Antifungal use influences Candida species distribution and susceptibility in the intensive care unit

Stephanoascus ciferrii Complex: The Current State of Infections and Drug Resistance in Humans

In recent years, the incidence of fungal infections in humans has increased dramatically, accompanied by an expansion in the number of species implicated as etiological agents, especially environmental fungi never involved before in human infection. Among fungal pathogens, Candida species are the most common opportunistic fungi that can cause local and systemic infections, especially in immunocompromised individuals. Candida albicans (C. albicans) is the most common causative agent of mucosal and healthcare-associated systemic infections. However, during recent decades, there has been a worrying increase in the number of emerging multi-drug-resistant non-albicans Candida (NAC) species, i.e., C. glabrata, C. parapsilosis, C. tropicalis, C. krusei, C. auris, and C. ciferrii. In particular, Candida ciferrii, also known as Stephanoascus ciferrii or Trichomonascus ciferrii, is a heterothallic ascomycete yeast-like fungus that has received attention in recent decades as a cause of local and systemic fungal diseases. Today, the new definition of the S. ciferrii complex, which consists of S. ciferrii, Candida allociferrii, and Candida mucifera, was proposed after sequencing the 18S rRNA gene. Currently, the S. ciferrii complex is mostly associated with non-severe ear and eye infections, although a few cases of severe candidemia have been reported in immunocompromised individuals. Low susceptibility to currently available antifungal drugs is a rising concern, especially in NAC species. In this regard, a high rate of resistance to azoles and more recently also to echinocandins has emerged in the S. ciferrii complex. This review focuses on epidemiological, biological, and clinical aspects of the S. ciferrii complex, including its pathogenicity and drug resistance.

An Analysis of the Use of Systemic Antifungals (Fluconazole, Itraconazole, and Terbinafine) in Galicia, Spain, between 2019 and 2022

In the present work, we examined the consumption of systemic antifungals (fluconazole, itraconazole, and terbinafine) in outpatients in the four provinces of Galicia, Spain, between 2019 and 2022. We also described the variability in the use of these types of drugs between these provinces. In addition, we detected any deviation in consumption at a seasonal level and analyzed possible changes during the study period. A descriptive, cross-sectional, and retrospective study of the use of antifungals, expressed in terms of a defined daily dose per 1000 inhabitants per day, was carried out. The results obtained revealed statistically significant differences between provinces and by the active principle consumed in the four Galician provinces (p < 0.001), which can be explained by multiple factors. This study also revealed that there was stable consumption during the study period, with no significant seasonal differences observed. This study represents a contribution to the knowledge about the consumption of antifungals for systemic use in Galicia and serves as a basis for subsequent studies. This will allow us to understand the consumption patterns of these types of drugs and, ultimately, will help to establish stewardship strategies and prevent the development of resistance.

Pharmacokinetic and pharmacodynamic considerations for antifungal therapy optimisation in the treatment of intra-abdominal candidiasis

Intra-abdominal candidiasis (IAC) is one of the most common of invasive candidiasis observed in critically ill patients. It is associated with high mortality, with up to 50% of deaths attributable to delays in source control and/or the introduction of antifungal therapy. Currently, there is no comprehensive guidance on optimising antifungal dosing in the treatment of IAC among the critically ill. However, this form of abdominal sepsis presents specific pharmacokinetic (PK) alterations and pharmacodynamic (PD) challenges that risk suboptimal antifungal exposure at the site of infection in critically ill patients. This review aims to describe the peculiarities of IAC from both PK and PD perspectives, advocating an individualized approach to antifungal dosing. Additionally, all current PK/PD studies relating to IAC are reviewed in terms of strength and limitations, so that core elements for the basis of future research can be provided.

Evaluation of an Antifungal Stewardship Initiative Targeting Micafungin at an Academic Medical Center

Delays in the treatment of proven invasive fungal disease have been shown to be harmful. However, empiric treatment for all patients at risk of infection has not demonstrated benefit. This study evaluates the effects of a micafungin stewardship initiative on the duration of therapy and clinical outcomes at the University of Mississippi Medical Center in Jackson, Mississippi. This single-center quasi-experiment evaluated patients who received micafungin. Adult inpatients who received at least one treatment dose of micafungin in the pre-intervention (1 October 2020 to 30 September 2021) or post-intervention (1 October 2021 to 30 April 2022) groups were included. Patients were placed on micafungin for prophylaxis and those who required definitive micafungin therapy were excluded. An algorithm was used to provide real-time recommendations in order to assess change in the treatment days of micafungin therapy. A total of 282 patients were included (141 pre-group versus 141 post-group). Over 80% of the patients included in the study were in an intensive care unit, and other baseline characteristics were similar. The median number of treatment days with micafungin was 4 [IQR 3-6] in the pre-group and 3 [IQR 2-6] in the post-group (p = 0.005). Other endpoints, such as time to discontinuation or de-escalation, hospital mortality, and hospital length of stay, were not significantly different between the groups. An antifungal stewardship initiative can be an effective way to decrease unnecessary empiric antifungal therapy for patients who are at risk of invasive fugal disease.

Retrospective Evaluation of Risk Factors for Invasive Candida Infections in a Medical Intensive Care Unit

Objective

We aimed to detect the risk factors for invasive candida infections by evaluating the fungal strains cultivated from samples taken in a medical intensive care unit (ICU).

Materials and Methods

We investigated fungal growths between January 1, 2016, and December 1, 2018, retrospectively. All reported fungal growths and demographic characteristics, clinical features, treatments and outcomes of the patients with fungal growths were recorded.

Results

Fungal growths were reported from 384 different samples obtained from 179 ICU patients. The most common strain was determined to be C. albicans (47.9%).The incidence of non-albicansCandida strains was increased over the years (2016 - 44%, 2017 - 52.5%, 2018 - 49%), most significantly C. glabrata (7.7% to 14.6%). The most common strain was C. parapsilosis (57.9%) in patients with candidemia, and infection was more severe among them. Fluconazole resistance was rare. When patients with and without fungal growth were compared, a significant difference was found between groups in terms of age, acute physiology and chronic health evaluation II (APACHE II) score, length of ICU and hospital stay, ICU and hospital mortality (p<0.001, p =0.011, p<0.001, p=0.031, p =0.016). Candida score was significantly higher in candidemic patients (3.0 vs 0.0 p<0.001).

Conclusion

Among fungal growths in samples from critically ill patients, the incidence of non-albicans Candida strains was gradually increasing. Older age, higher APACHE II score, and longer hospital and ICU stay were associated with fungal growths.

Surveillance of Antifungal Resistance in Candidemia Fails to Inform Antifungal Stewardship in European Countries

Background: The increasing burden of candidemia and the emergence of resistance, especially among non-Candida albicans strains, represent a new threat for public health. We aimed to assess the status of surveillance and to identify publicly accessible resistance data in Candida spp blood isolates from surveillance systems and epidemiological studies in 28 European and 4 European Free Trade Association member states. Methods: A systematic review of national and international surveillance networks, from 2015 to 2020, and peer-reviewed epidemiological surveillance studies, from 2005 to 2020, lasting for at least 12 consecutive months and with at least two centers involved, was completed to assess reporting of resistance to amphotericin B, azoles, and echinocandins in C. albicans, C. glabrata, C. parapsilosis, C. tropicalis, C. krusei, and C. auris. Results: Only 5 (Austria, Italy, Norway, Spain, and United Kingdom) of 32 countries provided resistance data for Candida spp blood isolates. Among 322 surveillance studies identified, 19 were included from Belgium, Denmark, Iceland, Italy, Portugal, Spain, Sweden, Switzerland, and United Kingdom. C. albicans and C. glabrata were the most monitored species, followed by C. parapsilosis and C. tropicalis. C. krusei was not included in any national surveillance system; 13 studies assessed resistance. No surveillance system or study reported resistance for C. auris. Fluconazole, voriconazole, caspofungin, and amphotericin B resistance in C. albicans, C. glabrata, and C. parapsilosis were the most common drug–species combination monitored. Quality of surveillance data was poor, with only two surveillance systems reporting microbiological methods and clinical data. High heterogeneity was observed in modalities of reporting, data collection, and definitions. Conclusion: Surveillance of antifungal resistance in Candida spp blood-isolates is fragmented and heterogeneous, delaying the application of a translational approach to the threat of antifungal resistance and the identification of proper targets for antifungal stewardship activities. International efforts are needed to implement antifungal resistance surveillance programs in order to adequately monitor antifungal resistance.

Epidemiology of candidemia in NICE area, France: A five-year study of antifungal susceptibility and mortality

OBJECTIVES

The aim of this study was to investigate the epidemiology of candidemia, the fungal susceptibility, the first-line therapy and the morality rate over 5 years. Knowing the differences of the yeasts in the candidemia local epidemiology, is essential to obtain information on fungal epidemiology to adapt antifungal strategies.

MATERIALS/METHODS

This retrospective study was conducted from January 2014 to December 2018. The susceptibility of the Candida strains were tested for amphotericin B, caspofungin, voriconazole and fluconazole.

RESULTS

The 304 strains were isolated from 290 patients (40 patients in 2014, 65 in 2015, 72 in 2016, 62 in 2017 and 51 in 2018). The three most common Candida spp isolated from blood cultures were Candida albicans (44%), Candida glabrata (22%) and Candida parapsilosis (13%). The proportion of non-albicans Candida decreased from 68% in 2014 to 45% in 2018. C. albicans and C. parapsilosis were to the four antifungals tested. As first-line therapy, 60% of patients received caspofungin and 26% fluconazole. There was no significant difference in the mortality between the two arms of patients (, 27% and 21%, p = 0.47 at 30 days respectively). Thirty day all-cause mortality was 31% and it decreased from 2014 (46%) to 2018 (18%).

CONCLUSIONS

We report that the absence of antifungal resistance of our C. albicans and C. parapsilosis candidemia suggests possible treatment after MALDI-TOF identification with fluconazole as first-line therapy in our hospital, as soon as possible and while continuing to perform the antifungal test.

Can We Improve Antifungal Susceptibility Testing?

Systemic antifungal agents are increasingly used for prevention or treatment of invasive fungal infections, whose prognosis remains poor. At the same time, emergence of resistant or even multi-resistant strains is of concern as the antifungal arsenal is limited. Antifungal susceptibility testing (AFST) is therefore of key importance for patient management and antifungal stewardship. Current AFST methods, including reference and commercial types, are based on growth inhibition in the presence of an antifungal, in liquid or solid media. They usually enable Minimal Inhibitory Concentrations (MIC) to be determined with direct clinical application. However, they are limited by a high turnaround time (TAT). Several innovative methods are currently under development to improve AFST. Techniques based on MALDI-TOF are promising with short TAT, but still need extensive clinical validation. Flow cytometry and computed imaging techniques detecting cellular responses to antifungal stress other than growth inhibition are also of interest. Finally, molecular detection of mutations associated with antifungal resistance is an intriguing alternative to standard AFST, already used in routine microbiology labs for detection of azole resistance in Aspergillus and even directly from samples. It is still restricted to known mutations. The development of Next Generation Sequencing (NGS) and whole-genome approaches may overcome this limitation in the near future. While promising approaches are under development, they are not perfect and the ideal AFST technique (user-friendly, reproducible, low-cost, fast and accurate) still needs to be set up routinely in clinical laboratories.

Preliminary Characterization of NP339, a Novel Polyarginine Peptide with Broad Antifungal Activity

Fungi cause disease in nearly one billion individuals worldwide. Only three classes of antifungal agents are currently available in mainstream clinical use. Emerging and drug-resistant fungi, toxicity, and drug-drug interactions compromise their efficacy and applicability. Consequently, new and improved antifungal therapies are urgently needed. In response to that need, we have developed NP339, a 2-kDa polyarginine peptide that is active against pathogenic fungi from the genera Candida, Aspergillus, and Cryptococcus, as well as others. NP339 was designed based on endogenous cationic human defense peptides, which are constituents of the cornerstone of immune defense against pathogenic microbes. NP339 specifically targets the fungal cell membrane through a charge-charge-initiated membrane interaction and therefore possesses a differentiated safety and toxicity profile to existing antifungal classes. NP339 is rapidly fungicidal and does not elicit resistance in target fungi upon extensive passaging in vitro. Preliminary analyses in murine models indicate scope for therapeutic application of NP339 against a range of systemic and mucocutaneous fungal infections. Collectively, these data indicate that NP339 can be developed into a highly differentiated, first-in-class antifungal candidate for poorly served invasive and other serious fungal diseases.

Core Recommendations for Antifungal Stewardship: A Statement of the Mycoses Study Group Education and Research Consortium

In recent years, the global public health community has increasingly recognized the importance of antimicrobial stewardship (AMS) in the fight to improve outcomes, decrease costs, and curb increases in antimicrobial resistance around the world. However, the subject of antifungal stewardship (AFS) has received less attention. While the principles of AMS guidelines likely apply to stewarding of antifungal agents, there are additional considerations unique to AFS and the complex field of fungal infections that require specific recommendations. In this article, we review the literature on AMS best practices and discuss AFS through the lens of the global core elements of AMS. We offer recommendations for best practices in AFS based on a synthesis of this evidence by an interdisciplinary expert panel of members of the Mycoses Study Group Education and Research Consortium. We also discuss research directions in this rapidly evolving field. AFS is an emerging and important component of AMS, yet requires special considerations in certain areas such as expertise, education, interventions to optimize utilization, therapeutic drug monitoring, and data analysis and reporting.

Impact of Loading Dose of Caspofungin in Pharmacokinetic-Pharmacodynamic Target Attainment for Severe Candidiasis Infections in Patients in Intensive Care Units: the CASPOLOAD Study

This study evaluated the impact of a high loading dose of caspofungin (CAS) on the pharmacokinetics of CAS and the pharmacokinetic-pharmacodynamic (PK-PD) target attainment in patients in intensive care units (ICU). ICU patients requiring CAS treatment were prospectively included to receive a 140-mg loading dose of CAS. Plasma CAS concentrations (0, 2, 3, 5, 7, and 24 h postinfusion) were determined to develop a two-compartmental population PK model. A Monte Carlo simulation was performed and the probabilities of target attainment (PTAs) were computed using previously published MICs. PK-PD targets were ratios of area under the concentration-time curve from 0 to 24 h (AUC_0-24h) divided by the MIC (AUC_0-24h/MIC) of 250, 450, and 865 and maximal concentration (C _max) divided by the MIC (C _max/MIC) of 5, 10, 15, and 20. Among 13 included patients, CAS clearance was 0.98 ± 0.13 liters/h and distribution volumes were V₁ = 9.0 ± 1.2 liters and V₂ = 11.9 ± 2.9 liters. Observed and simulated CAS AUC_0-24h were 79.1 (IQR 55.2; 108.4) and 81.3 (IQR 63.8; 102.3) mg · h/liter during the first 24 h of therapy, which is comparable to values usually observed in ICU patients at day 3 or later. PTAs were >90% for MICs of 0.19 and 0.5 mg/liter, considering AUC/MIC = 250 and C _max/MIC = 10 as PK-PD targets, respectively. Thus, a high loading dose of CAS (140 mg) increased CAS exposure in the first 24 h of therapy, allowing early achievement of PK-PD targets for most Candida strains. Such a strategy seems to improve treatment efficacy, though further studies are needed to assess the impact on clinical outcomes. (This study has been registered at ClinicalTrials.gov under identifier NCT02413892.).

Comparative in vitro activities of seven antifungal drugs against clinical isolates of Candida parapsilosis complex

OBJECTIVE

Candida parapsilosis species complex, an important set of non-albicans Candida species, is known to cause candidaemia particularly in neonates and infants. However, the incidence has increased in recent years, owing to higher numbers of at individuals at risk for these infections. Our objective was to evaluate the in vitro susceptibility of clinical isolates of C. parapsilosis complex isolates from Iran to seven antifungal drugs.

MATERIAL AND METHODS

One hundred-one clinical isolates of C. parapsilosis species complex cultured from humans were included. Species identification had been previously confirmed by combined phenotypic characteristics, matrix-assisted laser desorption ionization-time of flight mass spectrometry-based assay and reconfirmed by DNA sequence analysis of the ITS rDNA region and D1/D2 gene. Minimum inhibitory concentrations (MICs) for amphotericin B, fluconazole, itraconazole, voriconazole, posaconazole, micafungin and anidulafungin were determined against well-characterized isolates by broth microdilution susceptibility testing according to the CLSI M27-A3 guideline.

RESULTS

Species identifications were performed on 101 isolates, of which 88 (87.2%) C. parapsilosis sensu stricto and 13 (12.8%) C. orthopsilosis. Amphotericin B and posaconazole were the most active drugs with 100% of isolates being wild-type (WT). Voriconazole and micafungin, 99% of isolates were WT. The low activity was recorded for fluconazole and itraconazole with 93.1% and 89.1% of isolates being WT, respectively. At the species level, all Candida parapsilosis sensu stricto isolates were WT to amphotericin B and posaconazole and all Candida orthopsilosis isolates were WT to amphotericin B, voriconazole, posaconazole, anidulafungin and micafungin. In contrast, the highest rate of non-WT was observed in C. orthopsilosis to itraconazole (4 of 13, 30.8%).

CONCLUSIONS

Although almost all of the tested drugs demonstrated potent activity against C. parapsilosis species complex, it seems that more especially C. orthopsilosis isolates had decreased susceptibility to itraconazole. Further studies are needed to determine how these findings may switch into in vivo efficacy.

Novel 2-indolinones containing a sulfonamide moiety as selective inhibitors of candida β-carbonic anhydrase enzyme

Inhibition of the β-carbonic anhydrase (CA, EC 4.2.1.1) from pathogenic Candida glabrata (CgNce103) by 1H-indole-2,3-dione 3-[N-(4-sulfamoylphenyl)thiosemicarbazones] 4a–m was investigated. All the compounds were found to be potent inhibitors of CgNce103, with inhibition constants in the range of 6.4-63.9 nM. The 5,7-dichloro substituted derivative 4l showed the most effective inhibition (K_I of 6.4 nM) as well as the highest selectivity for inhibiting CgNce103 over the cytosolic human (h) isoforms hCA I and II. A possible binding interaction of compound 4l within the active site of CgNce103 has been proposed based on docking studies.

Antifungal susceptibility of yeast bloodstream isolates collected during a 10-year period in Austria

BACKGROUND

Candida-associated infections put a significant burden on western healthcare systems. Development of (multi-)resistant fungi can become untreatable and threaten especially vulnerable target groups, such as the immunocompromised.

OBJECTIVES

We assessed antifungal susceptibility and explored possible influence factors of clinical Candida isolates collected from Austrian hospitals between 2007 and 2016.

METHODS

Thousand three hundred and sixty clinical Candida spp. isolated from blood cultures were subjected to antifungal susceptibility testing (AFST) in a liquid-handling aided continuous microdilution assay. We tested against fluconazole, voriconazole, posaconazole, itraconazole, isavuconazole, anidulafungin, caspofungin and micafungin according to EUCAST with additional recording of growth curves. We performed rigid quality control on each assay via growth curve assessment and included two standard reference strains. Minimal inhibitory concentrations (MIC) were quantified according to EUCAST guideline E.DEF 7.3.1, and susceptibility was evaluated using EUCAST clinical breakpoints.

RESULTS

The isolate collection consisted of Candida albicans (59%), C. glabrata (19%), C. parapsilosis (9%), C. tropicalis (5%) and C. krusei (3%) and few other Candida species and fungi (5%). During the observed time period, species abundance and antifungal resistance rates remained constant. Multi-resistance was rare and we found no single isolate which was resistant to both azoles and echinocandins. Within the antifungal resistance profile of our strain collection, we observed clusters along species boundaries.

CONCLUSIONS

Over the last decade, the distribution of Candida species and its level of antifungal resistance remained constant in Austria. Our data compare well with other European countries. Principal component analysis of the susceptibility profile of this collection revealed species-specific clusters and substantial intra-species variation, especially for C. glabrata.

Correlation between antifungal consumption and the distribution of Candida species in different hospital departments of a Lebanese medical Centre

Background

In recent years, there has been a significant increase in the incidence of fungal infections attributed to Candida species worldwide, with a major shift toward non-albicans Candida (NAC). In this study, we have described the distribution of Candida species among different hospital departments and calculated the antifungal consumption in our facility. We also correlated the consumption of certain antifungals and the prevalence of specific Candida species.

Methods

This was a retrospective review of all the Candida isolates recovered from the computerised microbiology laboratory database of Makassed General Hospital, a tertiary care centre in Beirut, Lebanon, between January 2010 and December 2015. Data on antifungal consumption between January 2008 and December 2015 were extracted from the hospital pharmacy electronic database. We used Spearman’s coefficient to find a correlation between Candida species distribution and antifungal consumption.

Results

Between 2008 and 2015, we observed that the highest antifungal consumption was in the haematology/oncology department (days of therapy/1000 patient days = 348.12 ± 85.41), and the lowest was in the obstetrics/gynaecology department (1.36 ± 0.47). In general, the difference in antifungal consumption among various departments was statistically significant (P < 0.0001). Overall, azoles were the most common first-line antifungals in our hospital. Echinocandins and amphotericin B were mostly prescribed in the haematology/oncology department. As for Candida species distribution, a total of 1377 non-duplicate isolates were identified between 2010 and 2015. A non-homologous distribution of albicans vs. non-albicans was noted among the different departments (P = 0.02). The most commonly isolated NAC was Candida glabrata, representing 14% of total Candida species and 59% of NAC. Candida famata (9% of NAC), Candida parapsilosis (3.6% of NAC) and Candida krusei (3% of NAC) were recovered unequally from the different departments. The total antifungal consumption correlated positively with the emergence of NAC. The use of azoles correlated positively with Candida glabrata, while amphotericin B formulations correlated negatively with it. None of these correlations reached statistical significance.

Conclusion

Different Candida species were unequally distributed among different hospital departments, and this correlated with consumption of antifungals in respective departments, highlighting the need for antifungal stewardship.

Evaluation of Candida bloodstream infection and antifungal utilization in a tertiary care hospital

BACKGROUND

Candida bloodstream infections carry a significant mortality risk, justifying the importance of adequate antifungal therapy. This study describes trends in antifungal consumption using the Defined Daily Dose (DDD) and Days of Therapy (DOT) metrics, identifies the microbiological profile, the time to initiation of empirical therapy, the adjustment after positive blood culture results for Candida, and the impact on in-hospital mortality rate in patients with candidemia.

METHODS

An analysis of antifungal consumption from 2008 to 2016, and of candidemia cases from 2012 to 2016 was carried out in a private tertiary hospital.

RESULTS

A total of 11,273 admissions were identified with a prescription for at least one type of antifungal therapy. Fluconazole was the most prescribed antifungal drug in terms of general consumption. Through the DDD and DOT metrics, we observed that over time, there was an increase in the consumption of liposomal amphotericin B, micafungin and voriconazole. Candida albicans was the most isolated species in blood cultures. Regarding candidemia, we analyzed samples from 115 patients. Empirical therapy was started within 24 h of blood culture in 44.3% of the cases, and in 81.7% of the cases, the antifungal was deemed to be adequate based in antifungal susceptibility testing, both of which were not associated with the in-hospital mortality rate.

CONCLUSIONS

Our study reinforces the importance of monitoring the consumption of antifungal agents, which helps in proposing actions that lead to their rational use and, consequently, reduces the appearance of resistant strains.

Risk factors and outcomes of candidemia caused by Candida parapsilosis complex in a medical center in northern Taiwan

To investigate the risk factors and outcomes associated with Candida parapsilosis candidemia, a retrospective study was conducted at a tertiary medical center in northern Taiwan. Patients with C. parapsilosis candidemia and corresponding controls with C. albicans candidemia were chosen and their demographics, comorbidities, risk factors, and clinical outcomes were reviewed. Antifungal susceptibility tests were performed using the Sensititre YeastOne colorimetric system. Matrix-assisted laser desorption ionization-time of flight mass spectrometry was used to classify the genomic species. Of the 270 candidemias found in 253 patients, C. albicans was the most common Candida species isolated (43.0%), followed by C. parapsilosis (22.6%), C. tropicalis (17.4%), and C. glabrata (10.0%). The 30-day mortality of C. parapsilosis candidemia was significantly lower than that of C. albicans candidemia (21.7% vs. 53.9%, P<0.001). C. parapsilosis was positively associated with antifungal agent exposure [OR 7.261 (95% CI, 1.603-32.879), P=0.010], but negatively associated with Candida colonization [OR 0.303 (95% CI, 0.123-0.745), P=0.009], and immunosuppressant use [OR 0.264 (95% CI, 0.099-0.705), P=0.008]. In-hospital mortality was associated with the Sequential Organ Failure Assessment Score [OR 1.255 (95% CI, 1.002-1.573), P=0.048]. The clinical outcomes did not differ across genomic species and in the minimum inhibitory concentrations of fluconazole.

Synthesis, biological evaluation and quantitative structure-active relationships of 1,3-thiazolidin-4-one derivatives. A promising chemical scaffold endowed with high antifungal potency and low cytotoxicity

With reference to recent studies reporting on the various biological properties of the thiazolidinone scaffold, we synthesized more than a hundred compounds characterized by a 1,3-thiazolidin-4-one nucleus derivatised at the C2 with a hydrazine bridge linked to (cyclo)aliphatic or hetero(aryl) moieties, and their N-benzylated derivatives. These molecules were assayed as potential anti-Candida agents and they were shown to possess comparable, and in some cases higher biological activity than well-established topical and systemic antimycotic drugs (i.e. clotrimazole, fluconazole, ketoconazole, miconazole, tioconazole, amphotericin B). Compounds endowed with the lowest MICs underwent further testing in order to assess their cytotoxic effect (CC₅₀) on Hep2 cells, which demonstrated their relative safety. Finally, QSAR and 3-D QSAR models were used to predict putative chemical modifications of the 1,3-thiazolidin-4-one scaffold in order to design new and potential more active compounds against Candida spp.

Antifungal stewardship considerations for adults and pediatrics

Antifungal stewardship refers to coordinated interventions to monitor and direct the appropriate use of antifungal agents in order to achieve the best clinical outcomes and minimize selective pressure and adverse events. Antifungal utilization has steadily risen over time in concert with the increase in number of immunocompromised adults and children at risk for invasive fungal infections (IFI). Challenges in diagnosing IFI often lead to delays in treatment and poorer outcomes. There are also emerging data linking prior antifungal exposure and suboptimal dosing to the emergence of antifungal resistance, particularly for Candida. Antimicrobial stewardship programs can take a multi-pronged bundle approach to ensure suitable prescribing of antifungals via post-prescription review and feedback and/or prior authorization. Institutional guidelines can also be developed to guide diagnostic testing in at-risk populations; appropriate choice, dose, and duration of antifungal agent; therapeutic drug monitoring; and opportunities for de-escalation and intravenous-to-oral conversion.

Drivers and impact of antifungal therapy in critically ill patients with Aspergillus-positive respiratory tract cultures

Invasive pulmonary aspergillosis (IPA) is an increasingly recognised problem in critically ill patients. Little is known about how intensivists react to an Aspergillus-positive respiratory sample or the efficacy of antifungal therapy (AFT). This study aimed to identify drivers of AFT prescription and diagnostic workup in patients with Aspergillus isolation in respiratory specimens as well as the impact of AFT in these patients. ICU patients with an Aspergillus-positive respiratory sample from the database of a previous observational, multicentre study were analysed. Cases were classified as proven/putative IPA or Aspergillus colonisation. Demographic, microbiological, diagnostic and therapeutic data were collected. Outcome was recorded 12 weeks after Aspergillus isolation. Patients with putative/proven IPA were more likely to receive AFT than colonised patients (78.7% vs. 25.5%; P <0.001). Patients with host factors for invasive fungal disease were more likely to receive AFT (72.5% vs. 37.4%) as were those with multiorgan failure (SOFA score >7) (68.4% vs. 36.9%) (both P <0.001). Once adjusted for disease severity, initiation of AFT did not alter the odds of survival (HR = 1.40, 95% CI 0.89-2.21). Likewise, treatment within 48 h following diagnosis did not change the clinical outcome (75.7% vs. 61.4%; P = 0.63). Treatment decisions appear to be based on diagnostic criteria and underlying disease severity at the time of Aspergillus isolation. IPA in this population has a dire prognosis and AFT is not associated with reduced mortality. This may be explained by delayed diagnosis and an often inevitable death due to advanced multiorgan failure.

Oral candidiasis among African human immunodeficiency virus-infected individuals: 10 years of systematic review and meta-analysis from sub-Saharan Africa

Oral candidiasis (OC) is the most common opportunistic fungal infection among immunocompromised individuals. This systematic review and meta-analysis reports on the contribution of non-albicans Candida species in causing OC among human immunodeficiency virus (HIV)-infected individuals in sub-Saharan Africa between 2005 and 2015. Thirteen original research articles on oral Candida infection/colonization among HIV-infected African populations were reviewed. The prevalence of OC ranged from 7.6% to 75.3%. Pseudomembranous candidiasis was found to range from 12.1% to 66.7%. The prevalence of non-albicans Candida species causing OC was 33.5% [95% confidence interval (CI) 30.9–36.39%]. Of 458 non-albicans Candida species detected, C. glabrata (23.8%; 109/458) was the most common, followed by C. tropicalis (22%; 101/458) and C. krusei (10.7%; 49/458). The overall fluconazole resistance was 39.3% (95% CI 34.4–44.1%). Candida albicans was significantly more resistant than non-albicans Candida species to fluconazole (44.7% vs 21.9%; p < 0.001). One-quarter of the cases of OC among HIV-infected individuals in sub-Saharan Africa were due to non-albicans Candida species. Candida albicans isolates were more resistant than the non-albicans Candida species to fluconazole and voriconazole. Strengthening the capacity for fungal diagnosis and antifungal susceptibility testing in sub-Saharan Africa is mandatory in order to track the azole resistance trend.

Weekly high-dose liposomal amphotericin B (L-AmB) in critically ill septic patients with multiple Candida colonization: The AmBiDex study

Background

To demonstrate the feasibility and safety of weekly high-dose liposomal amphotericin B (L-AmB) (as a pre-emptive antifungal treatment) for 2 weeks in patients with septic shock and Candida colonization.

Methods

Pilot, multicentre, open-label, prospective study conducted in seven French ICUs. Non-immunocompromised patients, receiving mechanical ventilation were eligible if they presented ICU-acquired severe sepsis requiring newly administered antibacterial agents and Candida colonization in at least two sites. Exclusion criteria included the need for antifungal therapy and creatinine > 220 μmol/L. All patients were to receive a high-dose L-AmB (10 mg/kg/week) for two weeks. A follow-up period of 21 days following the second administration of L-AmB was conducted. Treated patients were compared to 69 matched untreated controls admitted in the same ICUs before the study period.

Results

Twenty-one patients were included in the study, of which 20 received at least one infusion of high-dose L-AmB. A total of 24 adverse events were identified in 13(61%) patients. Fourteen adverse events were categorized as serious in 8(38%) patients. In four cases the adverse events were considered as potentially related to study drug administration and resulted in L-AmB discontinuation in one patient. Few patients experienced severe renal toxicity since no patient presented with severe hypokalemia. No patients required renal replacement therapy. Compared to matched controls, no significant increase in serum creatinine levels in patients receiving high-dose L-AmB was reported.

Conclusions

Weekly administration of high-dose L-AmB has a manageable safety profile and is feasible in patients with ICU-acquired sepsis and multiple Candida colonization. Trials of L-AmB versus other antifungal agents used as pre-emptive antifungal therapy are warranted.

Trial registration

ClinicalTrials.gov NCT00697944

Distribution and antifungal susceptibility of yeasts isolates from intensive care unit patients

Yeasts frequently colonize non-sterile sites in the body. The aim of the study was to determine distribution in clinical samples and antifungal susceptibility to five antifungals. From January 2013 through June 2015, 800 isolates were obtained from intensive care unit patients. Candida albicans (58.9%), Candida glabrata (20.4%), Candida krusei (8.6%), and Candida parapsilosis (3.6%) were the leading species. Majority of the C. albicans isolates were susceptible to the fluconazole. Elevated voriconazole minimal inhibitory concentrations (MICs) were observed in isolates exhibiting high fluconazole MICs, most frequently in C. glabrata. Isolates with echinocandins MICs suggesting reduced susceptibility were only sporadic cases with the exception of Trichosporon spp. The amphotericin B MICs were slightly higher for some C. krusei.

ICU-acquired candidaemia in France: Epidemiology and temporal trends, 2004-2013 - A study from the REA-RAISIN network

OBJECTIVE

Candidaemia is a life-threatening infectious disease, associated with septic shock, multiple organ failure, and a high mortality rate. In France, reported data on the incidence of ICU-acquired candidaemia and the causative Candida species are scarce. The objective of this study was to determine temporal trends in epidemiology and risk factors of intensive care unit-acquired candidaemia (ICU-Cand) and ICU mortality among a very large population of ICU patients.

METHOD

Demographics, patient risk factors, invasive device exposure and nosocomial infection in ICU patient were collected from 2004 to 2013 in a national network of 213 ICUs: REA-RAISIN. Incidence and risk factors for candidaemia and ICU mortality were assessed.

RESULTS

Out of 246,459 ICU patients, 851 developed an ICU-cand, representing 0.3 per 1000 patients-days. The incidence rose sharply over time. Candida albicans was the main species. The overall and ICU mortality was 52.4% in ICU-cand patients. The main risk factors of ICU-cand were length of stay, severity of illness and antimicrobial therapy at ICU admission, immune status and use of invasive procedure. ICU-cand was an independent risk factor of mortality (OR: 1.53; 95%CI [1.40-1.70]); in a sub-group analysis, independent effects on mortality were observed with C. albicans (OR: 1.45 [1.23-1.71]), Candida tropicalis (OR: 2.11 [1.31-3.39]) and "other" Candida species (OR: 1.64 [1.09-2.45]).

CONCLUSION

ICU candidaemia ranked sixth among bloodstream infections, and its average annual incidence was 0.3 per 1000 patients days. Despite of new therapy and international recommendation, the incidence rose sharply during the study period, and ICU mortality remained high.

Impact of echinocandin on prognosis of proven invasive candidiasis in ICU: A post-hoc causal inference model using the AmarCAND2 study

OBJECTIVE

guidelines recommend first-line systemic antifungal therapy (SAT) with echinocandins in invasive candidiasis (IC), especially in critically ill patients. This study aimed at assessing the impact of echinocandins compared to azoles as initial SAT on the 28-day prognosis in adult ICU patients.

METHODS

From the prospective multicenter AmarCAND2 cohort (835 patients), we selected those with documented IC and treated with echinocandins (ECH) or azoles (AZO). The average causal effect of echinocandins on 28-day mortality was assessed using an inverse probability of treatment weight (IPTW) estimator.

RESULTS

397 patients were selected, treated with echinocandins (242 patients, 61%) or azoles (155 patients, 39%); septic shock: 179 patients (45%). The median SAPSII was higher in the ECH group (48 [35; 62] vs. 43 [31; 58], p = 0.01). Crude mortality was 34% (ECH group) vs. 25% (AZO group). After adjustment on baseline confounders, no significant association emerged between initial SAT with echinocandins and 28-day mortality (HR: 0.95; 95% CI: [0.60; 1.49]; p = 0.82). However, echinocandin tended to benefit patients with septic shock (HR: 0.46 [0.19; 1.07]; p = 0.07).

CONCLUSION

Patients who received echinocandins were more severely ill. Echinocandin use was associated with a non-significant 7% decrease of 28-day mortality and a trend to a beneficial effect for patient with septic shock.

Novel 1,3-thiazolidin-4-one derivatives as promising anti-Candida agents endowed with anti-oxidant and chelating properties

Pursuing our recent outcomes regarding the antifungal activity of N-substituted 1,3-thiazolidin-4-ones, we synthesized thirty-six new derivatives introducing aliphatic, cycloaliphatic and heteroaromatic moieties at N1-hydrazine connected with C2 position of the thiazolidinone nucleus and functionalizing the lactam nitrogen with differently substituted (NO2, NH2, Cl and F) benzyl groups. These compounds were tested to evaluate their minimum inhibitory concentration (MIC) against several clinical Candida spp. with respect to topical and systemic reference drugs (clotrimazole, fluconazole, ketoconazole, miconazole, tioconazole, amphotericin B). Moreover, anti-oxidant properties were also evaluated by using different protocols including free radical scavenging (DPPH and ABTS), reducing power (CUPRAC and FRAP), metal chelating and phosphomolybdenum assays. Moreover, for the most active derivatives we assessed the toxicity (CC50) against Hep2 human cells in order to characterize them as multi-target agents for fungal infections.

Effects of fluconazole on the metabolomic profile of Candida albicans

BACKGROUND

Little is known about the effects of fluconazole on the metabolism of Candida albicans. We performed LC/MS-based metabolomic profiling of the response of C. albicans cells to increasing doses of fluconazole.

METHODS

C. albicans cells were cultured to mid-logarithmic growth phase in liquid medium and then inoculated in replicate on to nitrocellulose filters under vacuum filtration. Organisms were cultured to mid-logarithmic growth phase and treated with 0-4 mg/L fluconazole. Following metabolic quenching at mid-logarithmic growth phase, intracellular metabolites were extracted and analysed by LC/MS. Changes in pool sizes of individual metabolites were verified by Student's t-test, adjusted for multiple hypothesis testing by Benjamini-Hochberg correction. Distribution of metabolites was analysed by the Kyoto Encyclopedia of Genes and Genomes metabolic pathways database.

RESULTS

We reproducibly detected 64 metabolites whose identities were confirmed by comparison against a pure standard and a library of accurate mass-retention time pairs. These 64 metabolites were broadly representative of eukaryotic central metabolic pathways. Among them 12 had their mean abundance significantly altered in response to increasing fluconazole concentrations. Pool sizes of four intermediates of central carbon metabolism (α-ketoglutarate, glucose-6-phosphate, phenylpyruvate and ribose-5-phosphate) and mevalonate were increased by 0.5-1.5-fold (P ≤ 0.05). Five amino acids (glycine, proline, tryptophan, aminoisobutanoate and asparagine) and guanine were decreased by 0.5-0.75-fold (P ≤ 0.05).

CONCLUSIONS

Fluconazole treatment of C. albicans resulted in increased central carbon and decreased amino acid synthesis intermediates, suggesting a rerouting of metabolic pathways. The function of these metabolomic changes remains to be elucidated; however, they may represent previously unrecognized mechanisms of metabolic injury induced by fluconazole against C. albicans.

How could we reduce antifungal use in the intensive care unit?

Fungal infection is common in critically ill patients. However, this infection is difficult to diagnose, and a large proportion of patients receive empirical antifungal treatment without further confirmation of invasive fungal disease. Whilst prompt appropriate antifungal treatment is associated with better outcome in patients with confirmed infections, this treatment has several drawbacks. In addition, no clear beneficial effect of empirical antifungal treatment was found in patients without confirmed infection. Reducing antifungal treatment in the intensive care unit (ICU) is feasible, and would allow avoiding drawbacks of this treatment without negative impact on outcome. Antifungal stewardship, preemptive antifungal treatment, based on colonization index and fungal biomarkers; and de-escalation of antifungal treatment based on microbiology results and fungal biomarkers could be suggested to reduce antifungal use in the ICU, and are currently under investigation.

Anti-Candida activity and cytotoxicity of a large library of new N-substituted-1,3-thiazolidin-4-one derivatives

On the basis of the recent findings about the biological properties of thiazolidinones and taking into account the encouraging results about the antifungal activity of some (thiazol-2-yl)hydrazines, new N-substituted heterocyclic derivatives were designed combining the thiazolidinone nucleus with the hydrazonic portion. In details, 1,3-thiazolidin-4-ones bearing (cyclo)aliphatic or (hetero)aromatic moieties linked to the N1-hydrazine at C2 were synthesized and classified into three series according to the aromatic or bicyclic rings connected to the lactam nitrogen of the thiazolidinone. These molecules were assayed for their anti-Candida effects in reference to the biological activity of the conventional topic (clotrimazole, miconazole, tioconazole) and systemic drugs (fluconazole, ketoconazole, amphotericin B). Finally, we investigated the selectivity against fungal cells by testing the compounds endowed with the best MICs on Hep2 cells in order to assess their cell toxicity (CC50) and we noticed that two derivatives were less cytotoxic than the reference drug clotrimazole. Moreover, a preliminary molecular modelling approach has been performed against lanosterol 14-α demethylase (CYP51A1) to rationalize the activity of the tested compounds and to specify the target protein or enzyme.

Impact of antifungal prescription on relative distribution and susceptibility of Candida spp. - Trends over 10 years

INTRODUCTION

The incidence of Candida spp. infections is worrisome, particularly in critically ill patients. Previous reports suggested that increasing use of antifungal therapy might affect resistance profiles of invasive strains. The study objective was to describe the distribution resistance profile of Candida spp. strains, and to correlate it with antifungal consumptions within one ICU.

METHOD

Antifungal drug consumption was measured as the number of defined daily doses per 1000 hospital days. The distribution of Candida spp. over a 10 year period 2004-2013 and the MICs of antifungal drugs over 2007-2013 were determined. Time series analyses were performed.

RESULTS

Of 2403 identified Candida spp. from 5360 patients, Candida albicans predominated (53.1%), followed by Candida glabrata (16.2%), Candida parapsilosis (7.9%) and Candida tropicalis (7.5%). C. parapsilosis increased from 5.7% in 2004 to 8.4% in 2013 (P = 0.02). The increase in caspofungin use is correlated with the increase in caspofungin MICs of C. parapsilosis (P = 0.01), C. glabrata (P = 0.001) and C. albicans (P = 0.02). Polyenes consumption correlated with an increase in amphotericin B MICs of C. glabrata (P = 0.04).

CONCLUSION

Previous history of antifungal prescription within an ICU influences Candida species distribution and susceptibility profile to antifungal agents. The significant selective pressure exerted by caspofungin and amphotericin B on C. glabrata is a concern.

Consumption of systemic antifungal agents among acute care hospitals in Catalonia (Spain), 2008-2013

Objective To know the patterns and consumption trends (2008-2013) of antifungal agents for systemic use in 52 acute care hospitals affiliated to VINCat Program in Catalonia (Spain). Methods Consumption was calculated in defined daily doses (DDD)/100 patient-days and analyzed according to hospital size and complexity and clinical departments. Results Antifungal consumption was higher in intensive care units (ICU) (14.79) than in medical (3.08) and surgical departments (1.19). Fluconazole was the most consumed agent in all type of hospitals and departments. Overall antifungal consumption increased by 20.5%during the study period (p = 0.066); a significant upward trend was observed in the consumption of both azoles and echinocandins. In ICUs, antifungal consumption increased by 12.4% (p = 0.019). Conclusions The study showed a sustained increase in the overall consumption of systemic antifungals in a large number of acute care hospitals of different characteristics in Catalonia. In ICUs there was a trend towards the substitution of older agents by the new ones.

Nosocomial Candidiasis: Antifungal Stewardship and the Importance of Rapid Diagnosis

Candidemia and other forms of candidiasis are associated with considerable excess mortality and costs. Despite the addition of several new antifungal agents with improved spectrum and potency, the frequency of Candida infection and associated mortality have not decreased in the past two decades. The lack of rapid and sensitive diagnostic tests has led to considerable overuse of antifungal agents resulting in increased costs, selection pressure for resistance, unnecessary drug toxicity, and adverse drug interactions. Both the lack of timely diagnostic tests and emergence of antifungal resistance pose considerable problems for antifungal stewardship. Whereas antifungal stewardship with a focus on nosocomial candidiasis should be able to improve the administration of antifungal therapy in terms of drug selection, proper dose and duration, source control and de-escalation therapy, an important parameter, timeliness of antifungal therapy, remains a victim of slow and insensitive diagnostic tests. Fortunately, new proteomic and molecular diagnostic tools are improving the time to species identification and detection. In this review we will describe the potential impact that rapid diagnostic testing and antifungal stewardship can have on the management of nosocomial candidiasis.

Failure of empirical systemic antifungal therapy in mechanically ventilated critically ill patients

RATIONALE

Systemic antifungal treatments are empirically administered to the sickest critically ill patients, often without documented invasive fungal infection.

OBJECTIVES

To estimate the impact of systemic antifungal treatment on 30-day survival of patients suspected to have invasive candidiasis.

METHODS

All nonneutropenic, nontransplant recipients managed in five intensive care units intubated for at least 5 days, and free of invasive candidiasis, were included. To account for differences in patients' characteristics recorded daily before study end point, a causal model for longitudinal data was used to assess benefits from antifungal treatment. The composite primary end point was hospital mortality or occurrence of invasive candidiasis.

MEASUREMENTS AND MAIN RESULTS

Among 1,491 patients, 100 (6.7%) received antifungal treatment for a suspected infection. Patients treated with antifungals were more severely ill than untreated patients. Within the 30-day follow-up period, 363 (24.3%) patients died, and 22 (1.5%) exhibited documented invasive candidiasis. After adjustment on baseline and time-dependent confounders (underlying illness, severity, invasive procedures, Candida colonization), and using a marginal structural model for longitudinal data, treatment was not associated with a decreased risk of mortality or of occurrence of invasive candidiasis (hazard ratio, 1.05; 95% confidence interval, 0.56-1.96; P = 0.91).

CONCLUSIONS

This study failed to show outcome benefits for empirical systemic antifungal therapy in the sickest critically ill, nonneutropenic, nontransplanted patients. The post hoc power did not allow us to conclude to an absence of treatment effect especially for specific subgroups. Studies to refine indications for empirical treatment based on surrogate markers of invasive candidiasis are warranted.

IgG1 anti-cell wall and IgG2 anti-phosphopeptidomannan antibodies in the diagnosis of invasive candidiasis and heavy Candida colonization

We conducted a retrospective study to evaluate the usefulness of immunoglobulin G (IgG) subclasses against Candida cell wall fragments (CW) and phosphopeptidomannan (PPM) for the diagnosis of invasive candidiasis (IC). We analyzed 54 patients with IC (n = 19), Candida heavy colonization (HC; n = 16), and controls (no IC or HC, n = 19).In nonneutropenic patients (n = 47), the sensitivity and specificity values of IgG1 anti-CW and IgG2 anti-PPM in IC were 88%, 59%, and 88%, 94%, respectively. The areas under the receiver operating characteristic curves were 0.69 (0.51-0.88) and 0.901 (0.78-1.02), respectively. IgG1 mean values (arbitrary units) and 95% confidence interval were 46 (20-71), 42 (-0.38 to 84) and 20 (8.3-32) in IC, HC, and in controls, respectively, and discriminated IC but not HC from controls (P = .032, and P = .77, respectively). IgG2 mean values were 26 (9.2-42), 19 (4.4-33), and 3.2 (0.28-6.6) in IC, HC, and in controls, respectively, and discriminated both IC and HC from controls (P < .0001 and P = .035, respectively) but did not separate IC from HC (P = .2). IgG2 showed positivity as early as one day after the IC diagnosis. Antibodies were detected in only two out of a total of seven neutropenic patients.For both IC and HC patients, the diagnostic performance of IgG2 anti-PPM was better than the one of IgG1 anti-CW. In nonneutropenic patients, IgG2 anti-PPM accurately identified not only IC patients but also HC patients at high risk for IC. This marker may help clinicians in the initiation of early preemptive therapy.

Temporal Trends in Blood Stream Infection Isolates from Surgical Patients

BACKGROUND

Blood stream infections (BSIs) are a common source of morbidity and death in hospitalized patients. We hypothesized that the proportions of bacteremia from gram-positive and fungal pathogens have decreased over time, whereas rates of gram-negative bacteremia have increased as a result of better central venous catheter management.

METHODS

All U.S. Centers for Disease Control and Prevention-defined BSIs in patients treated on the general surgery and trauma services at our institution between January 1, 1998, and December 31, 2009 were identified prospectively. These cases were analyzed on a yearly basis to compare rates of various infections over time. The Cochran-Armitage test for trend was used to evaluate categorical data, whereas the Jonckheere-Terpstra test for ordered values was used to analyze continuous data.

RESULTS

A total of 1,040 patients had 1,441 episodes of BSI caused by 1,632 strains of bacteria or fungi. There was no difference over time in the proportion of BSI among overall infections. Rates of BSI for gram-negative and fungal pathogens increased over time (p=0.03 and<0.0001, respectively), whereas rates of gram-positive BSI decreased (p<0.0001). Positive changes in anaerobic BSI approached statistical significance.

CONCLUSION

Although our hypothesis was only partly true, over the last 12 y, our institution clearly has witnessed a shift in the types of organisms causing BSIs. There was a decrease in the rates of BSI caused by gram-positive pathogens with an associated increase in the rates of BSI of infections by fungal and gram-negative pathogens. Interventions to reduce institutional rates of BSI should include targeted therapies based on historical institutional trends.

Outcomes associated with routine systemic antifungal therapy in critically ill patients with Candida colonization

PURPOSE

To assess the evolution of patient deep colonization by Candida spp. in a surgical ICU over an 8-year period.

METHODS

This retrospective, observational study included all patients hospitalized for more than 2 days in a surgical and trauma ICU of a university hospital, from 2005 to 2012. Mycological samples were monitored weekly from five sites (oropharyngeal, rectal, gastric, tracheal and urinary). Preemptive fluconazole therapy was started in patients highly colonized with Candida albicans. The evolution in Candida spp. involved in the deep colonization sites distribution over the study period (main outcome measure, trend chi-square and time-series analysis), antifungal consumption, ICU-acquired candidemia and mortality were determined.

RESULTS

Among the 3029 patients with ICU stay >48 h, 2651 had at least one set of mycological sampling. Thirty percent of the 31,171 samples were positive to Candida spp. Caspofungin consumption increased over the years, whereas fluconazole consumption decreased. No trend in C. albicans colonization was observed, after adjusting on colonization risk-factors. A significant increase of acquired C. glabrata colonization was observed, whereas the clearing of C. parapsilosis colonization significantly decreased. No significant shift of colonization to other Candida spp. and mortality was observed.

CONCLUSIONS

Preemptive strategy of antifungal drug prescriptions in highly colonized ICU patients induced an increase in C. glabrata colonization without significant shift of colonization to other Candida spp. in surgical ICU patients. However, the potential detrimental impact of fluconazole on Candida ecology in ICU and/or on Candida susceptibility to antifungal drugs should be considered, and deserves further studies.

Management of invasive candidiasis in nonneutropenic ICU patients

Invasive candidiasis (IC) is a leading cause of morbidity and mortality among nonneutropenic ICU patients and these life-threatening nosocomial infections require early diagnosis and prompt treatment. However, none of the predictive tools are sufficiently accurate to identify high-risk patients and the potential interest of IC prophylactic, empirical and preemptive treatment in the nonneutropenic ICU population has not yet been demonstrated. In the case of nosocomial severe sepsis after necrotizing pancreatitis or upper digestive anastomotic leakage, early probabilistic antifungals are probably indicated. In the remaining ICU surgical and medical patients, prophylactic and empirical strategies are highly debated because they may promote antifungal selective pressure through an overuse of these molecules. In this context, non-culture-based methods such as mannan or β-D glucan or polymerase chain reaction tests are promising. However, none of these tests used alone in ICU patients is sufficiently accurate to avoid overuse of empirical/preemptive treatment. The interest of strategies associating predictive clinical scores and non-culture-based methods still needs to be demonstrated by well-conducted randomized, controlled trials. While awaiting these studies, we consider that probabilist treatment should be stopped earlier if IC is not proven.

Hospital use of systemic antifungal drugs: a multi-center surveillance update from Germany

BACKGROUND

The consumption of antifungal agents increased over the last decade, resulting in the development of resistant organisms and causing a significant pharmaco economic burden. Antifungal drugs are widely used for the treatment of systemic fungal infections and high-risk patients, especially with severe hematological or oncological conditions. Up to date, there are no reliable and systematically reported data on the consumption of antifungal substances on a nationwide level available. The presented study gives an update to the previously published multicenter study investigating antifungal consumption in different settings from five university hospital centers in Germany from 2001 to 2003.

METHODS

Consumption data for systemic antifungal drugs were obtained through the hospital pharmacies for 2001-2003 and 2008-2011 regarding the medical and surgical services of five university hospital centers in Germany (A-E). Drug use densities were calculated as yearly RDDs/100 patient days. These calculations were performed for the surgical and medical services, and independently for surgical and medical ICUs, as well as for the hematology-oncology services.

RESULTS

We report an increased utilization of systemic antifungal drugs in both study periods. The mean drug use density (mean value of all 5 hospitals) in the medical services increased by 24% between 2001 and 2003. In 2011, this value was 37% above the level from 2001 (12.4 RDD/100 patient days in 2001, 15.4 RDD/100 patient days in 2003, 17.0 RDD/100 patient days in 2011). The 4-year average drug use density (2008-2011) of medical services ranged between 11.6 RDD/100 patient days (hospital E) and 23.8 RDD/100 patient days (hospital A). Drug use densities were in medical intensive care units 29.4 RDD/100 patient days and hematology-oncology services 49.9 RDD/100 patient days.

CONCLUSIONS

Despite the variability of the prescribing patterns between the tertiary hospitals, the presented pharmaco-epidemiological data are a cornerstone for the initiation and implementation of effective antifungal stewardship programmes and might serve as important benchmarking information for other hospitals with similar structures and baseline settings.

Empiric/pre-emptive anti-Candida therapy in non-neutropenic ICU patients

The potential of the systemic antifungal treatment of non-immunocompromised patients with sepsis, extra-digestive Candida colonization and multiple organ failure is unknown, although it represents three out of four antifungal treatments prescribed in intensive care units. It may allow an early treatment of invasive fungal infection at incubation phase, but exposes patients to unnecessary antifungal treatments with subsequent costs and antifungal selection pressure. As early diagnostic tests for invasive candidiasis are still considered insufficient, the potential of this strategy needs to be demonstrated by a randomized controlled trial. Such a trial is currently ongoing.

Incidence, characteristics and outcome of ICU-acquired candidemia in India

PURPOSE

A systematic epidemiological study on intensive care unit (ICU)-acquired candidemia across India.

METHOD

A prospective, nationwide, multicentric, observational study was conducted at 27 Indian ICUs. Consecutive patients who acquired candidemia after ICU admission were enrolled during April 2011 through September 2012. Clinical and laboratory variables of these patients were recorded. The present study is an analysis of data specific for adult patients.

RESULTS

Among 1,400 ICU-acquired candidemia cases (overall incidence of 6.51 cases/1,000 ICU admission), 65.2 % were adult. Though the study confirmed the already known risk factors for candidemia, the acquisition occurred early after admission to ICU (median 8 days; interquartile range 4-15 days), even infecting patients with lower APACHE II score at admission (median 17.0; mean ± SD 17.2 ± 5.9; interquartile range 14-20). The important finding of the study was the vast spectrum of agents (31 Candida species) causing candidemia and a high rate of isolation of Candida tropicalis (41.6 %). Azole and multidrug resistance were seen in 11.8 and 1.9 % of isolates. Public sector hospitals reported a significantly higher presence of the relatively resistant C. auris (8.2 vs. 3.9 %; p = 0.008) and C. rugosa (5.6 vs. 1.5 %; p = 0.001). The 30-day crude and attributable mortality rates of candidemia patients were 44.7 and 19.6 %, respectively. Logistic regression analysis revealed significant independent predictors of mortality including admission to public sector hospital, APACHE II score at admission, underlying renal failure, central venous catheterization and steroid therapy.

CONCLUSION

The study highlighted a high burden of candidemia in Indian ICUs, early onset after ICU admission, higher risk despite less severe physiology score at admission and a vast spectrum of agents causing the disease with predominance of C. tropicalis.

Worrisome trends in incidence and mortality of candidemia in intensive care units (Paris area, 2002-2010)

Purpose

To analyze trends in incidence and mortality of candidemia in intensive care units (ICUs) vs. non-ICU hospitalized patients and to determine risk factors for infection by specific species and for death.

Methods

Active hospital-based surveillance program of incident episodes of candidemia due to common species in 24 tertiary care hospitals in the Paris area, France between October 2002 and September 2010.

Results

Among 2,507 adult cases included, 2,571 Candida isolates were collected and species were C. albicans (56 %), C. glabrata (18.6 %), C. parapsilosis (11.5 %), C. tropicalis (9.3 %), C. krusei (2.9 %), and C. kefyr (1.8 %). Candidemia occurred in ICU in 1,206 patients (48.1 %). When comparing ICU vs. non-ICU patients, the former had significantly more frequent surgery during the past 30 days, were more often preexposed to fluconazole and treated with echinocandin, and were less frequently infected with C. parapsilosis. Risk factors and age remained unchanged during the study period. A significant increased incidence in the overall population and ICU was found. The odds of being infected with a given species in ICU was influenced by risk factors and preexposure to fluconazole and caspofungin. Echinocandins initial therapy increased over time in ICU (4.6 % first year of study, to 48.5 % last year of study, p < 0.0001). ICU patients had a higher day-30 death rate than non-ICU patients (odds ratio [OR] 2.12; 95 % confidence interval [CI] 1.66–2.72; p < 0.0001). The day-30 and early (<day 8) death rates increased over time in ICU (from 41.5 % the first to 56.9 % the last year of study (p = 0.001) and 28.7–38.8 % (p = 0.0292), respectively). Independent risk factors for day-30 death in ICU were age, arterial catheter, Candida species, preexposure to caspofungin, and lack of antifungal therapy at the time of blood cultures results (p < 0.05).

Conclusions

The availability of new antifungals and the publication of numerous guidelines did not prevent an increase of candidemia and death in ICU patients in the Paris area.

Resistance of Candida spp. to antifungal drugs in the ICU: where are we now?

Current increases in antifungal drug resistance in Candida spp. and clinical treatment failures are of concern, as invasive candidiasis is a significant cause of mortality in intensive care units (ICUs). This trend reflects the large and expanding use of newer broad-spectrum antifungal agents, such as triazoles and echinocandins. In this review, we firstly present an overview of the mechanisms of action of the drugs and of resistance in pathogenic yeasts, subsequently focusing on recent changes in the epidemiology of antifungal resistance in ICU. Then, we emphasize the clinical impacts of these current trends. The emergence of clinical treatment failures due to resistant isolates is described. We also consider the clinical usefulness of recent advances in the interpretation of antifungal susceptibility testing and in molecular detection of the mutations underlying acquired resistance. We pay particular attention to practical issues relating to ICU patient management, taking into account the growing threat of antifungal drug resistance.