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Correia JL, Fiuza JG, Ferreira G, Almeida MD, Moreira D, Neto VD. Embolic stroke and misidentification candida species endocarditis: Case presentation and literature review. Diagn Microbiol Infect Dis 2024; 108:116133. [PMID: 37984110 DOI: 10.1016/j.diagmicrobio.2023.116133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/09/2023] [Accepted: 11/11/2023] [Indexed: 11/22/2023]
Abstract
Fungal endocarditis is a rare but serious form of infective endocarditis associated with high morbidity and mortality. Among fungal pathogens, Candida species are the most frequently isolated and commonly found in individuals with predisposing factors, such as prosthetic heart valves. The clinical presentation of endocarditis is highly variable and nonspecific, often including symptoms and signs of embolization. In this paper, we present a case of fungal prosthetic valve endocarditis in which the initial presentation was an acute ischemic stroke. The initial misidentification of Candida famata was attributed to limitations in the presumptive methodology used through selective chromogenic culture identification. However, the surgical specimen underwent mass spectrometry, leading to the correct identification of Candida guilliermondii instead of Candida famata. Furthermore, we conducted a non-systematic narrative review of the literature on Candida endocarditis. Our findings underscore the importance of considering fungal endocarditis in the differential diagnosis of patients with possible extracardiac complications, particularly those with a history of heart valve replacement. Early diagnosis and a comprehensive treatment strategy tailored by species identification and antifungal susceptibility testing are crucial in improving patient outcomes.
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Affiliation(s)
| | | | | | | | | | - Vanda Devesa Neto
- Tondela-Viseu Hospital Center, Viseu, Portugal; Faculty of Health Sciences - University of Beira Interior, Covilhã, Portugal
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2
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Fuller R, Jacobs SE. Candida Infectious Endocarditis and Implantable Cardiac Device Infections. Mycopathologia 2023; 188:893-905. [PMID: 37277679 DOI: 10.1007/s11046-023-00745-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/09/2023] [Indexed: 06/07/2023]
Abstract
Intravascular diseases due to Candida species, including endocarditis and cardiac device-associated infections, are rare yet devastating manifestations of invasive candidiasis affecting an already vulnerable population. Despite their significant associated morbidity and mortality, limited prospective data exist to inform the optimal diagnostic and therapeutic approaches to these entities. Herein, we review the existing literature pertaining to the epidemiology, diagnosis, and management of infectious endocarditis, rhythm management device infections, and circulatory support device infections caused by Candida species and suggest areas for future research.
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Affiliation(s)
- Risa Fuller
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Samantha E Jacobs
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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3
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Nedel W, Boniatti MM, Lisboa T. Endocarditis in critically ill patients: a review. Curr Opin Crit Care 2023; 29:430-437. [PMID: 37646776 DOI: 10.1097/mcc.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
PURPOSE OF REVIEW To summarize the advances in literature that support the best current practices regarding infective endocarditis (IE) in critically ill patients. RECENT FINDINGS IE due to rheumatic diseases has decreased significantly, and in fact, the majority of cases are associated with degenerative valvopathies, prosthetic valves, and cardiovascular implantable electronic devices. The Duke criteria were recently updated, addressing the increasing incidence of new risk factors for IE, such as IE associated with the use of endovascular cardiac implantable electronic devices and transcatheter implant valves. The presence of organ dysfunction, renal replacement therapies, or extracorporeal membrane oxygenation should be considered in the choice of drug and dosage in critically ill patients with suspected or confirmed IE. As highlighted for other severe infections, monitoring of therapeutic antibiotic levels is a promising technique to improve outcomes in critically ill patients with organ dysfunction. SUMMARY The diagnostic investigation of IE must consider the current epidemiological criteria and the diagnostic particularities that these circumstances require. A careful evaluation of these issues is necessary for the prompt clinical or surgical management of this infection.
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Affiliation(s)
- Wagner Nedel
- Hospital de Clinicas de Porto Alegre
- Hospital Nossa Senhora Conceição
| | - Marcio Manozzo Boniatti
- Hospital de Clinicas de Porto Alegre
- Programa de Pos-Graduação Cardiologia, UFRGS
- Universidade LaSalle, Canoas
| | - Thiago Lisboa
- Hospital de Clinicas de Porto Alegre
- Universidade LaSalle, Canoas
- Programa de Pos-Graduação Ciencias Pneumológicas, UFRGS, Porto Alegre
- Hospital Santa Rita, Complexo Hospitalar Santa Casa de Porto Alegre, Brazil
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Thompson GR, Jenks JD, Baddley JW, Lewis JS, Egger M, Schwartz IS, Boyer J, Patterson TF, Chen SCA, Pappas PG, Hoenigl M. Fungal Endocarditis: Pathophysiology, Epidemiology, Clinical Presentation, Diagnosis, and Management. Clin Microbiol Rev 2023; 36:e0001923. [PMID: 37439685 PMCID: PMC10512793 DOI: 10.1128/cmr.00019-23] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
Fungal endocarditis accounts for 1% to 3% of all infective endocarditis cases, is associated with high morbidity and mortality (>70%), and presents numerous challenges during clinical care. Candida spp. are the most common causes of fungal endocarditis, implicated in over 50% of cases, followed by Aspergillus and Histoplasma spp. Important risk factors for fungal endocarditis include prosthetic valves, prior heart surgery, and injection drug use. The signs and symptoms of fungal endocarditis are nonspecific, and a high degree of clinical suspicion coupled with the judicious use of diagnostic tests is required for diagnosis. In addition to microbiological diagnostics (e.g., blood culture for Candida spp. or galactomannan testing and PCR for Aspergillus spp.), echocardiography remains critical for evaluation of potential infective endocarditis, although radionuclide imaging modalities such as 18F-fluorodeoxyglucose positron emission tomography/computed tomography are increasingly being used. A multimodal treatment approach is necessary: surgery is usually required and should be accompanied by long-term systemic antifungal therapy, such as echinocandin therapy for Candida endocarditis or voriconazole therapy for Aspergillus endocarditis.
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Affiliation(s)
- George R. Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California-Davis Medical Center, Sacramento, California, USA
- Department of Medical Microbiology and Immunology, University of California-Davis, Davis, California, USA
| | - Jeffrey D. Jenks
- Durham County Department of Public Health, Durham, North Carolina, USA
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - John W. Baddley
- Department of Medicine, Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - James S. Lewis
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Matthias Egger
- Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Department of Medicine, Medical University of Graz, Graz, Austria
| | - Ilan S. Schwartz
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Johannes Boyer
- Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Department of Medicine, Medical University of Graz, Graz, Austria
| | - Thomas F. Patterson
- Department of Medicine, Division of Infectious Diseases, The University of Texas Health Science Center, San Antonio, Texas, USA
| | - Sharon C.-A. Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Sydney, New South Wales, Australia
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter G. Pappas
- Department of Medicine Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Martin Hoenigl
- Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Department of Medicine, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
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Barros N, Rosenblatt RE, Phipps MM, Fomin V, Mansour MK. Invasive fungal infections in liver diseases. Hepatol Commun 2023; 7:e0216. [PMID: 37639701 PMCID: PMC10462082 DOI: 10.1097/hc9.0000000000000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/07/2023] [Indexed: 08/31/2023] Open
Abstract
Patients with liver diseases, including decompensated cirrhosis, alcohol-associated hepatitis, and liver transplant recipients are at increased risk of acquiring invasive fungal infections (IFIs). These infections carry high morbidity and mortality. Multiple factors, including host immune dysfunction, barrier failures, malnutrition, and microbiome alterations, increase the risk of developing IFI. Candida remains the most common fungal pathogen causing IFI. However, other pathogens, including Aspergillus, Cryptococcus, Pneumocystis, and endemic mycoses, are being increasingly recognized. The diagnosis of IFIs can be ascertained by the direct observation or isolation of the pathogen (culture, histopathology, and cytopathology) or by detecting antigens, antibodies, or nucleic acid. Here, we provide an update on the epidemiology, pathogenesis, diagnosis, and management of IFI in patients with liver disease and liver transplantation.
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Affiliation(s)
- Nicolas Barros
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Division of Infectious Diseases, Department of Medicine, Indiana University Health, Indianapolis, Indiana, USA
| | - Russell E. Rosenblatt
- Department of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Meaghan M. Phipps
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Vladislav Fomin
- Department of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Michael K. Mansour
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Soriano A, Honore PM, Puerta-Alcalde P, Garcia-Vidal C, Pagotto A, Gonçalves-Bradley DC, Verweij PE. Invasive candidiasis: current clinical challenges and unmet needs in adult populations. J Antimicrob Chemother 2023:7176280. [PMID: 37220664 DOI: 10.1093/jac/dkad139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Invasive candidiasis (IC) is a serious infection caused by several Candida species, and the most common fungal disease in hospitals in high-income countries. Despite overall improvements in health systems and ICU care in the last few decades, as well as the development of different antifungals and microbiological techniques, mortality rates in IC have not substantially improved. The aim of this review is to summarize the main issues underlying the management of adults affected by IC, focusing on specific forms of the infection: IC developed by ICU patients, IC observed in haematological patients, breakthrough candidaemia, sanctuary site candidiasis, intra-abdominal infections and other challenging infections. Several key challenges need to be tackled to improve the clinical management and outcomes of IC patients. These include the lack of global epidemiological data for IC, the limitations of the diagnostic tests and risk scoring tools currently available, the absence of standardized effectiveness outcomes and long-term data for IC, the timing for the initiation of antifungal therapy and the limited recommendations on the optimal step-down therapy from echinocandins to azoles or the total duration of therapy. The availability of new compounds may overcome some of the challenges identified and increase the existing options for management of chronic Candida infections and ambulant patient treatments. However, early identification of patients that require antifungal therapy and treatment of sanctuary site infections remain a challenge and will require further innovations.
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Affiliation(s)
- Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, CIBERINF, University of Barcelona, Barcelona, Spain
| | - Patrick M Honore
- CHU UCL Godinne Namur, UCL Louvain Medical School, Namur, Belgium
| | - Pedro Puerta-Alcalde
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, CIBERINF, University of Barcelona, Barcelona, Spain
| | - Carolina Garcia-Vidal
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, CIBERINF, University of Barcelona, Barcelona, Spain
| | | | | | - Paul E Verweij
- Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
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Mahmoud A, Khalid AB, Ehle A, Kahf Y, Afzal A, Peltzer B. Does Heart Failure Mask Candida Tricuspid Endocarditis? Cureus 2023; 15:e38951. [PMID: 37313062 PMCID: PMC10259750 DOI: 10.7759/cureus.38951] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 06/15/2023] Open
Abstract
Infective endocarditis (IE) carries high morbidity and mortality. Although minimal in incidence, fungal causes (mostly Candida species) carry the highest mortality among all cases of infective endocarditis. We describe a rare case of a 47-year-old male with a past medical history of cerebral vascular accident (CVA), heart failure with reduced ejection fraction status post (SP) automated implantable cardioverter defibrillator (AICD) placement, paroxysmal atrial fibrillation, coronary artery disease (CAD), infective endocarditis with mitral valve replacement and tricuspid valve replacement, and pulmonary hypertension who presented to the emergency department (ED) with complaints of shortness of breath and weakness for four days. The patient was admitted to the cardiac care unit (CCU) due to persistent hypotension despite being on a continuous milrinone drip at home. The patient was initially started on antimicrobial agents for sepsis most likely secondary to pneumonia. Echocardiographic imaging showed a large vegetation on the tricuspid valve; hence, blood cultures were sent and came back positive for Candida sp. Appropriate antifungals (micafungin) were added to the medication regimen, and the patient was transferred to a tertiary hospital for surgical intervention. Patients with bioprosthetic valve replacement require regular follow-ups as this would allow providers to catch symptoms of developing endocarditis and prevent disease progression. These appointments may also decrease other risk factors for the disease, including but not limited to infected lines.
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Affiliation(s)
- Anas Mahmoud
- Internal Medicine, St. Joseph's University Medical Center, Paterson, USA
| | - Alman B Khalid
- Internal Medicine, St. Joseph's University Medical Center, Paterson, USA
| | - Alejandra Ehle
- Internal Medicine, St. Joseph's University Medical Center, Paterson, USA
| | - Yusuf Kahf
- Internal Medicine, St. Joseph's University Medical Center, Paterson, USA
| | - Adil Afzal
- Internal Medicine, St. Joseph's University Medical Center, Paterson, USA
| | - Bradley Peltzer
- Cardiology, St. Joseph's University Medical Center, Paterson, USA
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Erol Ç, Sarı N, Yanık-Yalçın T, Yeşilkaya A, Asena L, Gür-Güngör S, Kurt-Azap Ö. Ophthalmologic Examination and Echocardiography Should be the Essential Components of Candidemia Bundle. INFECTIOUS DISEASES & CLINICAL MICROBIOLOGY 2023; 5:40-48. [PMID: 38633906 PMCID: PMC10986693 DOI: 10.36519/idcm.2023.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/16/2023] [Indexed: 04/19/2024]
Abstract
Objective Candidemia is the most common form of invasive candidiasis, and it is associated with end-organ involvement, prolonged hospitalization, increased mortality, and higher healthcare costs. Candidemia can lead to metastatic heart and ocular infections. This study aimed to define the incidence, characteristics, and mortality of candidemia episodes and compare the data with our center's previous results. Materials and Methods In this single-center retrospective observational study, we enrolled 250 patients over 18 years diagnosed with candidemia between January 2015 and December 2020. We obtained patients' demographic, clinical, laboratory, and therapeutic data from medical records. An ophthalmologic examination and screening with echocardiography were carried out within the first week after candidemia diagnosis. Results There were 275 candidemia episodes from 250 patients. The incidence of candidemia was 2.8/1000 admissions and 5.68/ 10,000 inpatient days, higher than our previous results (1.23/1000 and 3.29/10,000). The median age was 65 (interquartile range [IQR]=52-75) years. Malignancies were the most frequent comorbidity (50%). The most common type was Candida albicans (n=115, 41.8%). Candida glabrata (n=61, 22.2%) was common, particularly in surgical patients, patients with malignancy, and critically ill patients. There was Infectious disease consultation in 93.3% (257) episodes.The ophthalmoscopic examination was made in 145 episodes (52.7%), and ophthalmitis was detected in 16 (11.0%). Echocardiography was performed in 139 (50.5%) episodes; one case had an endocarditis diagnosis. The 30-day mortality was 44.7% (n=123). Mortality rates in C. glabrata and Candida krusei infections were higher (54.1% and 66.7). The factors related to mortality were intensive care unit requirement (p=0.0001), chronic liver disease (p=0.005), corticosteroid usage (p=0.0001), previous antibiotic usage (p=0.013), multiple antibiotic usage ( p=0.020), and CVC related candidemia (p=0.010). Conclusion Because of the life-threatening complications such as endocarditis, increased mortality rates, and higher healthcare costs, systematic and comprehensive candidemia bundle applications would be effective strategies for providing an effective antifungal stewardship program.
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Affiliation(s)
- Çiğdem Erol
- Department of Infectious Diseases and Clinical Microbiology, Başkent University School of Medicine, Ankara, Turkey
| | - Nuran Sarı
- Department of Infectious Diseases and Clinical Microbiology, Başkent University School of Medicine, Ankara, Turkey
| | - Tuğba Yanık-Yalçın
- Department of Infectious Diseases and Clinical Microbiology, Başkent University School of Medicine, Ankara, Turkey
| | - Ayşegül Yeşilkaya
- Department of Infectious Diseases and Clinical Microbiology, Başkent İstanbul Hospital, İstanbul, Turkey
| | - Leyla Asena
- Department of Ophthalmology, Başkent University School of Medicine, Ankara, Turkey
| | - Sirel Gür-Güngör
- Department of Ophthalmology, Başkent University School of Medicine, Ankara, Turkey
| | - Özlem Kurt-Azap
- Department of Infectious Diseases and Clinical Microbiology, Başkent University School of Medicine, Ankara, Turkey
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9
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Griesmer KB, Knight SW. Woman with dyspnea and hypoxia. J Am Coll Emerg Physicians Open 2023; 4:e12895. [PMID: 36726447 PMCID: PMC9883663 DOI: 10.1002/emp2.12895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 01/30/2023] Open
Affiliation(s)
- Katherine B. Griesmer
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Stephen W. Knight
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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10
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Rauseo AM, Olsen MA, Stwalley D, Mazi PB, Larson L, Powderly WG, Spec A. Creation and Internal Validation of a Clinical Predictive Model for Fluconazole Resistance in Patients With Candida Bloodstream Infection. Open Forum Infect Dis 2022; 9:ofac447. [PMID: 36119958 PMCID: PMC9472663 DOI: 10.1093/ofid/ofac447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/27/2022] [Indexed: 11/20/2022] Open
Abstract
Background Fluconazole is recommended as first-line therapy for candidemia when risk of fluconazole resistance (fluc-R) is low. Lack of methods to estimate resistance risk results in extended use of echinocandins and prolonged hospitalization. This study aimed to develop a clinical predictive model to identify patients at low risk for fluc-R where initial or early step-down fluconazole would be appropriate. Methods Retrospective analysis of hospitalized adult patients with positive blood culture for Candida spp from 2013 to 2019. Multivariable logistic regression model was performed to identify factors associated with fluc-R. Stepwise regression was performed on bootstrapped samples to test individual variable stability and estimate confidence intervals (CIs). We used receiver operating characteristic curves to assess performance across the probability spectrum. Results We identified 539 adults with candidemia and 72 Candida isolates (13.4%) were fluc-R. Increased risk of fluc-R was associated with older age, prior bacterial bloodstream infection (odds ratio [OR], 2.02 [95% CI, 1.13-3.63]), myelodysplastic syndrome (OR, 3.09 [95% CI, 1.13-8.44]), receipt of azole therapy (OR, 5.42 [95% CI, 2.90-10.1]) within 1 year of index blood culture, and history of bone marrow or stem cell transplant (OR, 2.81 [95% CI, 1.41-5.63]). The model had good discrimination (optimism-corrected c-statistic 0.771), and all of the selected variables were stable. The prediction model had a negative predictive value of 95.7% for the selected sensitivity cutoff of 90.3%. Conclusions This model is a potential tool for identifying patients at low risk for fluc-R candidemia to receive first-line or early step-down fluconazole.
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Affiliation(s)
- Adriana M Rauseo
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Margaret A Olsen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Dustin Stwalley
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Patrick B Mazi
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Lindsey Larson
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - William G Powderly
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
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Association between Following the ESCMID Guidelines for the Management of Candidemia and Mortality: A Retrospective Cohort Study. J Fungi (Basel) 2022; 8:jof8050541. [PMID: 35628796 PMCID: PMC9147446 DOI: 10.3390/jof8050541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 12/12/2022] Open
Abstract
Objectives: The objective of this study was to evaluate the association between ESCMID adherence and 30-day mortality in candidemia. Methods: We performed a retrospective cohort study in two French tertiary-care hospitals. All patients with at least one positive blood culture (BC) for Candida spp. between January 2013 and December 2019 were included. An adherent case was defined as a candidemia case for which the treatment fulfilled a bundle of defined criteria based on the latest ESCMID recommendations. We explored factors associated with adherence to ESCMID recommendations in an unadjusted model, and we used a propensity score method to address potential channeling biases with regard to 30-day mortality. Results: During the study period, 165 cases of candidemia were included. Among the ESCMID criteria, funduscopic examination was not performed in 45% and neither was echocardiography in 31%, while the ESCMID criteria were fully implemented in 44 cases (27%). In the propensity score analysis, the all-cause 30-day mortality rate was significantly lower among adherent cases (3.4/36.6, 9%) than among nonadherent cases (42.4/119.5, 36%) (OR = 5.3 95% CI [1.6–17.1]). Conclusions: In our study, adherence to the bundle of criteria for candidemia management was associated with increased survival, supporting additional efforts to implement these recommendations.
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Keighley C, Cooley L, Morris AJ, Ritchie D, Clark JE, Boan P, Worth LJ. Consensus guidelines for the diagnosis and management of invasive candidiasis in haematology, oncology and intensive care settings, 2021. Intern Med J 2021; 51 Suppl 7:89-117. [DOI: 10.1111/imj.15589] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Caitlin Keighley
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney Camperdown New South Wales Australia
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, New South Wales Health Pathology Westmead New South Wales Australia
- Southern IML Pathology, Sonic Healthcare Coniston New South Wales Australia
| | - Louise Cooley
- Department of Microbiology and Infectious Diseases Royal Hobart Hospital Hobart Tasmania Australia
- University of Tasmania Hobart Tasmania Australia
| | - Arthur J. Morris
- LabPLUS, Clinical Microbiology Laboratory Auckland City Hospital Auckland New Zealand
| | - David Ritchie
- Department of Clinical Haematology Peter MacCallum Cancer Centre and Royal Melbourne Hospital Melbourne Victoria Australia
| | - Julia E. Clark
- Department of Infection Management Queensland Children's Hospital, Children's Health Queensland Brisbane Queensland Australia
- Child Health Research Centre The University of Queensland Brisbane Queensland Australia
| | - Peter Boan
- PathWest Laboratory Medicine WA, Department of Microbiology Fiona Stanley Fremantle Hospitals Group Murdoch Western Australia Australia
- Department of Infectious Diseases Fiona Stanley Fremantle Hospitals Group Murdoch Western Australia Australia
| | - Leon J. Worth
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
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13
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Mind the gaps: challenges in the clinical management of invasive candidiasis in critically ill patients. Curr Opin Infect Dis 2021; 33:441-448. [PMID: 33044240 DOI: 10.1097/qco.0000000000000684] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Strict adherence to clinical practice guidelines is recognized to improve outcomes but the inconvenient truth is that only a small subset of what is done in medicine has been tested in appropriate, well designed studies. In this article, we aim to review controversial aspects of the clinical management of invasive candidiasis recommended by guidelines. RECENT FINDINGS Despite still being recommended by guidelines, we fail to identify a single randomized clinical trial documenting that the use of antifungal drugs in high-risk critically ill patients without microbiologic documentation of Candida infection decreases mortality. Regarding deep-seated Candida infections, most cohort studies of patients with candidemia found less than 5% of patients developed endophthalmitis and endocarditis. In this scenario, it is reasonable to reconsider routine universal screening of both complications in candidemic patients. Finally, a large number of studies have shown that critically ill patients usually have lower echinocandin exposure when compared with other populations. We need more data on the clinical relevance of this finding. SUMMARY We need robust studies to validate new strategies for the clinical management of candidemia in ICU, including: the use of fungal biomarkers in the early initiation or interruption of antifungal therapy in high-risk patients to replace the conventional empirical antifungal therapy driven by predictive rules; validation of targeted screening of eye infection and endocarditis with the aid of fungal biomarkers only in high-risk patients; we should clarify if higher doses of candins are necessary to treat invasive candidiasis in critically ill patients, especially in the case of intra-abdominal infections where drug penetration is suboptimal.
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Huggins JP, Hohmann S, David MZ. Candida Infective Endocarditis: A Retrospective Study of Patient Characteristics and Risk Factors for Death in 703 United States Cases, 2015-2019. Open Forum Infect Dis 2020; 8:ofaa628. [PMID: 33614813 PMCID: PMC7881760 DOI: 10.1093/ofid/ofaa628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/16/2020] [Indexed: 12/02/2022] Open
Abstract
Background Candida endocarditis is a rare, sometimes fatal complication of candidemia. Past investigations of this condition are limited by small sample sizes. We used the Vizient clinical database to report on characteristics of patients with Candida endocarditis and to examine risk factors for in-hospital mortality. Methods This was a multicenter, retrospective cohort study of 703 inpatients admitted to 179 US hospitals between October 2015 and April 2019. We reviewed demographic, diagnostic, medication administration, and procedural data from each patient’s initial encounter. Univariate and multivariate logistic regression analyses were used to identify predictors of in-hospital mortality. Results Of 703 patients, 114 (16.2%) died during the index encounter. One hundred fifty-eight (22.5%) underwent an intervention on a cardiac valve. On multivariate analysis, acute and subacute liver failure was the strongest predictor of death (odds ratio [OR], 9.2; 95% confidence interval [CI], 4.8 –17.7). Female sex (OR, 1.9; 95% CI, 1.2–3.0), transfer from an outside medical facility (OR, 1.8; 95% CI, 1.1–2.8), aortic valve pathology (OR, 2.7; 95% CI, 1.5–4.9), hemodialysis (OR, 2.1; 95% CI, 1.1–4.0), cerebrovascular disease (OR, 2.2; 95% CI, 1.2–3.8), neutropenia (OR, 2.5; 95% CI, 1.3–4.8), and alcohol abuse (OR, 2.9; 95% CI, 1.3–6.7) were also associated with death on adjusted analysis, whereas opiate abuse was associated with a lower odds of death (OR, 0.5; 95% CI, 0.2–0.9). Conclusions We found that the inpatient mortality rate was 16.2% among patients with Candida endocarditis. Acute and subacute liver failure was associated with a high risk of death, whereas opiate abuse was associated with a lower risk of death.
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Affiliation(s)
- Jonathan P Huggins
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Duke University School of Medicine, Duke University, Durham, North Carolina, USA
| | - Samuel Hohmann
- Department of Health Systems Management, Rush University, Chicago, Illinois, USA.,Vizient, Chicago, Illinois, USA
| | - Michael Z David
- Department of Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Morelli MK, Veve MP, Lorson W, Shorman MA. Candida spp. infective endocarditis: Characteristics and outcomes of twenty patients with a focus on injection drug use as a predisposing risk factor. Mycoses 2020; 64:181-186. [PMID: 33073384 DOI: 10.1111/myc.13200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/07/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Candida spp. infective endocarditis (CIE) although rare is associated with high morbidity and mortality. Risk factors include prosthetic heart valves and injection drug use (IDU). We reviewed all cases of CIE at our institution to describe the microbiology, treatment and outcomes of patients focusing on IDU as a predisposing factor. METHODS Retrospective cohort of patients with definite CIE between 2013 and 2019 at a university hospital was analysed. Demographic data collected included IDU, microbiologic, treatment and mortality. The primary outcome of interest was 12-month, all-cause mortality. RESULTS Twenty patients were included (one had two separate episodes of CIE); CIE accounted for 4% of total infective endocarditis (IE) cases during the study period. The median (IQR) age was 38 (30-58) years, 10 (50%) had a previous history of IE, and 4 (20%) patients had prosthetic heart valves or an implanted cardiac device. Thirteen (65%) patients were IDU. The tricuspid valve was the primary valve involved (8/18, 44%), and C albicans was the most frequently isolated organism (8, 36%). Echinocandin was the most common treatment strategy (8, 40%). Only three (15%) patients underwent valve replacement during hospitalisation. There were no in-hospital fatalities, and 5 (25%) patients died at one year; all were IDU (39% to 0%, p = .11). CONCLUSION CIE is a rare infectious disease seen more commonly in the IDU population. Cardiac surgery was rarely performed, and long-term mortality was 25%. Additional data are needed to identify ideal management strategies in this population.
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Affiliation(s)
- Morgan K Morelli
- University of Tennessee Medical Center, Knoxville, TN, USA.,University of Tennessee Health Science Center, Knoxville, TN, USA
| | - Michael P Veve
- University of Tennessee Medical Center, Knoxville, TN, USA.,University of Tennessee Health Science Center, Knoxville, TN, USA
| | - William Lorson
- University of Tennessee Medical Center, Knoxville, TN, USA.,University of Tennessee Health Science Center, Knoxville, TN, USA
| | - Mahmoud A Shorman
- University of Tennessee Medical Center, Knoxville, TN, USA.,University of Tennessee Health Science Center, Knoxville, TN, USA
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16
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Bal AM. European confederation of medical mycology quality of clinical candidaemia management score: A review of the points based best practice recommendations. Mycoses 2020; 64:123-131. [PMID: 33058251 DOI: 10.1111/myc.13196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 12/14/2022]
Abstract
Candidaemia is associated with high mortality. In the last few years, several guidelines have been published on the management of Candida bloodstream infection. However, adherence to the practice guidelines has been suboptimal. In order to facilitate and objectively measure the adherence to good practice recommendations, a scoring criterion was published by the European Confederation of Medical Mycology (ECMM). The ECMM Quality (EQUAL) of Clinical Candidaemia Management is an audit tool that comprises of 10 quality indicators. Each quality indicator is allotted between 1 and 3 points. The maximum achievable score is 22 or 19 in patients with or without a central venous catheter, respectively. This paper reviews each of the 10 quality indicators and provides the context for improving quality within the individual domains. The review also suggests areas that are in need of further clarity or areas which merit attention in the future updates of the EQUAL scoring system so that clinicians are able to derive maximum benefit from the audit tool. The EQUAL scoring tool is an important milestone in the quality improvement aspect of the management of candidaemia and contributes to the various components of clinical governance in the management of Candida infection of the bloodstream.
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Affiliation(s)
- Abhijit M Bal
- Department of Microbiology, University Hospital Crosshouse, Kilmarnock, UK
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