value 0.505) and colonization (20 out of 51, 39%) (aHR 0.86, 95%CI [0.51-1.43], p-value 0.556), as compared to patients never detecting fungi (68 out of 165, 41%, reference). According to the isolated mycotic species, as compared to Candida sp. group (reference), the risk of death was greater when different fungal species (e.g., Aspergillus sp. and Candida sp.) were concomitantly isolated in the same patient (OR 1.17, 95%CI [1.12-11.07], p-value 0.031. Conclusions: In the overall population, 23% V-V ECMO patients recorded 'late' fungal infections and 18% fungal colonizations, with a similar risk of death as compared to patients never experiencing fungi during the V-V ECMO course. The detection of concomitant different fungal species was an independent risk factor for 1-year mortality.

Evaluating antimicrobial stewardship strategies in candidemia: a novel desirability of outcome ranking (DOOR) analysis comparing blood culture versus T2Candida diagnostic approaches

The T2Candida Panel (T2 Biosystems, Lexington, MA) is a rapid diagnostic test that detects Candida from whole blood within 3-5 hours. We developed and applied a desirability of outcome ranking (DOOR) analysis to investigate if an antimicrobial stewardship program (ASP) strategy centered on T2Candida diagnosis is associated with improved outcomes compared to an ASP strategy that relies on conventional blood culture diagnosis in critically ill patients with candidemia. This is a retrospective, observational cohort of patients with candidemia identified ≤72 h of intensive care unit admission at two medical centers in Detroit, MI (one T2Candida site and one blood culture site) from 2016 to 2023. Management strategies for candidemia were compared using an original DOOR analysis with inverse probability of treatment weighting (IPTW) to account for confounding. Two hundred patients were included, 100 from each site. Baseline illness severity, race, and Candida species varied between groups; however, source control procedures, echocardiogram, and ophthalmologic exam occurred at similar frequencies. T2Candida/ASP was associated with faster median (interquartile range [IQR]) detection of candidemia (7.0 [5.0-10.75] h vs 45.5 h [34.25-68.75], P < 0.001) and timelier median (IQR) initiation of directed antifungal therapy (6.0 [0-11.0] h vs 49.0 [34.0-77.0] h, P < 0.001). T2Candida/ASP patients had a 58.0% probability of achieving an overall better outcome compared to those managed with blood culture/ASP (95% confidence interval: 50.4-65.2%) in IPTW-adjusted DOOR analysis. An ASP strategy incorporating T2Candida was associated with an overall better patient outcome compared to patients managed via conventional blood culture diagnosis.IMPORTANCECandida species are a significant cause of bloodstream infections in critically ill patients. Conventional diagnostic methods, such as blood cultures, have poor sensitivity and delayed results. The T2Candida Panel is a diagnostic tool that rapidly detects Candida directly from the blood in 3-5 h, enabling faster initiation of antifungal therapy. Antimicrobial stewardship programs (ASPs) optimize the management of bloodstream infections and may benefit from incorporating T2Candida to improve patient outcomes. This study examined whether an ASP intervention based on T2Candida diagnosis, compared to one relying on traditional blood culture methods, could improve outcomes in candidemia using a desirability of outcome ranking (DOOR) analysis. The DOOR method provides a comprehensive evaluation by integrating multiple outcomes into a single end point, which is ideal given the complexity of patients with candidemia. The T2Candida/ASP intervention resulted in an overall better patient outcome, considering infectious complications, treatment failure, and all-cause mortality.

Risk factors and outcome for bloodstream infections due to fluconazole-resistant Candida parapsilosis: a 22-year single-center retrospective study

Candidemia ranks among the top causes of nosocomial bloodstream infections, significantly increasing hospital stays and costs. Rapid and effective empirical antifungal therapy is crucial. The Candida parapsilosis species complex, the second most common cause of candidemia, has shown rising fluconazole resistance globally and in our country. Additionally, echinocandins exhibit higher minimum inhibitory concentrations (MICs) for C. parapsilosis, complicating empirical treatment decisions. This retrospective study analyzed 173 C. parapsilosis candidemia cases over 22 years in a tertiary care hospital. We compared 88 fluconazole non-susceptible (minimum inhibitory concentration [MIC] = 4 µg/mL: susceptible dose dependent; MIC ≥ 8 µg/ml resistant) and 85 fluconazole susceptible cases, examining demographics, clinical characteristics, risk factors, and 28-day mortality. Independent risk factors for fluconazole non-susceptibilty included age ≥ 66 years (p = 0.016), central venous catheter use (p < 0.001), total parenteral nutrition (p = 0.003), and colostomy (p = 0.049). Fluconazole non-susceptible cases had lower microbiological cure rates and higher mortality. Mortality in this group was independently associated with microbiological cure failure (p < 0.001). This study highlights the importance of identifying risk factors to estimate the likelihood of resistant pathogens, initiating targeted antifungal therapy, and providing individualized management. Monitoring local resistance patterns is essential to guide empirical therapy. Further multicenter research is needed to validate findings and optimize treatment for fluconazole resistant candidemia. Clinical trial number: Not applicable.

Surgical Infection Society Multi-Center Observational Study: Empiric Anti-Fungal Coverage after Non-Colonic Gastrointestinal Perforation

Background: Empiric anti-fungals are frequently administered in patients with non-colonic gastrointestinal (GI) perforations, but there is limited evidence of their benefit. We hypothesized that empiric anti-fungals would offer no clinical benefit compared with a standard course of antimicrobial therapy. Methods: This multi-center prospective cohort study included patients ≥18 years old undergoing operative management for non-colonic GI perforations across 15 centers between August 2021 and January 2024. The primary outcome was organ-space surgical site infection (SSI). We performed propensity score matching to adjust for confounders and a backward stepwise regression model to identify predictors of an organ-space SSI. A subgroup analysis of spontaneous upper GI perforations was performed as well. Results: A total of 192 patients were included; 138 (71.88%) received empiric anti-fungal therapy, and 17.7% developed an organ-space SSI. Before matching, empiric anti-fungal use was frequent in critically ill patients although not associated with organ-space SSI. After matching, there were no differences in organ-space SSI (17.5% vs. 17.5%, p = 0.99). In multi-variable regression, American Society of Anesthesiologists physical status classification system (ASA) category 3 increased the risk of organ-space SSI (odds ratio [OR] 2.49, p = 0.04), whereas perioperative proton-pump inhibitor (PPI) use was protective (OR 0.15, p = 0.004). In the subgroup analysis (N = 150), empiric anti-fungal therapy did not reduce infection risk. Pre-operative shock increased the risk of organ-space SSI (OR 2.83, p = 0.04), whereas PPI use remained protective (OR 0.15, p = 0.01). Conclusion: Empiric anti-fungal use was not associated with reduced organ-space SSI, even after adjusting for confounders. Given the lack of benefit, we caution against the use of routine empiric anti-fungal therapy in non-colonic GI perforations.

Evaluation of the Synergistic Activity of Antimicrobial Peptidomimetics or Colistin Sulphate with Conventional Antifungals Against Yeasts of Medical Importance

With rising multidrug-resistant yeast pathogens, conventional antifungals are becoming less effective, urging the need for adjuvants that enhance their activity at lower doses. This study evaluated the synergistic activity of antimicrobial peptidomimetics (TM8 and RK758) or colistin sulphate in combination with conventional antifungals against Candida albicans, C. tropicalis, C. parapsilosis, Meyerozyma guilliermondii, Nakaseomyces glabratus, Pichia kudriavzevii and Kluyveromyces marxianus, and Candidozyma auris using the checkerboard microdilution test. RK758 was synergistic with fluconazole in 78% of isolates, with the remaining 22% of isolates still showing partial synergy; it showed synergy with amphotericin B in 56% of isolates, and with caspofungin, 78% of isolates exhibited either synergy or partial synergy. TM8 showed synergy with fluconazole in 44% (with partial synergy in another 44%) of isolates, with amphotericin B in 67% of isolates, and with caspofungin in 44% (with partial synergy in another 44%) of isolates. Colistin with fluconazole or caspofungin exhibited synergy or partial synergy in 56% of the isolates. No antagonism was observed in any of the combinations. Additionally, a time-kill assay further demonstrated synergistic activity between fluconazole and TM8 or RK758. The effects of these peptidomimetics on cell membrane integrity were demonstrated in an ergosterol binding assay, supported by SYTOX Green and cellular leakage assays, both indicating a lytic effect. These results suggest that peptidomimetics can synergise with conventional antifungals, offering a potential strategy for combination therapy against yeast infections. The membrane lytic activity of the peptidomimetics likely plays a role in their synergistic interaction with antifungals, thereby enhancing the antimicrobial activities of both compounds at sub-MIC levels.

Heterogeneity of Biofilm Formation Among Staphylococcus aureus and Coagulase-Negative Staphylococcus Species in Clinically Relevant Intravenous Fat Emulsions

Background: Compared to soybean oil intravenous fat emulsion (SO-IFE), use of mixed-oil IFE (MO-IFE) is associated with reduced rates of catheter-related bloodstream infections caused by coagulase-negative Staphylococcus species (CoNS) in pediatric patients receiving parenteral nutrition. Methods: Using an in vitro biofilm model, this study aimed to assess the impact of IFEs on biofilm formation among Staphylococcus species. S. aureus, S. capitis, S. epidermidis, S. haemolyticus, S. hominis, and S. lugdunensis were cultivated as biofilms in media supplemented with SO-IFE, MO-IFE, or fish oil IFE (IFE). Biomass was quantified by the crystal violet method, and follow-up planktonic growth assays assessed antimicrobial effects of IFEs. Results: Compared to SO-IFE, MO-IFE and FO-IFE significantly inhibited biofilm formation of S. aureus but did not impact planktonic growth. Contrary to clinical data, CoNS biofilm formation was not impacted by any of the IFEs tested. S. aureus biofilm inhibition in IFEs was further investigated by comparing differences following growth in SO-IFE supplemented with capric acid, docosahexaenoic acid (DHA), or eicosapenaenoic acid (EPA) to concentrations matching those of MO-IFE. Capric acid supplementation was associated with significant reduction in biofilm formation compared to SO-IFE alone. However, this was attributed to a bactericidal effect based on follow-up planktonic growth assays. Conclusions: These results suggest that biofilm formation in S. aureus is variably impacted by fatty acid composition in clinically relevant IFEs, with capric acid exhibiting bactericidal activity against tested isolates.

Effectiveness of Vascular Catheter Removal Versus Retention in Non-ICU Patients with CRBSI or CABSI in Retrospective, Single-Center Study

Catheter-associated bloodstream infections (CABSIs) and catheter-related bloodstream infections (CRBSIs) are significant causes of morbidity and mortality worldwide. The current practice favors the removal of vascular access devices (VADs); however, the evidence on this topic remains inconclusive. This study evaluates the clinical outcomes in terms of in-hospital mortality and catheter retention vs. removal in CABSI and CRBSI cases. A retrospective, observational, single-center study was conducted at Luigi Sacco Hospital, Milan, Italy (May 2021-December 2023), and it analyzed non-ICU adult patients with VADs diagnosed with CRBSIs or CABSIs. Clinical and microbiological data were collected to assess the outcomes based on catheter management. Among 1874 patients with VADs, 147 were included, with 164 VAD infection events (92 CABSIs and 72 CRBSIs). Overall, 35 (23.8%) patients with CABSIs and CRBSIs died. Out of those who retained the catheter 19 (35.8%) patients died, while among removal patients 16 (17%) died (p = 0.018). A Candida spp. isolation was found to be significantly associated with a higher likelihood of catheter removal (p = 0.04). Our findings suggest that, in non-ICU CRBSI and CABSI cases, VAD removal may be associated with improved outcomes when feasible.

Predictive nomogram for early detection of invasive fungal disease deterioration --- a 10-year retrospective cohort study

BACKGROUND

Invasive fungal disease (IFD) is characterized by its capacity to rapidly escalate to life-threatening conditions, even when patients are hospitalized. However, the precise prognostic significance of baseline clinical characteristics related to the progression outcome of IFD remains elusive.

METHODS

A retrospective cohort study spanning a duration of 10 years was conducted at two prominent tertiary teaching hospitals in Southern China. Patients with proven IFD were queried and divided into serious and non-serious groups based on the disease deterioration. To establish robust predictive models, patients from the first hospital were randomly assigned to either a training set or an internal validation set, while patients from the second hospital constituted an external test set. To analyze the potential predictors of IFD deterioration and identify independent predictors, the study employed the least absolute shrinkage and selection operator (LASSO) method in conjunction with binary logistic regressions. Based on the outcomes of this analysis, a predictive nomogram was constructed. The performance of the developed model was thoroughly evaluated using the training set, internal validation set, and external test set.

RESULTS

A total of 480 cases from the first hospital and 256 cases from the second hospital were included in the study. Among the 480 patients, 81 cases (16.9%) experienced deterioration, and out of those, 45 (55.6%) cases resulted in mortality. Seven independent predictors were identified and utilized to construct a predictive nomogram. The nomogram exhibited excellent predictive performance in all three sets: the training set, internal validation set, and external test set. The area under the receiver operating characteristic curve (AUC) for the training set was 0.88, for the internal validation set was 0.91, and for the external test set was 0.90. The Hosmer-Lemeshow test and Brier score indicated a high goodness of fit for the model. Furthermore, the calibration curve demonstrated a strong agreement between the predicted outcomes from the nomogram and the actual observations. Additionally, the decision curve analysis exhibited that the nomogram provided significant clinical net benefits in predicting IFD deterioration.

CONCLUSIONS

The study successfully identified seven independent predictors and developed a predictive nomogram for early assessment of the likelihood of IFD deterioration.

Quality improvement project to reduce beta-D-glucan turnaround times in an NHS pathology network

Beta-D-glucan (BDG) is a cell wall component of many fungi, detecting this in patients' serum permits early diagnosis of invasive fungal infections, particularly in patients with haematological malignancy. In critically ill patients in an intensive-care unit, where the prevalence of invasive fungal infection is lower, the high negative predictive value of BDG facilitates withholding or discontinuation of empirical antifungal therapy, contributing to antifungal stewardship. However, for the results of BDG testing to impact patient management, they need to be available within a clinically useful timeframe.The South West London Pathology (SWLP) network routinely sent samples for BDG testing from hospital trusts in our area to the UK Health Security Agency Mycology Reference Laboratory (MRL) at Bristol for analysis. In 2021, the mean turnaround time (TAT) was more than two times the 5-working-days standard stated in the SWLP user handbook. In this quality improvement project (QIP), we identified that the greatest delay was the MRL posting hardcopy reports. We investigated electronic reporting, first for all patient samples, and then only for intensive-care patients. However, we found that information technology (IT) and staffing limitations meant this was not viable.We then investigated commercial solutions and identified an innovative assay, which enabled the implementation of in-house BDG testing that was a good fit with our available staffing resource and laboratory environment. Our aim was to achieve at least 90% of BDG results authorised within 5 working days of sample receipt. Our QIP improved performance on this from 0.88% to 92.8% and reduced the mean TAT from 11.6 to 2.5 days and at lower unit cost. The change has been well received by our laboratory staff, and our pathology operational leads have had very positive feedback from our clinical teams and our antifungal steward.

Management of Intra-Abdominal Candidiasis in Intensive Care Setting: A Narrative Review

Intra-abdominal candidiasis (IAC), with or without candidemia, is a common condition in patients in intensive care units (ICUs). Early diagnosis of IAC remains a challenge for clinicians despite new biomarkers. Early and appropriate antifungal treatment, which is associated with better clinical outcomes, is negatively affected by the increased isolation of non-albicans Candida strains that are resistant to the commonly used azoles and echinocandins. Based on the pharmacokinetic (PK) and pharmacodynamic (PD) properties of the different treatment options, liposomal amphotericin B, rezafungin or high doses of anidulafungin appear to be the most appropriate first-line options for complicated IAC in ICUs.

The Role of Empiric Antifungal Therapy in Patients With Perforated Peptic Ulcer: An Updated Systematic Review and Meta-Analysis

Fungal growth is common in intraoperative cultures of patients with perforated peptic ulcer (PPU) leading to the common use of empiric antifungal therapy, with current evidence not clearly supporting this practice. The goal of this updated systematic review and meta-analysis was to synthesize the effect of empiric antifungals in patients with PPU. Eligible studies were identified through a comprehensive literature search in the MEDLINE (PubMed) and EMBASE databases, following the PRISMA 2020 statement. A total of eight studies were identified reporting on 1802 patients. The population consisted of 67.3% males (n = 121/1802), with a mean age of 59.1 ± 13.2 years. Most of the population underwent surgery (n = 1763/1802, 97.8%), which was most frequently omental patch (n = 1169/1411, 82.8%), while 12.8% (n = 140/1096) underwent laparoscopic repair. Intraoperative cultures were obtained in 73.7% (n = 1262/1713); blood cultures were obtained in 54.5% (n = 467/857) and were positive for fungus in 44.1% (n = 558/1262) and in 5.6% (n = 26/467), respectively. Empiric antifungal treatment was administered in 19.6% (n = 353/1802). The most common agent was fluconazole reported in 6 studies. At a mean follow-up of 34.4 ± 9.9 days, 191/1787 (10.7%) patients died. Patients with fungus-positive intraoperative cultures had significantly increased odds of having diabetes mellitus (OR: 1.55; 95% CI: 1.05-2.30), history of malignancy (OR: 2.80; 95% CI: 1.22-6.45), being on steroids (OR: 5.13; 95% CI: 1.37-19.3), and increased mortality (OR: 2.49; 95% CI: 1.67-3.70). Empiric antifungal therapy did not significantly decrease the odds for death (OR: 1.45; 95% CI: 0.33-6.41). The presence of fungi in the peritoneal fluid is associated with increased risk of death, that is not affected by administration of empiric antifungal therapy.

Global guideline for the diagnosis and management of candidiasis: an initiative of the ECMM in cooperation with ISHAM and ASM

Candida species are the predominant cause of fungal infections in patients treated in hospital, contributing substantially to morbidity and mortality. Candidaemia and other forms of invasive candidiasis primarily affect patients who are immunocompromised or critically ill. In contrast, mucocutaneous forms of candidiasis, such as oral thrush and vulvovaginal candidiasis, can occur in otherwise healthy individuals. Although mucocutaneous candidiasis is generally not life-threatening, it can cause considerable discomfort, recurrent infections, and complications, particularly in patients with underlying conditions such as diabetes or in those taking immunosuppressive therapies. The rise of difficult-to-treat Candida infections is driven by new host factors and antifungal resistance. Pathogens, such as Candida auris (Candidozyma auris) and fluconazole-resistant Candida parapsilosis, pose serious global health risks. Recent taxonomic revisions have reclassified several Candida spp, potentially causing confusion in clinical practice. Current management guidelines are limited in scope, with poor coverage of emerging pathogens and new treatment options. In this Review, we provide updated recommendations for managing Candida infections, with detailed evidence summaries available in the appendix.

Voriconazole in the treatment of pediatric patients with hematologic malignancies and invasive fungal infections: a real-world study

PURPOSE

To evaluate the factors influencing voriconazole (VRC) administration, clinical efficacy, and safety in children with hematological malignancies (HM) and invasive fungal infection (IFD).

METHODS

This is a single-center, retrospective real-world study conducted between July 2018 and December 2023. Univariate and multivariate logistic regression analysis were used to analyze the affecting factors.

RESULTS

A total of 167 patients were included in this study. Among them, 13.77% (23/167) of children under 2 years old received off-label use of VRC, with an initial maintenance dose higher than that of other groups (P < 0.001). There were 8 cases (4.79%) of cured, 148 cases (88.62%) of improved, and 11 cases (6.59%) of ineffective. Thirty-eight cases experienced adverse drug reactions (ADR), with a highest incidence (10.2%) of hepatotoxicity. The concomitant proton pump inhibitors (PPIs), days of central venous catheterization and coagulopathy were independent influencing factors of ADR. Sixty-six patients underwent therapeutic drug monitoring (TDM), which increased the probability of achieving the target plasma trough concentration (Cmin). Among children < 2 years old underwent TDM, 88.89% (8/9) achieved therapeutic concentration, and the probability was higher than that of the older groups. Days of VRC treatment had a positive but not statistically significant effect on achievement of target Cmin. Hypoalbuminemia and days of antimicrobials treatment were independent influencing factors of Cmin distribution.

CONCLUSION

Attention to the off-label use of VRC in children < 2 years old, hypoalbuminemia and coagulopathy correction, potential drug interactions with VRC, and ADR monitoring is crucial for clinical efficacy and safety.

Intravesical fungus ball following robot-assisted radical prostatectomy in diabetes mellitus patient

Introduction

A case with a rare complication considered to be related to a robot-assisted radical prostatectomy procedure and medication given thereafter is presented.

Case presentation

A 73-year-old male diagnosed with prostate cancer underwent a robot-assisted radical prostatectomy and lymphadenectomy. The medical history included type II diabetes mellitus managed with canagliflozin hydrate. Six months after the operation, the patient was affected by pneumaturia and soft yellowish tissue discharge during micturition. Candida species were detected in urine and soft tissue cultures. Based on a diagnosis of intravesical fungus ball, a transurethral resection was performed. It was considered that partial impairment of vesical blood supply caused by clamping of a branch of the inferior vesical artery during the lymphadenectomy procedure likely contributed to intravesical fungus ball formation.

Conclusion

Awareness of the various arteries supplying vesical blood flow and urogenital infection following sodium-glucose cotransporter-2 inhibitor administration can be beneficial for the attending surgeon.

Candidemia in Left Ventricular Assist Device Recipients: Incidence, Risk Factors, and Outcomes

Background

Candidemia (Candida bloodstream infection [C-BSI]) in left ventricular assist device (LVAD) recipients is poorly understood. This study aimed to investigate the incidence, risk factors and outcomes of C-BSI in LVAD recipients.

Methods

We screened 656 adults who underwent LVAD implantation at our institution from 1 January 2015 to 4 April 2024. Patients with C-BSI (n = 18) were compared with 2 control groups: (1) matched LVAD recipients with no bloodstream infection (N-BSI; matched 1:5; n = 90) to determine risk factors for C-BSI and (2) unmatched LVAD recipients with bacteremia (bacterial BSI [B-BSI]; n = 79) to compare mortality and infectious complication rates. A random forest model identified key predictive factors for C-BSI. Kaplan-Meier survival curves were used for time-to-event analyses.

Results

Median time to C-BSI was 20 days after implantation (interquartile range, 6-42 days). Compared to N-BSI, C-BSI were more likely to require perioperative temporary mechanical circulatory support (9 patients [50%] vs 8 [8.9%], respectively), renal replacement therapy (12 [67%] vs 6 [6.7%]), total parenteral nutrition (6 [33%] vs 2 [2.2%]), and prolonged postoperative mechanical ventilation (for 12 days vs 1 day) (all P < .001). A random forest model identified ventilation duration, renal replacement therapy, and total parenteral nutrition as top predictors of C-BSI. In terms of outcomes, C-BSI was more likely to lead to device endocarditis than B-BSI (in 5 [28%] vs 7 [9.1%], respectively; P = .008) and was associated with shorter median survival after infection (25 [interquartile range, 12 to not estimable due to censoring] vs 490 [54 to not estimable due to censoring] days; P = .04).

Conclusions

C-BSI occurs early in LVAD recipients and is associated with a high mortality rate. Identified risk factors identified may guide antifungal prophylaxis or early empiric antifungal treatment in this susceptible patient population.

Urosepsis From Nephrolithiasis Caused by Candida glabrata: A Rare Etiology of Urinary Sepsis in an Immunocompetent Patient

Nephrolithiasis can often serve as an infection nidus, as it is typically associated with urease-producing bacteria and can obstruct the urinary tract, leading to pyelonephritis. While most urinary tract infections from septic stones are bacterial in etiology, fungal causes are less commonly reported in immunocompetent patients and rarely manifest as fungemia. Among fungal causes, Candida albicans is the most common. We describe the case of a 41-year-old immunocompetent patient with a history of recurrent kidney stones and percutaneous nephrostomy tube placement, who developed sepsis from a urinary source secondary to a nephrolithiasis. Blood culture isolates grew Candida glabrata. Following identification of the fungus, the patient received a two-week intravenous micafungin course and outpatient stone removal per urological surgery.

Genotypic Diversity and Molecular Basis of Fluconazole Resistance in Candida parapsilosis Clinical Isolates Collected Over 7 Years in a Tertiary-Care Hospital in North India

BACKGROUND

The recent rise in the global incidence of fluconazole resistance in C. parapsilosis has become a significant public health concern. Epidemiological studies suggest that fluconazole resistance in C. parapsilosis spreads through endemic clones. We, therefore, investigated the molecular epidemiology of fluconazole-resistant C. parapsilosis in our centre.

METHODS

C. parapsilosis isolates from 2016 through 2022 were investigated for antifungal susceptibility. Fluconazole-resistant isolates were analysed for ERG11 mutation using Sanger sequencing. Gene expression profiles of ERG11, CDR1 and MDR1 were assessed by real-time qPCR. The epidemiological relationship of resistant and susceptible isolates of C. parapsilosis was investigated using short tandem repeat typing. Additionally, biofilm production and cell wall ergosterol contents were also quantified and compared.

RESULTS

Among 572 C. parapsilosis isolates, 48 (8.4%) were resistant to fluconazole. Of 28 recoverable resistant isolates, 17.9% (5/28) were wild-type and 82.1% (23/28) harboured the following ERG11 mutations: Y132F (n = 3), K143R (n = 10) and K143R + R398I (10/28). Significant fold-changes were observed in ERG11 (p = 0.037) and MDR1 (p = 0.008) gene expressions in fluconazole resistant compared to susceptible isolates. Contrary to global reports, STR typing suggested a limited clonal transmission of resistant C. parapsilosis with multiple introductions of resistant isolates in our centre. On fluconazole exposure, ergosterol content significantly increased (p < 0.01) in resistant isolates, particularly in isolates harbouring ERG11K143R + R398I mutations. In contrast, fluconazole-susceptible isolates formed comparatively higher baseline biofilm (p < 0.05) than resistant isolates with ERG11K143R mutation.

CONCLUSION

The current study underscores the need for continuous molecular surveillance and tailored therapeutic options for effective management of fluconazole resistance in C. parapsilosis.

Suppressive antibiotic treatment (SAT) in the era of MDRO infections: a narrative review

INTRODUCTION

Antibiotics were originally developed to treat acute bacterial infections, and research studies focus their efforts on safety and efficacy in the short term; however, prolonged course of antibiotics has been documented in multiple clinical settings. The aim of this narrative review is to provide a new perspective on SAT and to discuss new therapeuticpossibilities.

AREAS COVERED

We discuss new clinical scenarios in which SAT could be considered. We provided a broad discussion about long-acting agents and new or repurposed oral agents as well as the use of OPAT with elastomeric pumps and an overview of the pipeline of new antifungals. Limitations of SAT are presented in this review and especially patients' adherence issues, possible spread of MDROs, possible rising of the incidence of Clostridioides difficile infections, drug-to-drug interactions and drug-related problems, cost-effectiveness evaluation issues.

EXPERT OPINION

Many research gaps are evident and further studies are needed. Above all, the efficacy and safety of SAT in the different clinical scenarios. Discovery of new molecules against MDROs and ongoing research on PK/PD variables as well as a better understanding of the relationship between SAT and the emergence of resistance could improve SAT usage and reduce the impact of DRPs.

Extra-pulmonary invasive fungal infection in a post-heart transplant patient

Infectious complications remain a lifelong risk after organ transplantation. Invasive fungal infections (IFIs), including fungal brain abscess, in these patients can be very morbid and fatal. Decreased host immunity due to lifelong immunosuppressive therapy is the single most important risk factor for IFIs. Unlike in the general population, IFIs are difficult to diagnose in immunosuppressed patients because of atypical presentations, low yield of pathogens from microbial cultures, and long turnaround time for culture results. Late diagnosis and delayed initiation of treatment may influence the final outcome.

Inpatient ophthalmology consultations for candidemia: a literature review and opinion

PURPOSE OF REVIEW

To examine the role of the ophthalmologist in screening for ocular candidiasis in patients with Candidemia .

RECENT FINDINGS

Recent evidence has shown that previously published incidence rates of endophthalmitis in Candidemia were overestimating risk due to nonuniform guidelines. Newer data suggest a very low rate of endophthalmitis in the Candidemia population. There is currently a lack of definitive data proving that retinal findings lead to significant changes in the clinical management of patients with regards to systemic treatment and overall outcomes.

SUMMARY

Given the low rates of endophthalmitis, minimal management changes with positive retinal findings, and recently published guidelines from the American Academy of Ophthalmology, we posit that ocular screening of all patients with Candidemia is not warranted. However, more research is required to better delineate high-risk features that could guide which patients would require ophthalmologic examination. Further collaboration between ophthalmology and infectious disease specialists is vital to create new evidence-based guidelines based on the recent data.

In vitro susceptibility profiles of invasive Candida bloodstream isolates to ten antifungal drugs in a southern area of China

Introduction. In recent years, with the increase of drug resistance of Candida, the incidence rate and mortality of candidemia have gradually increased, which has brought a huge economic and health burden to people.Gap Statement. The epidemiological characteristics and antifungal drug sensitivity patterns in different regions have varied.Aim. To analyse the distribution and antifungal susceptibility of Candida strains isolated from bloodstreams and provide a basis for the use of antifungal drugs for treatment.Methodology. A total of 115 strains of Candida were collected from the bloodstream, and 28 strains of colonized Candida albicans were collected from the upper respiratory tract. Candida species were identified using matrix-assisted laser desorption/ionization time-of-flight technology. Antifungal susceptibility was assessed using broth microdilution combined with redox methods.Results. There were eight types of Candida strains isolated from the bloodstream; C. albicans was the most common species (36.5%), followed by Candida parapsilosis (24.3%), Candida glabrata (17.4%) and Candida tropicalis (14.8%). There was no significant difference in the resistance of C. albicans to azole drugs between the bloodstream infection group and the upper respiratory tract colonization group, but there was a significant difference in the MIC values of micafungin and fluconazole, with P values of 0.017 and 0.003, respectively. Amphotericin B and echinocandins are the most susceptible drugs for all Candida species, but the MICs of echinocandins against C. parapsilosis are significantly higher than those of other Candida species. Candida (except for C. glabrata) is highly resistant to azoles, with C. parapsilosis showing resistance rates of 89.3% and 82.1% to itraconazole and posaconazole, respectively; the resistance rates of C. tropicalis are 100% and 94.1%, respectively.Conclusion. C. albicans remains the predominant pathogen responsible for candidemia. Although the resistance of Candida to antifungals is relatively stable, there are significant differences in the MICs of antifungal drugs against Candida, indicating the importance of strain identification in the treatment of candidemia. For empirical treatment, the use of echinocandin drugs is recommended.

Activity of rezafungin against Candida auris

The increasing prevalence of candidemia and invasive candidiasis infections caused by Candida auris represents a global health risk. Such infections are difficult to treat as they are often multidrug-resistant and are linked to high rates of mortality. Rezafungin is a second-generation echinocandin with antifungal activity against a range of Candida species, including wild type, and azole- and some echinocandin-resistant isolates. Its stability and prolonged half-life permit less frequent dosing compared with other echinocandins, leading to high front-loaded exposures and potential earlier mycological clearance from infection sites. These properties make rezafungin a candidate for the treatment of candidemia and invasive candidiasis infections due to C. auris. Accordingly, this narrative review article describes available evidence for the activity and effectiveness of rezafungin against C. auris isolates and infections. To date, the activity of rezafungin against C. auris isolates and infections has been demonstrated in in vitro and in vivo non-clinical experiments, and in pharmacokinetic/pharmacodynamic target attainment estimations utilizing clinical data. With similar potency to other echinocandins, rezafungin demonstrates in vitro and in vivo activity that is comparable to or better than that seen with other echinocandins, and similar to that for rezafungin in other Candida species. Like other echinocandins, its activity is reduced in fks-mutant isolates. Although there is currently a dearth of data on the therapeutic activity of rezafungin against C. auris, it is reasonable that rezafungin may be a viable choice for treating candidemia and invasive candidiasis caused by C. auris. Further clinical investigations are necessary.

Role of liposomal amphotericin B in intensive care unit: an expert opinion paper

INTRODUCTION

Invasive fungal infections (IFI) are frequent in patients admitted to the intensive care unit (ICU). The use of first-line antifungals like triazoles or echinocandins may be limited by the global spread of multi-drug resistance species, drug-drug interactions, low organ penetration, and some safety concerns in case of multi-organ failure. Liposomal amphotericin B (L-AmB) is a polyene drug with a broad activity against mold and yeast and an acceptable safety profile. To outline the role of L-AmB in the treatment of IFI in critically ill patients, a panel of experts was invited to draw up an expert opinion paper on the appropriate place in therapy of L-AmB in different clinical scenarios of patients admitted to ICU.

METHODS

A multidisciplinary group of 16 specialists in infectious disease, microbiology, pharmacology, and intensive care elaborated an expert opinion document through a multi-step approach: (1) the scientific panel defined the items and wrote the statements on the management of IFI in ICU, (2) a survey was submitted to an external panel to express agreement or disagreement on the statements, and (3) the panel reviewed the survey and implemented the final document.

RESULTS

The final document included 35 statements that focused on epidemiology and microbiological rationale of the use of systemic L-AmB in critically ill patients and its potential role in specific clinical scenarios in the ICU.

CONCLUSION

Systemic L-AmB may represent an appropriate therapeutic choice for IFI in ICU patients with different underlying conditions, especially when the use of first-line agents is undermined. This expert opinion paper may provide a useful guide for clinicians.

Evaluation of Satanin 1 as a potential antifungal antimicrobial peptide to treat Malassezia infections

Malassezia is a fungal genus that is part of the skin's normal mycobiota but can also cause various diseases. The emergence of resistance to antimicrobial agents in several microorganisms, including Malassezia yeasts, has led to the exploration of new therapeutic alternatives such as antimicrobial peptides. This study aimed to investigate the effect of Satanin 1, a recently identified antimicrobial peptide, against Malassezia using broth microdilution assays, Scanning Electron Microscopy (SEM) and Transmission Electron Microscopy (TEM), and a Galleria mellonella infection model. Results showed that the Minimal Inhibitory Concentration (MIC) of Satanin 1 against Malassezia ranged from 50 to 12.5 µg/mL, and the peptide works by affecting the fungal cell surface. Nonetheless, Satanin 1 treatment did not improve the survival of infected G. mellonella, possibly due to an exacerbated immune response in the larvae, as shown by hemocyte population characterization and histopathological analyses. Continued investigation into alternative molecules, like antimicrobial peptides, is essential to combat the increasing threat of antifungal resistant microorganisms.