Prolonged parenteral alimentation: Candida growth and the prevention of candidemia by amphotericin instillation

Polymicrobial bloodstream infection in pediatric patients: risk factors, microbiology, and antimicrobial management

BACKGROUND

Few studies focus on polymicrobial bloodstream infections (PBSIs) in children. In previous reports, children with PBSI frequently had complex underlying medical conditions and a high incidence of specific microorganisms, but systematic evaluation with controls was not performed. We postulated that specific clinical risk factors are associated with an increased risk of PBSI, and that illness may be more severe with these infections. Additionally, we suspected that routine empiric antimicrobial therapy may frequently be inadequate to treat the variety of pathogens in PBSI.

METHODS

Positive blood cultures from 1998 to 2004 were reviewed. Patients whose cultures grew >1 organism were age-matched with monomicrobial bloodstream infection controls. Records were reviewed to compare their underlying medical conditions, organisms isolated, adequacy of therapy, and clinical characteristics of illness.

RESULTS

Twenty-nine episodes of PBSI were identified in 18 subjects. PBSI patients were more likely to have chronic medical conditions, chronic gastrointestinal pathology, central venous catheters, and to be receiving parenteral nutrition than controls. Pathogens found more commonly in PBSI episodes included Enterococcus spp., coagulase-negative staphylococci, and Candida spp. Empiric antimicrobial therapy was less likely to be adequate in patients with PBSI. PBSI patients were hospitalized longer, required longer intensive care and had prolonged bloodstream infection. Subjects with PBSI had prolonged duration of fever and had higher degrees of sepsis than controls.

CONCLUSIONS

Chronic medical conditions, particularly gastrointestinal disease, are risk factors for PBSIs. Because clinical illness may be more severe, alteration of the empiric antimicrobial regimen should be considered in some of these patients.

Taurolidine 2% as an antimicrobial lock solution for prevention of recurrent catheter-related bloodstream infections

BACKGROUND

This case report describes our preliminary data on the use of taurolidine as a lock technique. Taurolidine is a novel antimicrobial agent that has found a niche in Europe for prevention of bacteremia in home parenteral nutrition (HPN) patients who have multiple catheter-related blood-stream infections.

METHODS

A 29-year-old male with short bowel syndrome was admitted 18 times in 9 years for treatment of Gram-positive, Gram-negative, and yeast-associated catheter-related bloodstream infections. Management consisted of conventional antibiotic treatment in accordance with blood culture and sensitivity results as well as catheter removal in 10 cases. Ten months before the last infection, the patient was instructed to instil 1.5 mL taurolidine 2% daily into his central line after finishing his HPN infusion and has continued to do so 2 years to date.

RESULTS

The incidence of catheter-related bloodstream infections decreased from 8.5 to 1.5 infections per 1000 catheter days.

CONCLUSIONS

These data support previous observations made outside North America and suggest that taurolidine may prove to be an effective and safe antimicrobial agent for the prevention of recurrent catheter-related bloodstream infections.

Fungal feeding-line infections: beware the eyes and teeth

Twenty-four fungal feeding-line infections occurred in 17 patients during 1984-1992. Thirteen were receiving long-term home parenteral feeding and, in them, the first infection occurred after a median of 30 months (range 1-120) continuous feeding with a line that had been in situ for a median of 20 months (range 1-37). Four were receiving short-term feeding through a line that had been inserted 1-2 months previously. At the time of the first infection all patients were febrile and most were anaemic (15/16), however a leucocytosis was rare (three of 16). The fungi isolated were Candida albicans(6), Candida parapsilosis(5), Candida glabrata(2), Candida guillermondii(2) and other species (2). In 16 patients, the feeding-line was removed at the time of the first infection and no other treatment was given, and no other complications occurred in eight (50%) of these. In 11, the line was reinserted a median of 7 days after removal (range 1-11). Four patients (24%) developed a Candida infection of the eye 1-8 weeks after the diagnosis, uveitis (2) and endophthalmitis (2) which, in one patient, led to complete blindness in one eye. Two patients had recurrent infections which began within a month of dental therapy. In one, the infections stopped after dental extractions and, in the other, after a dental clearance. An ophthalmoscopic examination should be performed in all patients with a fungal feeding-line infection. Recurrent candidal infections may have a dental origin.

Candidaemia: risk factors in patients with cystic fibrosis who have totally implantable venous access systems

Patients with cystic fibrosis who have totally implantable venous access devices often have other consequences of their multi-system disease which predispose them to catheter-associated systemic infection. We describe four episodes of fungaemia in three patients. Each case presented with persistent fever during an acute respiratory exacerbation. The four episodes were successfully treated, but removal of the venous access device was necessary in each case. Identified risk factors for systemic fungal injection were: combinations of a severe background respiratory deficiency; an acute respiratory exacerbation; malnutrition; repeated and frequent broad spectrum antibiotic therapy; parenteral nutrition; and diabetes mellitus. Unexplained fever in high risk patients with cystic fibrosis who have indwelling venous access systems should be treated empirically with antifungal agents while awaiting blood culture results. If fungaemia is confirmed the venous access device must be removed. Daily prophylactic fluconazole may prevent recurrences.

Bacteraemia and fungaemia in adults with cystic fibrosis

The incidence of bacteraemia and fungaemia was determined in 29 adults with cystic fibrosis (CF) during 50 consecutive admissions to hospital for management of infective exacerbations of pulmonary disease. Blood was drawn for aerobic, anaerobic and fungal cultures from all patients who were febrile on admission or who became febrile during treatment. The population included eight patients who had indwelling venous access systems in situ. The overall incidence of positive blood cultures in febrile patients was 3.5% [95% confidence interval (C.I.), 1-6%]. We recorded one case of Pseudomonas aeruginosa bacteraemia and two cases of Candida albicans fungaemia. The patient with P. aeruginosa bacteraemia died 5 days after isolation of the organism from her blood. The two patients with C. albicans bacteraemia had totally implantable venous access systems (TIVAS) in situ and both recovered following appropriate therapy. These observations suggest that bacteraemia is rare in patients with CF but that there is a significant risk of fungaemia in a susceptible minority. The implications of these findings, as they relate to management of infections and care of indwelling catheters in such patients, are discussed.

Treatment of central venous silastic catheter infections using hydrochloric acid

Patients receiving long-term home parenteral nutrition through a subcutaneously tunnelled central venous silastic catheter underwent a trial of 1.5 ml of 2M hydrochloric acid instilled into the catheter each time an episode of catheter sepsis was diagnosed. Four patients had eleven episodes of central venous catheter infection, with the hydrochloric acid clearing the infection on seven occasions, and unblocking the catheter once. The mainstay of therapy for catheter sepsis is removal of the catheter. However, in patients with subcutaneously tunnelled central venous silastic catheters, if reinserting the catheter is anticipated to be a major problem then a small dose of hydrochloric acid in an attempt to clear the infection may be worth a trial.

Candida infections in surgical patients. Dose requirements and toxicity of amphotericin B

The natural history of candidiasis in general surgical patients has been poorly documented, and the toxicity of amphotericin B is widely heralded. For these reasons therapy for candidiasis is frequently withheld in situations where antimicrobial treatment seems indicated on clinical grounds. The clinical courses of 47 general surgical patients who received amphotericin therapy for presumed Candida infection were reviewed. Nineteen patients had had solid tumors, but 12 were either localized or resected tumors. Only nine patients had received prior cancer themotherapy. Twenty-one patients were treated for fungemic disease, 10 for Candida in peritonitis fluid, and 16 for apparent colonization associated with fever and organ failure syndromes. Pre-existing renal or other organ failure was the primary determinant of survival with 4/22 survivors (18%) in patients with renal failure compared with 17/25 (78%) survivors in patients without such organ failure. In patients with serum creatinine values less than 2.5 mg/dl, amphotericin therapy was associated with a transient 30% fall in creatinine clearance and a proportionate rise in serum creatinine. Dose response curves were determined and revealed substantial sterilization of cultures in both fungemic and nonfungemic patients receiving greater than or equal to 6 mg/kg. This was confirmed by autopsy material. We suggest that in this acutely ill patient popoulation uncontrolled infection is the primary determinant of organ failure. Short-term limited dosing with amphotericin B (6-8 mg/kg total dose) in conjunction with appraisal of clinical response is adequate therapy for most presumed Candida infections. Long-term high dose therapy, such as that recommended in immuodepressed patients, is not a routine necessity.

Chemotherapy of experimental endogenous Candida albicans endophthalmitis

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Fungal endocarditis: patients at risk and their treatment

Fungal endocarditis is not rare. It usually develops in patients with abnormal or surgically traumatized hearts, to whose blood fungi have gained access, perhaps during temporary (often iatrogenic) impairment of host defences. Although the blood is cleared rapidly, the fungus can establish itself in the endocardium, where it grows slowly. Thus, clinical and laboratory procedures (including blood and urine cultures) that have permitted early diagnosis and treatment of bacterial endocarditis, are not reliable in early fungal endocarditis. Greater reliance must be placed on serological monitoring of patients who have had transient fungaemia and are at risk of endocarditis. The clinician must consider factors that enhance fungal proliferation and invasion and be cognizant of its dangers - even in the absence of clear signs of infection. Prophylactic measures should be employed to protect the patient at risk, including topical, oral and systemic use of appropriate antifungal agents. Early therapy, the extent and duration of which can be determined by (1) obtaining the MIC of transitory blood or urine isolates - which should not be ignored - and (2) monitoring serology, might eliminate early invaders of the endocardium. Sixty-four reported cures of fungal endocarditis caused by Candida, the most common fungal pathogen, are tabulated, 29 were of classic fungal endocarditis requiring surgery, 3 of whom were seen later by others as fatal recurrences. Those treated early (shortly after candidaemia was diagnosed - mostly in patients on treatment for bacterial endocarditis or after cardiac surgery) survived without need for surgical removal of vegetations or valve replacement. Despite strong suggestive evidence that the first 35 patients tabulated had fungal endocarditis, histological proof exists for only a few who had surgery.

Cures of endocarditis caused by other fungi are noted. Improved surgical and medical therapy has improved the prognosis even of patients with the far-advanced disease. However, development of classic fungal endocarditis has been reported one or more years after cardiac surgery and late recurrences after intensive therapy of fungal endocarditis, that had led to clinical recovery of 2 years or more, have been reported. Serological monitoring of vulnerable patients might alert the physician to recurrence early enough for efficacy of drug therapy, averting fatal outcome or the need for further surgery.

Candida arthritis. A manifestation of disseminated candidiasis

Fungal infections infrequently involve the joints. Review of the literature reveals that Candida arthritis is rare, that it is usually a complication of disseminated candidiasis and that it occurs as a primary joint infection without spread from adjacent osteomyelitis. In the patient we describe Candida arthritis and bursitis of separate joints developed as a late manifestation of disseminated infection following "transient" C. tropicalis fungemia. Treatment consisting of aspiration and parenteral amphotericin B eradicated the joint infection without the need for surgery. Bursectomy, however, was required to eradicate the bursal infection. Awareness of this as well as other late complications of candidemia which signify disseminated infection is important. Optimal therapy will be determined only by further clinical experience with this unusual manifestation of Candida infection.

Routine subclavian vein catheterization in abdominal surgical practice

Ninety-four routine subclavian vein catheterizations in patients with abdominal surgical procedures were performed by the resident surgical staff at the Medical University of South Carolina Hospital over a ten month period. This was done primarily to have ready access to large veins during surgery and to free the patients' extremities from uncomfortable immobilization and the risk of superficial thrombophlebitis in the postoperative period. The procedure is safe, and complications can be kept to a minimum if experienced personnel place and then care for the catheter.

Hematogenous candida osteomyelitis. Report of three cases and review of the literature

Candida osteomyelitis of the spine and intervertebral disc developed in three patients without evidence of back trauma of overlying cutaneous infection. Two patients were prone to the development of disseminated candidiasis by the use of multiple antibiotics and other predisposing modalities following abdominal surgery. One patient had no identifiable cause for development of the infection. The diagnosis was established in all three cases by x-ray evidence of osteomyelitis and culture from needle aspirate. Two patients had bone scans consistent with infection. Each patient received different therapy. One was treated with amphotericin B, one with spinal fusion and 5-fluorocytosine, and one with no antifungal therapy. All patients had complete healing of the involved vertebrae. Candida organisms have the potential to cause destructive bone infection following hematogenous dissemination. The presence of Candida osteomyelitis may be helpful in diagnosing disseminated candidiasis.

Spontaneous resolution of endogenous Candida endophthalmitis complicating intravenous hyperalimentation

Untreated patients with endogenous Candida endophthalmitis who have not died of disseminated disease have required enucleation. A 57-year-old woman had endogenous Candida endophthalmitis developing subsequent to catheter sepsis during hyperalimentation, in which no antimycotic therapy was employed. The endophthalmitis resolved, and good visual acuity was preserved.

Emergency subclavian vein catheterization and intravenous hyperalimentation

One hundred consecutive subclavian catheter insertions were performed by the surgical house staff of Martland Hospital, Newark, New Jersey, over a ten month period. The only complications were three punctures of the subclavian artery and one systemic infection. The following conclusions were drawn from these data. Maintaining a closed intravenous system with minimal manipulation of the catheter is the most important factor in avoiding infectious complication. Neither the routine use of irrigation of the catheter with amphotericin B nor insertion of the catheter under strict aseptic conditions is necessary to minimize infectious complications. The morbidity related to insertion of the catheter can be kept to a minimum if the catheters are inserted by experienced personnel.

The effect of parenteral alimentation fluid, undiluted with saline or fresh sera, on the growth of Candida albicans in vitro at 37 degrees C

Parenteral alimentation is often complicated by Candida albicans infection which may be fatal. This study investigated the effect of alimentation fluid (Aminosol) on C. albicans' growth in vitro. It was found that concentrated Aminosol (1400 millisomoles) maintained C. albicans in a viable state but inhibited replication. Dilution of alimentation fluid to physiological concentrations (300 milliosmoles) with either saline or aged pooled normal sera promoted in vitro growth of C. albicans which was equivalent to that obtained in BHI broth and was slightly less than that obtained in Sabouraud's broth. The effects of fresh sera with full complement activity were also investigated. In fresh sera appropriately diluted with physiological saline, some clumping of the yeasts was observed and all formed germ tubes. Growth as defined by budding or the formation of hyphae was inhibited. When Aminosol was diluted to 300 milliosomoles with fresh sera, all yeasts were noted to be in clumps with germ tubes as well as continually growing hyphae. Growth was approximately equal to that seen in Aminosol similarly diluted with saline.

Fungal septicemia in surgical patients

Opportunistic systemic fungal infections are more frequent than generally realized. Increased awareness and a high index of suspicion of fungal super-infection in the presence of sepsis is required to bring about recognition and therapy. The intravenous catheter is an important portal of entry or may act as a foreign body favoring localization of a septic process. In its presence, fungemia must be guarded against. Whenever an intravenous catheter is removed, its tip should be cultured. Removal alone may be a critical item in therapy. In febrile patients, in whom the course of fever is not established, frequent blood cultures with attention directed specifically at fungi should be obtained. Fungi are not easily isolated and identified and only by requesting special attention from the microbiologist can the diagnosis be established in the average institutional laboratory in time to permit appropriate therapy. Since available therapeutic measures are strikingly effective when instituted early, awareness and alertness on the part of the clinician constitute the key to cure.

Candida sepsis: pathogenesis and principles of treatments

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Candidiasis of the larynx

Candida albicans, the fungus which is responsible for moniliasis, is a common inhabitant of the throat and not ordinarily a pathogen in the adult. In the presence of lowered host resistance by disease, corticosteroid therapy, immunosuppressive drugs or in the presence of altered normal flora by prolonged use of broad spectrum antibiotics, a candida infection may occur. Usually there is little difficulty in assessing the significance of this fungus when it is associated with visible mucus membrane or cutaneous lesions in healthy individuals. However, multiple or persistent isolations of the fungus from body fluids even after the removal of provocative factors such as antibiotics and foreign bodies indicates an invasive disease which requires specific therapy. Mucocutaneous and superficial Candida infections usually respond to topical therapy such as nystatin spray or gargle. When this is ineffective and the patient is still symptomatic, low doses of intravenously administered amphotercin B should be considered as the next step in the management of the infection. In patients with Candida meningitis or endocarditis this regimen is not recommended.