Secular trends of candidemia over 12 years in adult patients at a tertiary care hospital

Candida endocarditis: Update on management considerations

The rise in incidence rates of invasive candidiasis warrants an increase in attention and efforts toward preventing and treating this virulent infection. Cardiac involvement is one of the most feared sequelae and has a poor prognosis. Despite the introduction of several novel antifungal agents over the past quarter century, complications and mortality rates due to Candida endocarditis have remained high. Although fungal endocarditis has a mechanism similar to bacterial endocarditis, no specific diagnostic criteria or algorithm exists to help guide its management. Furthermore, recent data has questioned the current guidelines recommending a combined approach of antifungal agents with surgical valve or indwelling prostheses removal. With the emergence of multidrug-resistant Candida auris, a focus on improved prophylactic measures and management strategies is necessary.

Non-traditional approaches for control of antibiotic resistance

INTRODUCTION

The drying up of antibiotic pipeline has necessitated the development of alternative therapeutic strategies to control the problem of antimicrobial resistance (AMR) that is expected to kill 10-million people annually by 2050. Newer therapeutic approaches address the shortcomings of traditional small-molecule antibiotics - the lack of specificity, evolvability, and susceptibility to mutation-based resistance. These 'non-traditional' molecules are biologicals having a complex structure and mode(s) of action that makes them resilient to resistance.

AREAS COVERED

This review aims to provide information about the non-traditional drug development approaches to tackle the problem of antimicrobial resistance, from the pre-antibiotic era to the latest developments. We have covered the molecules under development in the clinic with literature sourced from reviewed scholarly articles, official company websites involved in innovation of concerned therapeutics, press releases from the regulatory bodies, and clinical trial databases.

EXPERT OPINION

Formal introduction of non-traditional therapies in general practice can be quick and feasible only if supported with companion diagnostics and used in conjunction with established therapies. Owing to relatively higher development costs, non-traditional therapeutics require more funding as well as well as clarity in regulatory and clinical path. We are hopeful these issues are adequately addressed before AMR develops into a pandemic.

Candida Bloodstream Infections: Changes in Epidemiology and Increase in Drug Resistance

The literature on bloodstream infections (BSIs) have predominantly been biased towards bacteria, given their superior clinical significance in comparison with the other types of microorganisms. Fungal pathogens have epidemiologically received relatively less attention, although they constitute an important proportion of BSI aetiologies. In this review, the authors discuss the clinical relevance of fungal BSIs in the context of Candida species, as well as treatment options for the infections, emphasizing the compelling need to develop newer antifungals and strengthen antimicrobial stewardship programmes in the wake of the rapid spread of antifungal resistance.

Molecular Docking and QSAR Studies of Coumarin Derivatives as NMT Inhibitors: Simple Structural Features as Potential Modulators of Antifungal Activity

Background:

Treatments of fungal diseases, including Candidiasis, remain not up to scratch in spite of the mounting catalog of synthetic antifungal agents. These have served as the impetus for investigating new antifungal agents based on natural products. Consequently, genetic algorithm-multiple linear regression (GA-MLR) based QSAR (Quantitative Structure-Activity Relationship) studies of coumarin analogues along with molecular docking were carried out.

Methods:

Coumarin analogues with their MIC values were used to generate the training and test sets of compounds for QSAR models development; the analogues were also docked into the binding pocket of NMT (MyristoylCoA: protein N-myristoyltransferase).

Results and Discussion:

The statistical parameters for internal and external validation of QSAR analysis (R2 = 0.830, Q2 = 0.758, R2Pred = 0.610 and R2m overall = 0.683 ), Y Randomization, Ridge trace, VIF, tolerance and model criteria of Golbraikh and Tropsha data illustrate the robustness of the best proposed QSAR model. Most of the analogues bind to the electrostatic, hydrophobic clamp and display hydrogen bonding with amino acid residues of NMT. Interestingly, the most active coumarin analogue (MolDock score of -189.257) was docked deeply within the binding pocket of NMT, thereby displaying hydrogen bonding with Tyr107, Leu451, Leu450, Gln226, Cys393 and Leu394 amino acid residues.

Conclusion:

The combinations of descriptors from various descriptor subsets in QSAR analysis have highlighted the role of atomic properties such as polarizability and atomic van der Waals volume to explain the inhibitory activity. The models and related information may pave the way for important insight into the designing of putative NMT inhibitors for Candida albicans.

Mixed fungaemia: an 18-year report from a tertiary-care university hospital and a systematic review

BACKGROUND

While fungaemia caused by two or more different species of yeasts (mixed fungaemia, MF) is infrequent, it might be underestimated.

AIMS

This study aimed to determine the incidence of MF, clinical characteristics of the patients, and antifungal susceptibility profiles of the isolates with a systematic review of the literature.

SOURCES

Data sources were PubMed and Scopus.

STUDY ELIGIBILITY CRITERIA

Studies reporting ten or more mixed fungaemia episodes.

CONTENT

Study included MF episodes in adults between January 2000 and August 2018 in Hacettepe University Hospitals, Turkey. The isolation, identification and antifungal susceptibility testing (AFST) of the isolates were by standard mycological methods. Patient data were obtained retrospectively. Literature search was performed using relevant keywords according to PRISMA systematic review guidelines. A total of 32 patients with 33 MF episodes were identified. Among all fungaemia episodes, MF incidence was 3.7% (33/883). All patients had one or more underlying disorders among which solid-organ cancer (50.0%, 16/32) was the most common. Overall mortality was 51.5% (17/33). The most preferred antifungal agents for initial treatment were fluconazole (48.5%, 16/33) and echinocandins (39.4%, 13/33). Fluconazole susceptible-dose-dependent (S-DD) or -resistant Candida species were detected in 15 episodes, and an isolate of C. parapsilosis was classified as S-DD by AFST. All Candida isolates were susceptible to echinocandins. Non-candida yeasts with intrinsic resistance/reduced susceptibility to both echinocandins and fluconazole were detected in two episodes. Systematic review of the literature revealed 24 studies that reported more than ten MF episodes. Methodology was variable. Improvement of detection rates was reported when chromogenic agars were used. Most studies underlined detection of isolates with reduced susceptibility.

IMPLICATIONS

Although rare, the MF rate is affected by the detection methods, which have improved in recent years. Fluconazole and echinocandins were used for initial treatment in accordance with the current guideline recommendations; however, isolates non-susceptible to both were detected. Detection of a mixed infection offers an opportunity for optimum treatment.

The Yin and Yang of Current Antifungal Therapeutic Strategies: How Can We Harness Our Natural Defenses?

Fungal infections have aroused much interest over the last years because of their involvement in several human diseases. Immunocompromission due to transplant-related therapies and malignant cancer treatments are risk factors for invasive fungal infections, but also aggressive surgery, broad-spectrum antibiotics and prosthetic devices are frequently associated with infectious diseases. Current therapy is based on the administration of antifungal drugs, but the occurrence of resistant strains to the most common molecules has become a serious health-care problem. New antifungal agents are urgently needed and it is essential to identify fungal molecular targets that could offer alternatives for development of treatments. The fungal cell wall and plasma membrane are the most important structures that offer putative new targets which can be modulated in order to fight microbial infections. The development of monoclonal antibodies against new targets is a valid therapeutic strategy, both to solve resistance problems and to support the immune response, especially in immunocompromised hosts. In this review, we summarize currently used antifungal agents and propose novel therapeutic approaches, including new fungal molecular targets to be considered for drug development.

Helminth eggs as parasitic indicators of fecal contamination in agricultural irrigation water, biosolids, soils and pastures

INTRODUCTION

A very common practice in agriculture is the disposal of wastewater and biosolids from water treatment systems due to their high nutrient content, which substantially improves crop yields. However, the presence of pathogens of fecal origin creates a sanitary risk to farmers and consumers.

OBJECTIVE

To determine the presence and concentration of helminth eggs in irrigation waters, biosolids, agricultural soils, and pastures.

MATERIALS AND METHODS

Water, biosolids, soil, and pasture samples were collected and analyzed for helminth egg detection, total eggs and viable eggs counts. The behavior of helminth eggs was evaluated in irrigation waters and dairy cattle grassland, where biosolids had been used as an organic amendment.

RESULTS

Concentrations between 0.1-3 total helminth eggs/L, and 0.1-1 viable helminth eggs/L were found in water. In biosolids and soil, we found 3-22 total helminth eggs/4 g of dry weight, and 2-12 viable helminth eggs/4 g of dry weight, and in grass, we found <2-9 total helminth eggs/g of fresh weight, and <1-3 viable helminth eggs/g of fresh weight. The presence of helminth eggs in each matrix varied from days to months, which may represent a sanitary risk to farmers as well as to consumers.

CONCLUSIONS

The presence of helminth eggs in the assessed matrixes confirms the sanitary risk of such practices. Therefore, it is important to control and incorporate regulations related to the use of wastewater and biosolids in agriculture.

Cost Effectiveness of Candida Polymerase Chain Reaction Detection and Empirical Antifungal Treatment among Patients with Suspected Fungal Peritonitis in the Intensive Care Unit

BACKGROUND

Mortality from intra-abdominal candidiasis in intensive care units (ICUs) is high. It takes many days for peritoneal-fluid fungal culture to become positive, and the recommended empirical antifungal therapy involves excessive costs. Polymerase chain reaction (PCR) should produce results more rapidly than fungal culture.

OBJECTIVES

To perform a cost-effectiveness analysis of the combination of several diagnostic and therapeutic strategies to manage Candida peritonitis in non-neutropenic adult patients in ICUs.

METHODS

We constructed a decision tree model to evaluate the cost effectiveness. Cost and effectiveness were taken into account in a 1-year time horizon and from the French National Health Insurance perspective. Six strategies were compared: fluconazole or echinocandin as an empirical therapy, plus diagnosis by fungal culture or detection by PCR of all Candida species, or use of PCR to detect most fluconazole-resistant Candida species (i.e., Candida krusei and Candida glabrata).

RESULTS

The use of fluconazole empirical treatment and PCR to detect all Candida species is more cost effective than using fluconazole empirical treatment without PCR (incremental cost-effectiveness ratio of €40,055/quality-adjusted life-year). Empirical treatment with echinocandin plus PCR to detect C. krusei and C. glabrata is the most effective strategy, but has an incremental cost-effectiveness ratio of €93,776/quality-adjusted life-year. If the cost of echinocandin decreases, then strategies involving PCR plus empirical echinocandin become more cost-effective.

CONCLUSIONS

Detection by PCR of all Candida species and of most fluconazole-resistant Candida species could improve the cost-effectiveness of fluconazole and echinocandin given to non-neutropenic patients with suspected peritoneal candidiasis in ICUs.

Epidemiology, species distribution, clinical characteristics and mortality of candidaemia in a tertiary care university hospital in Turkey, 2007-2014

Candidaemia still continues to be a serious medical concern and the epidemiology of candidaemia varies according to geographical areas. We aim to determine the incidence, local epidemiology, Candida species distribution and crude mortality rates of candidaemia. We retrospectively evaluated candidaemia episodes in between January 2007 and August 2014. We compared demographic, clinical, microbiological findings and mortality rates of episodes caused by Candida albicans and non-albicans Candida species. Overall the candidaemia incidences were 1.23 episodes/1000 admissions. A significant negative slope among candidaemia episodes and years was determined. Overall C. albicans (54.6%) was the most common species followed by Candida glabrata, Candida tropicalis and Candida parapsilosis respectively. Preinfection hospital stay and length of hospital stay were statistically longer in patients with non-albicans Candida candidaemia than in patients with C. albicans candidaemia. The source of candidaemia was unknown in 52.5% of all episodes. Central venous catheters among non-albicans Candida candidaemia episodes and urinary system among C. albicans candidaemia episodes were common source of candidaemia compared to each other. Previous antifungal therapy preceding candidaemia and concomitant bacteraemia were significantly associated with non-albicans Candida candidaemia. Continuous local surveillance will preserve its pivotal importance in formulating empirical antifungal therapy and improving management of candidaemia.

Epidemiology, Risk Factors, and Outcomes of Candida albicans Versus Non-albicans Candidemia in Nonneutropenic Patients

Background:

Candidemia is a major cause of morbidity and mortality in hospitalized patients.

Objectives:

To describe the epidemiology of and risk factors for non-albicans candidemia (NAC) in nonneutropenic adults and the impact of NAC on patient outcomes and treatment cost.

Methods:

We conducted a retrospective cohort analysis comparing demographics and risk factors for Candida albicans candidemia (CAC) versus NAC in 144 nonneutropenic patients with candidemia over a 6 year period (1997–2002) at Detroit Receiving Hospital.

Results:

Candida species distribution included albicans (50%), parapsilosis (13%), tropicalis (10%), and glabrata (13%). Predominant species varied by patient care unit, with C. glabrata more common in the medical intensive care unit (ICU) and C. parapsilosis in the burn ICU. In multivariate analysis, NAC was associated with the absence of antibiotic use at the onset of candidemia, recent history of solid tumor, and male sex, NAC was not associated with an increase in mortality or length of stay compared with CAC, but was found to have a higher cost of antifungal therapy ($2030 vs $780; p = 0.05).

Conclusions:

The epidemiology of candidemia is complex and varies among the different patient care units. Specifically, patients appear less likely to develop NAC if they are receiving antibiotics at the onset of candidemia. Increased awareness of risk factors for NAC can be used to guide adequate initial antifungal 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.

Invasive Candida infections and the harm from antibacterial drugs in critically ill patients: data from a randomized, controlled trial to determine the role of ciprofloxacin, piperacillin-tazobactam, meropenem, and cefuroxime

OBJECTIVE

Use of antibiotics in critically ill patients may increase the risk of invasive Candida infection. The objective of this study was to determine whether increased exposure to antibiotics is associated with increased prevalence of invasive Candida infection.

DESIGN

Substudy using data from a randomized controlled trial, the Procalcitonin And Survival Study 2006-2010.

SETTING

Nine multidisciplinary ICUs across Denmark.

PATIENTS

A total of 1,200 critically ill patients.

INTERVENTION

Patients were randomly allocated to either a "high exposure" antibiotic therapy (intervention arm, n = 604) or a "standard exposure" guided by current guidelines (n = 596).

MEASUREMENTS AND MAIN RESULTS

Seventy-four patients met the endpoint, "invasive Candida infection," 40 in the high exposure arm and 34 in standard exposure arm (relative risk = 1.2; 95% CI, 0.7-1.8; p = 0.52). Among medical patients in the high exposure arm, the use of ciprofloxacin and piperacillin/tazobactam was 51% and 75% higher than in the standard exposure arm; no difference in antibiotic exposure was observed between the randomized arms in surgical patients. Among medical intensive care patients, invasive Candida infection was more frequent in the high exposure arm (6.2%; 27/437) than in standard exposure arm (3.3%; 14/424) (hazard ratio = 1.9; 95% CI, 1.0-3.6; p = 0.05). Ciprofloxacin used at study entry independently predicted invasive Candida infection (adjusted hazard ratio = 2.1 [1.1-4.1]); the risk gradually increased with duration of ciprofloxacin therapy: six of 384 in patients not exposed (1.6%), eight of 212 (3.8%) when used for 1-2 days (hazard ratio = 2.5; 95% CI, 0.9-7.3), and 31 of 493 (6.3%) when used for 3 days (hazard ratio = 3.8; 95% CI, 1.6-9.3; p = 0.002). Patients with any ciprofloxacin-containing antibiotic regimen the first 3 days in the trial had a higher risk of invasive Candida infection than did patients on any antibiotic regimen not containing ciprofloxacin (unadjusted hazard ratio = 3.7; 95% CI, 1.6-8.7; p = 0.003; adjusted hazard ratio, 3.4; 95% CI, 1.4-8.0; p = 0.006).

CONCLUSIONS

High exposure to antibiotics is associated to increased risk of invasive Candida infection in medical intensive care patients. Patients with ciprofloxacin-containing regimens had higher risk of invasive Candida infection. Other antibiotics, such as meropenem, piperacillin/tazobactam, and cefuroxime, were not associated with such a risk.

Influence of culture media on biofilm formation by Candida species and response of sessile cells to antifungals and oxidative stress

The aims of the study were to evaluate the influence of culture media on biofilm formation by C. albicans, C. glabrata, C. krusei, and C. parapsilosis and to investigate the responses of sessile cells to antifungals and reactive oxygen species (ROS) as compared to planktonic cells. For biofilm formation, the Candida species were grown at different periods of time in YP or YNB media supplemented or not with 0.2 or 2% glucose. Sessile and planktonic cells were exposed to increasing concentrations of antifungals, H₂O₂, menadione or silver nanoparticles (AgNPs). Biofilms were observed by scanning electron microscopy (SEM) and quantified by the XTT assay. C. albicans formed biofilms preferentially in YPD containing 2% glucose (YPD/2%), C. glabrata in glucose-free YNB or supplemented with 0.2% glucose (YNB/0.2%), while C. krusei and C. parapsilosis preferred YP, YPD/0.2%, and YPD/2%. Interestingly, only C. albicans produced an exopolymeric matrix. This is the first report dealing with the in vitro effect of the culture medium and glucose on the formation of biofilms in four Candida species as well as the resistance of sessile cells to antifungals, AgNPs, and ROS. Our results suggest that candidiasis in vivo is a multifactorial and complex process where the nutritional conditions, the human immune system, and the adaptability of the pathogen should be considered altogether to provide an effective treatment of the patient.

A case of pediatric acute lymphoblastic leukemia with invasive candidiasis: short review

Mortality rate associated with invasive fungal infections is very high. Early suspicion for fungal infections is important during intensive chemotherapy for acute leukemia. Empirical treatment with antifungals amphotericin B or caspofungin should be started if patient is not responding to broad spectrum antibiotics and if expected duration of neutropenia is prolonged. We are reporting a 3 years old girl child with diagnosis of pre-B acute lymphoblastic leukemia who developed invasive candidiasis with typical clinical and radiological findings during induction chemotherapy. Candida non-albicans was isolated and she was treated with amphotericin B followed by caspofungin. Patient deteriorated after initial response and succumbed to death. Species identification and sensitivity pattern of fungus can help in selecting appropriate antifungal drug.

Micafungin at physiological serum concentrations shows antifungal activity against Candida albicans and Candida parapsilosis biofilms

We assessed the in vitro activity of micafungin against preformed Candida biofilms by measuring the concentration of drug causing the most fungal damage and inhibition of regrowth. We studied 37 biofilm-producing Candida spp. strains from blood cultures. We showed that micafungin was active against planktonic and sessile forms of Candida albicans strains and moderately active against Candida parapsilosis sessile cells. Concentrations of micafungin above 2 μg/ml were sufficiently high to inactivate regrowth of Candida sessile cells.

Development and validation of a risk model for identification of non-neutropenic, critically ill adult patients at high risk of invasive Candida infection: the Fungal Infection Risk Evaluation (FIRE) Study

BACKGROUND

There is increasing evidence that invasive fungal disease (IFD) is more likely to occur in non-neutropenic patients in critical care units. A number of randomised controlled trials (RCTs) have evaluated antifungal prophylaxis in non-neutropenic, critically ill patients, demonstrating a reduction in the risk of proven IFD and suggesting a reduction in mortality. It is necessary to establish a method to identify and target antifungal prophylaxis at those patients at highest risk of IFD, who stand to benefit most from any antifungal prophylaxis strategy.

OBJECTIVES

To develop and validate risk models to identify non-neutropenic, critically ill adult patients at high risk of invasive Candida infection, who would benefit from antifungal prophylaxis, and to assess the cost-effectiveness of targeting antifungal prophylaxis to high-risk patients based on these models.

DESIGN

Systematic review, prospective data collection, statistical modelling, economic decision modelling and value of information analysis.

SETTING

Ninety-six UK adult general critical care units.

PARTICIPANTS

Consecutive admissions to participating critical care units.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Invasive fungal disease, defined as a blood culture or sample from a normally sterile site showing yeast/mould cells in a microbiological or histopathological report. For statistical and economic modelling, the primary outcome was invasive Candida infection, defined as IFD-positive for Candida species.

RESULTS

Systematic review: Thirteen articles exploring risk factors, risk models or clinical decision rules for IFD in critically ill adult patients were identified. Risk factors reported to be significantly associated with IFD were included in the final data set for the prospective data collection.

DATA COLLECTION

Data were collected on 60,778 admissions between July 2009 and March 2011. Overall, 383 patients (0.6%) were admitted with or developed IFD. The majority of IFD patients (94%) were positive for Candida species. The most common site of infection was blood (55%). The incidence of IFD identified in unit was 4.7 cases per 1000 admissions, and for unit-acquired IFD was 3.2 cases per 1000 admissions. Statistical modelling: Risk models were developed at admission to the critical care unit, 24 hours and the end of calendar day 3. The risk model at admission had fair discrimination (c-index 0.705). Discrimination improved at 24 hours (c-index 0.823) and this was maintained at the end of calendar day 3 (c-index 0.835). There was a drop in model performance in the validation sample. Economic decision model: Irrespective of risk threshold, incremental quality-adjusted life-years of prophylaxis strategies compared with current practice were positive but small compared with the incremental costs. Incremental net benefits of each prophylaxis strategy compared with current practice were all negative. Cost-effectiveness acceptability curves showed that current practice was the strategy most likely to be cost-effective. Across all parameters in the decision model, results indicated that the value of further research for the whole population of interest might be high relative to the research costs.

CONCLUSIONS

The results of the Fungal Infection Risk Evaluation (FIRE) Study, derived from a highly representative sample of adult general critical care units across the UK, indicated a low incidence of IFD among non-neutropenic, critically ill adult patients. IFD was associated with substantially higher mortality, more intensive organ support and longer length of stay. Risk modelling produced simple risk models that provided acceptable discrimination for identifying patients at 'high risk' of invasive Candida infection. Results of the economic model suggested that the current most cost-effective treatment strategy for prophylactic use of systemic antifungal agents among non-neutropenic, critically ill adult patients admitted to NHS adult general critical care units is a strategy of no risk assessment and no antifungal prophylaxis.

FUNDING

Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research.

Epidemiology, species distribution, antifungal susceptibility, and outcome of candidemia across five sites in Italy and Spain

Candidemia has become an important bloodstream infection that is frequently associated with high rates of mortality and morbidity, and its growing incidence is related to complex medical and surgical procedures. We conducted a multicenter study in five tertiary care teaching hospitals in Italy and Spain and evaluated the epidemiology, species distribution, antifungal susceptibilities, and outcomes of candidemia episodes. In the period of 2008 to 2010, 995 episodes of candidemia were identified in these hospitals. The overall incidence of candidemia was 1.55 cases per 1,000 admissions and remained stable during the 3-year analysis. Candida albicans was the leading agent of infection (58.4%), followed by Candida parapsilosis complex (19.5%), Candida tropicalis (9.3%), and Candida glabrata (8.3%). The majority of the candidemia episodes were found in the internal medicine department (49.6%), followed by the surgical ward, the intensive care unit (ICU), and the hemato-oncology ward. Out of 955 patients who were eligible for evaluation, 381 (39.9%) died within 30 days from the onset of candidemia. Important differences in the 30-day mortality rates were noted between institutions: the lowest mortality rate was in the Barcelona hospital, and the highest rate was in the Udine hospital (33.6% versus 51%, respectively; P = 0.0005). Overall, 5.1% of the 955 isolates tested were resistant or susceptible dose dependent (SDD) to fluconazole, with minor differences between the hospitals in Italy and Spain (5.7% versus 3.5%, respectively; P = 0.2). Higher MICs for caspofungin were found, especially with C. parapsilosis complex (MIC90, 1 μg/ml). Amphotericin B had the lowest MICs. This report shows that candidemia is a significant source of morbidity in Europe, causing a substantial burden of disease and mortality.

Invasive candidiasis as a cause of sepsis in the critically ill patient

Invasive fungal infections are an increasingly frequent etiology of sepsis in critically ill patients causing substantial morbidity and mortality. Candida species are by far the predominant agent of fungal sepsis accounting for 10% to 15% of health-care associated infections, about 5% of all cases of severe sepsis and septic shock and are the fourth most common bloodstream isolates in the United States. One-third of all episodes of candidemia occur in the intensive care setting. Early diagnosis of invasive candidiasis is critical in order to initiate antifungal agents promptly. Delay in the administration of appropriate therapy increases mortality. Unfortunately, risk factors, clinical and radiological manifestations are quite unspecific and conventional culture methods are suboptimal. Non-culture based methods (such as mannan, anti-mannan, β-d-glucan, and polymerase chain reaction) have emerged but remain investigational or require additional testing in the ICU setting. Few prophylactic or pre-emptive studies have been performed in critically ill patients. They tended to be underpowered and their clinical usefulness remains to be established under most circumstances. The antifungal armamentarium has expanded considerably with the advent of lipid formulations of amphotericin B, the newest triazoles and the echinocandins. Clinical trials have shown that the triazoles and echinocandins are efficacious and well tolerated antifungal therapies. Clinical practice guidelines for the management of invasive candidiasis have been published by the European Society for Clinical Microbiology and Infectious Diseases and the Infectious Diseases Society of North America.

ESCMID* guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients

This part of the EFISG guidelines focuses on non-neutropenic adult patients. Only a few of the numerous recommendations can be summarized in the abstract. Prophylactic usage of fluconazole is supported in patients with recent abdominal surgery and recurrent gastrointestinal perforations or anastomotic leakages. Candida isolation from respiratory secretions alone should never prompt treatment. For the targeted initial treatment of candidaemia, echinocandins are strongly recommended while liposomal amphotericin B and voriconazole are supported with moderate, and fluconazole with marginal strength. Treatment duration for candidaemia should be a minimum of 14 days after the end of candidaemia, which can be determined by one blood culture per day until negativity. Switching to oral treatment after 10 days of intravenous therapy has been safe in stable patients with susceptible Candida species. In candidaemia, removal of indwelling catheters is strongly recommended. If catheters cannot be removed, lipid-based amphotericin B or echinocandins should be preferred over azoles. Transoesophageal echocardiography and fundoscopy should be performed to detect organ involvement. Native valve endocarditis requires surgery within a week, while in prosthetic valve endocarditis, earlier surgery may be beneficial. The antifungal regimen of choice is liposomal amphotericin B +/- flucytosine. In ocular candidiasis, liposomal amphotericin B +/- flucytosine is recommended when the susceptibility of the isolate is unknown, and in susceptible isolates, fluconazole and voriconazole are alternatives. Amphotericin B deoxycholate is not recommended for any indication due to severe side effects.

Mixed bloodstream infections involving bacteria and Candida spp

OBJECTIVES

Polymicrobial bloodstream infection (BSI) is an imprecisely defined entity purportedly associated with a worse outcome than monomicrobial BSI. This study examines trends in BSI episodes caused by bacteria and Candida spp. (mixed-BSI) in a large teaching hospital.

METHODS

All episodes of BSI from January 2000 to December 2010 were reviewed. Three groups (n = 54 each) of patients were compared: all adults with mixed-BSI from January 2006 to December 2010 (cases) and randomly selected patients with polybacterial BSI (polyB-BSI) (Control 1) or Candida spp. BSI (Candida-BSI) (Control 2) in this same period.

RESULTS

A total of 139 episodes of mixed-BSI were recorded (0.7% of all BSI, 6.9% of all poly-BSI and 18.0% of all Candida-BSI episodes). The incidence of mixed-BSI was 0.21 cases/1000 admissions, increasing from 0.08 (2000) to 0.34 (2010) cases/1000 admissions (P = 0.007). Mixed-BSI represented 11.8% and 22.9% of all episodes of candidaemia in 2000 and 2010, respectively (P = 0.011). Compared with polyB-BSI, mixed-BSI patients showed fewer malignancies, more frequent nosocomial or intravenous catheter BSI source and less frequent intra-abdominal origin, were more frequently admitted to an intensive care unit (ICU), received more antimicrobials and showed a longer hospital stay and higher mortality. Compared with Candida-BSI, mixed-BSI patients showed more severe underlying diseases, were more frequently admitted to an ICU or oncology-haematology unit, showed a higher APACHE II score, more often progressed to septic shock or multiorgan failure and received more antimicrobials. Mortality was similar.

CONCLUSIONS

Mixed-BSI is a rare, distinct infection with a worse prognosis than polyB-BSI. We were unable to detect differences in the prognosis of mixed-BSI when compared with Candida-BSI.

Comparison of epidemiology and treatment outcome of patients with candidemia at a teaching hospital in Northern Taiwan, in 2002 and 2010

BACKGROUND

The incidence of candidemia varied between hospitals and different study periods. Few, if any, studies provide the reasons. This hospital-based population study aimed to describe and compare the patient population hospitalized in 2002 and 2010 and determine the disease-specific incidences of candidemia and evaluate the impact of time to initiate antifungal therapy on 30-day mortality.

PATIENTS AND METHODS

All patients hospitalized at a 2300-bed teaching hospital in Taiwan in 2002 and 2010 were analyzed for the distribution of age, sex, and type of underlying diseases (maximum of six diagnoses). All patients with blood isolates that were collected in 2002 and 2010 and yielded Candida species were included for analysis of the demographic and clinical characteristics, distribution of Candida species, length of hospital stay before candidemia, stay in the intensive care units at onset of candidemia, time of initiating systemic antifungal agent, antifungal regimen, and 30-day crude mortality.

RESULTS

In 2010, the hospitalized patients were older (p < 0.001), had a higher Charlson Comorbidity Index (p < 0.001), and more underlying disease/status, including chronic pulmonary diseases, moderate-to-severe renal diseases, leukemia, lymphoma, and gastrointestinal malignancies (p < 0.001) than those seen in 2002. Multivariate analysis identified the following host factors were associated with the occurrence of candidemia in 2010: neonate (adjust odds ratio [OR], 3.67), 45-64 year (OR, 2.18) and the elderly (OR 2.64), compared with young adult (20-44 year); patients with moderate-to-severe renal diseases (OR, 8.08), leukemia (OR, 4.58) and lymphoma (OR 3.98) and gastrointestinal malignancies (OR 2.80). The incidence density of candidemia was 0.34 and 0.41 per 1000 patient-days in 2002 and 2010, respectively (p = 0.04). The majority of characteristics of patients with candidemia and disease-specific incidences of candidemia did not differ between 2002 and 2010. Despite more patients in 2010 receiving antifungal therapy on the same day or 1 day after onset (27.5% vs. 41.2%, respectively, p = 0.002), the 30-day mortality remained high (45.9% in 2002 and 44.4% in 2010). Moreover, time to initiate antifungal therapy had no impact on 30-day mortality.

CONCLUSION

This hospital-based population study demonstrated that the incidence density of candidemia was high and increased in 2010 compared with 2002, which was at least in part due to the increase in the proportion of patients at a higher risk of candidemia. Although antifungal therapy was initiated earlier in 2010, the 30-day mortality remained high.

Candida species: new insights into biofilm formation

Biofilms of Candida albicans, Candida parapsilosis, Candida glabrata and Candida tropicalis are associated with high indices of hospital morbidity and mortality. Major factors involved in the formation and growth of Candida biofilms are the chemical composition of the medical implant and the cell wall adhesins responsible for mediating Candida-Candida, Candida-human host cell and Candida-medical device adhesion. Strategies for elucidating the mechanisms that regulate the formation of Candida biofilms combine tools from biology, chemistry, nanoscience, material science and physics. This review proposes the use of new technologies, such as synchrotron radiation, to study the mechanisms of biofilm formation. In the future, this information is expected to facilitate the design of new materials and antifungal compounds that can eradicate nosocomial Candida infections due to biofilm formation on medical implants. This will reduce dissemination of candidiasis and hopefully improve the quality of life of patients.

Trends in the utilization of, spending on, and prices for outpatient antifungal agents in US Medicaid programs: 1991-2009

BACKGROUND

The incidence of invasive fungal infections (IFIs) has increased substantially in the recent past. Advances in medical technology, including broad-spectrum antibiotics, may increase the risk for fungal infections. Moreover, immunocompromised patients with cancer, HIV/AIDS, and/or transplants are susceptible to IFIs. Meanwhile, superficial fungal infections (SFIs) are common and can be difficult to cure.

OBJECTIVE

To provide a historical perspective on a dynamic market with expensive medications, this study describes trends in the utilization of, spending on, and average per-prescription spending on outpatient antifungal medications individually, in classes (for IFIs or SFIs), and overall, by the US Medicaid programs from 1991 to 2009.

METHODS

The publicly available Medicaid State Drug Utilization Data, maintained by the Centers for Medicare & Medicaid Services, were used. Annual prescription counts and reimbursement amounts were calculated for each of the antifungals reimbursed by Medicaid. Average per-prescription spending as a proxy for drug price was calculated by dividing reimbursement by the number of prescriptions.

RESULTS

Overall utilization for Medicaid beneficiaries remained steady, with 4.56 million prescriptions in 1991 and 4.51 million in 2009. Expenditures rose from $93.87 million to $143.76 million (in current-year US$) over the same time period. The drop in the utilization of first-generation azoles over the last 5 years of the study period can be explained in part by the movement of dual-eligibles from Medicaid to Medicare Part D and in part to a rise in fungal infections better treated with second-generation azoles or echinocandins. Whereas the average per-prescription price for generic (oral) fluconazole was $8 in 2009, the price per prescription of branded (intravenous) voriconazole was $2178.

CONCLUSIONS

Overall spending by Medicaid on outpatient antifungal medications increased more slowly than did the growth of the Medicaid programs from 1991 to 2009. However, the utilization of antifungal agents for IFIs increased almost 10-fold over this period, far outpacing the rise in the number of Medicaid beneficiaries.

Canadian clinical practice guidelines for invasive candidiasis in adults

Candidemia and invasive candidiasis (C/IC) are life-threatening opportunistic infections that add excess morbidity, mortality and cost to the management of patients with a range of potentially curable underlying conditions. The Association of Medical Microbiology and Infectious Disease Canada developed evidence-based guidelines for the approach to the diagnosis and management of these infections in the ever-increasing population of at-risk adult patients in the health care system. Over the past few years, a new and broader understanding of the epidemiology and pathogenesis of C/IC has emerged and has been coupled with the availability of new antifungal agents and defined strategies for targeting groups at risk including, but not limited to, acute leukemia patients, hematopoietic stem cell transplants and solid organ transplants, and critical care unit patients. Accordingly, these guidelines have focused on patients at risk for C/IC, and on approaches of prevention, early therapy for suspected but unproven infection, and targeted therapy for probable and proven infection.

An observational study on the epidemiological and mycological profile of Candidemia in ICU patients

Background

This study aimed to analyze the epidemiological and mycological profile of candidemia in intensive care unit (ICU) patients attending a tertiary care teaching hospital in the Himalayan region of northern India.

Material/Methods

A 15-bed medico-surgical ICU and a 5-bed pediatric ICU. Ninety-one consecutively admitted ICU patients were screened for the presence of candidemia by performing blood cultures at periodic intervals.

Results

The recovered Candida isolates were speciated and subjected to antifungal susceptibility testing using standard procedures. Forty-one of the recruited patients (45%) were found to be candidemic, with the majority of patients being in the extremes of age (13 neonates and 15 >65 years of age). Four risk factors were found to be significantly associated with the occurrence of candidemia in our patients – a period of hospitalization exceeding 7 days (p=0.0008), previous use of antibiotics (p=0.001), presence of chronic renal failure (p=0.003), and ongoing cancer chemotherapy (p= 0.041). Ninety-six Candida isolates were recovered from the 41 culture-positive patients, with Candida albicans being the commonest isolate recovered (n=75, 78.1%), followed by Candida tropicalis (n=15, 16%), and Candida glabrata (n=6, 6.5%). Fluconazole resistance was observed among 26% of all Candida isolates and 17.3% of C. albicans isolates.

Conclusions

Contrary to the majority of recent reports, species shift towards non-albicans candidemia has not been observed in our center, though the prevalence of azole resistance is alarmingly high even among the C. albicans isolates.

Anidulafungin compared with fluconazole in severely ill patients with candidemia and other forms of invasive candidiasis: support for the 2009 IDSA treatment guidelines for candidiasis

Introduction

During the past decade, the incidence of Candida infections in hospitalized patients has increased, with fluconazole being the most commonly prescribed systemic antifungal agent for these infections. However, the 2009 Infectious Diseases Society of America (IDSA) candidiasis guidelines recommend an echinocandin for the treatment of candidemia/invasive candidiasis in patients who are considered to be "moderately severe or severely" ill. To validate these guidelines, clinical trial data were reviewed.

Methods

A secondary analysis of data from a previously published prospective, randomized, double-blind clinical trial was performed; it compared anidulafungin with fluconazole for the treatment of invasive candidiasis and candidemia. Patients with critical illness were identified at study entry by using the following criteria: Acute Physiology and Chronic Health Evaluation (APACHE) II score of ≥ 15, evidence of severe sepsis (sepsis and one or more end-organ dysfunctions) present, and/or patient was in intensive care. Global response rates were compared at the end of intravenous study treatment (the primary end point of the original study) and all-cause mortality at 14 and 28 days from study entry in this group.

Results

The patients (163 (66.5%) of 245) fulfilled at least one criterion for critical illness (anidulafungin, n = 89; fluconazole, n = 74). No significant differences were found in baseline characteristics between the two treatment groups. The global response rate was 70.8% for anidulafungin and 54.1% for fluconazole (P = 0.03; 95% confidence interval (CI): 2.0 to 31.5); all-cause mortality was 10.1% versus 20.3% at 14 days (P = 0.08; 95% CI, -0.9 to 21.3) and was 20.2% versus 24.3% at 28 days (P = 0.57; 95% CI, -8.8 to 17.0) for anidulafungin and fluconazole, respectively.

Conclusions

In this post hoc analysis, anidulafungin was more effective than fluconazole for treatment of severely ill patients with candidemia, thus supporting the 2009 IDSA guidelines.

Trial registration

Clinicaltrials.gov NCT00058682.

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

OBJECTIVES

Antifungal prescription practices have changed over the last decade, and the impact of these changes is unclear. Our objective here was to evaluate the effect of antifungal drug use on the distribution and drug susceptibility of Candida spp. in a French intensive care unit (ICU).

METHODS

Antifungal drug use was measured as the number of defined daily doses per 1000 hospital days (DDDs/1000HD). The distribution of Candida spp. over a 6 year period (2004-09) and the MICs of antifungal drugs over 2007-09 were determined. Statistical analyses were performed to assess relationships between antifungal drug use, Candida spp. distribution and MIC changes over time.

RESULTS

Of 26,450 samples from 3391 patients, 1511 were positive for Candida spp. Candida albicans predominated (52.5%), followed by Candida glabrata (16.6%) and Candida parapsilosis (7.5%). C. parapsilosis increased significantly, from 5.7% in 2004 to 12.5% in 2009 (P = 0.0005). Caspofungin use increased significantly between 2004 (17.9 DDDs/1000HD) and 2009 (69.9 DDDs/1000HD) (P < 0.0001). Between 2007 and 2009, the increase in caspofungin use correlated significantly with the increase in caspofungin MICs displayed by C. parapsilosis (P < 0.0001) and C. glabrata (P = 0.03). Amphotericin B consumption changed over time and correlated with an increase in amphotericin B MICs for C. albicans (P = 0.0002) and C. glabrata (P = 0.0005). Significant declines occurred in both fluconazole use (P < 0.0001) and fluconazole MICs of C. albicans (P < 0.001)

CONCLUSIONS

Antifungal drug use in the ICU is associated with major changes in the distribution and drug susceptibility of Candida spp.

Epidemiology, species distribution, antifungal susceptibility and outcome of nosocomial candidemia in a tertiary care hospital in Italy

Candida is an important cause of bloodstream infections (BSI), causing significant mortality and morbidity in health care settings. From January 2008 to December 2010 all consecutive patients who developed candidemia at San Martino University Hospital, Italy were enrolled in the study. A total of 348 episodes of candidaemia were identified during the study period (January 2008–December 2010), with an incidence of 1,73 episodes/1000 admissions. Globally, albicans and non-albicans species caused around 50% of the cases each. Non-albicans included Candida parapsilosis (28.4%), Candida glabrata (9.5%), Candida tropicalis (6.6%), and Candida krusei (2.6%). Out of 324 evaluable patients, 141 (43.5%) died within 30 days from the onset of candidemia. C. parapsilosis candidemia was associated with the lowest mortality rate (36.2%). In contrast, patients with C. krusei BSI had the highest mortality rate (55.5%) in this cohort. Regarding the crude mortality in the different units, patients in Internal Medicine wards had the highest mortality rate (54.1%), followed by patients in ICU and Hemato-Oncology wards (47.6%).

This report shows that candidemia is a significant source of morbidity in Italy, with a substantial burden of disease, mortality, and likely high associated costs. Although our high rates of candidemia may be related to high rates of BSI in general in Italian public hospitals, reasons for these high rates are not clear and warrant further study. Determining factors associated with these high rates may lead to identifying measures that can help to prevent disease.

Candida bloodstream infections in intensive care units: analysis of the extended prevalence of infection in intensive care unit study

OBJECTIVES

To provide a global, up-to-date picture of the prevalence, treatment, and outcomes of Candida bloodstream infections in intensive care unit patients and compare Candida with bacterial bloodstream infection.

DESIGN

A retrospective analysis of the Extended Prevalence of Infection in the ICU Study (EPIC II). Demographic, physiological, infection-related and therapeutic data were collected. Patients were grouped as having Candida, Gram-positive, Gram-negative, and combined Candida/bacterial bloodstream infection. Outcome data were assessed at intensive care unit and hospital discharge.

SETTING

EPIC II included 1265 intensive care units in 76 countries.

PATIENTS

Patients in participating intensive care units on study day.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Of the 14,414 patients in EPIC II, 99 patients had Candida bloodstream infections for a prevalence of 6.9 per 1000 patients. Sixty-one patients had candidemia alone and 38 patients had combined bloodstream infections. Candida albicans (n = 70) was the predominant species. Primary therapy included monotherapy with fluconazole (n = 39), caspofungin (n = 16), and a polyene-based product (n = 12). Combination therapy was infrequently used (n = 10). Compared with patients with Gram-positive (n = 420) and Gram-negative (n = 264) bloodstream infections, patients with candidemia were more likely to have solid tumors (p < .05) and appeared to have been in an intensive care unit longer (14 days [range, 5-25 days], 8 days [range, 3-20 days], and 10 days [range, 2-23 days], respectively), but this difference was not statistically significant. Severity of illness and organ dysfunction scores were similar between groups. Patients with Candida bloodstream infections, compared with patients with Gram-positive and Gram-negative bloodstream infections, had the greatest crude intensive care unit mortality rates (42.6%, 25.3%, and 29.1%, respectively) and longer intensive care unit lengths of stay (median [interquartile range]) (33 days [18-44], 20 days [9-43], and 21 days [8-46], respectively); however, these differences were not statistically significant.

CONCLUSION

Candidemia remains a significant problem in intensive care units patients. In the EPIC II population, Candida albicans was the most common organism and fluconazole remained the predominant antifungal agent used. Candida bloodstream infections are associated with high intensive care unit and hospital mortality rates and resource use.

Changes in the incidence of candidaemia during 2000-2008 in a tertiary medical centre in northern Taiwan

Candidaemia is associated with high mortality and high healthcare costs. The incidence of candidaemia in Taiwan rose markedly during the period 1980-2000. We conducted this hospital-based surveillance study in order to explore the secular trend in incidence of candidaemia during the period 2000 to 2008. In our study, Candida spp. were the fourth most common cause of bloodstream infections, with a 30-day crude mortality rate of 36.7%. Candida albicans was the most common species identified, although mortality rate did not differ significantly among species. The incidence of candidaemia began to decrease in 2004. Risk factors related to higher mortality included longer hospital stay before onset of candidaemia, liver cirrhosis, malignancy, end-stage renal disease requiring renal dialysis, dependence on mechanical ventilation and urinary catheterisation.

Nationwide sentinel surveillance of bloodstream Candida infections in 40 tertiary care hospitals in Spain

Candidemia studies have documented geographic differences in rates and epidemiology, underscoring the need for surveillance to monitor trends. We conducted prospective candidemia surveillance in Spain to assess the incidence, species distribution, frequency of antifungal resistance, and risk factors for acquiring a Candida infection. Prospective laboratory-based surveillance was conducted from June 2008 to June 2009 in 40 medical centers located around the country. A case of candidemia was defined as the isolation of a Candida species from a blood culture. Incidence rates were calculated per 1,000 admissions. Antifungal susceptibility tests were performed by using broth microdilution assay according to the guidelines of the Clinical and Laboratory Standards Institute. We detected 984 cases, for an overall incidence of 1.09 cases per 1,000 admissions. The crude mortality was 20.20%. Candida albicans was the most common species (49.08%), followed by C. parapsilosis (20.73%), C. glabrata (13.61%), and C. tropicalis (10.77%). Overall, decreased susceptibility to fluconazole occurred in 69 (7.01%) incident isolates. Antifungal resistance was rare, and a moderate linear correlation between fluconazole and voriconazole MICs was observed. This is the largest multicenter candidemia study conducted to date and shows the substantial morbidity and mortality of candidemia in Spain.

Secular trends of candidemia in a tertiary care hospital

BACKGROUND

Candidemias account for 8% to 15% of hospital-acquired bloodstream infections. They have been associated with previous exposure to antimicrobials and are considered high-morbidity infections with high treatment costs. This study characterizes candidemias in a tertiary care hospital and assesses their incidence rates, clinical and microbiological features, and use of antifungals.

METHODS

We assessed hospital-acquired candidemias in the period from January 1997 to July 2007 in a high-complexity private hospital.

RESULTS

There were 151 cases of candidemia in 147 patients. The incidence rate was 0.74 episodes/1000 admissions. The mean age of the patients was 60 years (standard deviation +/- 24.9), and the mean length of hospital stay before the blood culture identified candidemia was 40.9 days (standard deviation +/- 86.3). The in-hospital mortality rate was 44.2%. C albicans was isolated in 44% (n = 67) of the cases, and no difference in mortality rates was found between species (Candida albicans vs C non-albicans, P = .6). The average use of antifungals in the period was 104.0 defined daily dose/1000 patient-days.

CONCLUSION

We found a high mortality rate associated to candidemia events and an increasingly important role of Candida non-albicans. New approaches to health care-related infection control and to defining prophylactic and preemptive therapies should change this scenario in the future.

Invasive candidiasis in the intensive care unit

Invasive fungal disease by Candida spp. is on the rise in the modem era of prolonged patient survival by virtue of improved critical care measures, novel chemotherapy regimens, and increasing immunosuppression following organ transplants. Invasive candidiasis (IC) in the setting of an intensive care unit results in prolonged hospital stay and increased morbidity. Clinical suspicion plays a major role in the diagnosis of IC, as current laboratory methods are not very sensitive. Various serum markers and molecular techniques are under development to improve diagnostic strategies. Treatment options involve an expanding spectrum of antifungals. Knowledge of local epidemiology and the risk factors that predispose patients to this disease are essential for effective patient care in an intensive care setting.

Epidemiology, incidence and risk factors for invasive candidiasis in high-risk patients

Candida spp. are an increasing cause of bloodstream infections, and are associated with high morbidity and mortality in both neutropenic and non-neutropenic critically ill patients. Risk factors associated with candidaemia are diverse and include exposure to broad spectrum antimicrobial agents, mucosal colonization by Candida spp., indwelling vascular catheters, prior surgery and cancer chemotherapy. During the last 20 years, there has been an increasing incidence worldwide in invasive candidiasis, but differences in geographical epidemiology are emerging, in particular regarding a shift towards non-albicans species. This shift has been correlated with routine fluconazole prophylaxis adopted in some patients, and the intrinsic/acquired azole resistance of Candida spp., which represents a very real problem, in terms of both selecting the appropriate empirical therapeutic approach and making prophylactic choices.

Invasive candidiasis: an overview from Taiwan

Invasive candidiasis has emerged as an important nosocomial infection, especially in critically ill patients. We review the epidemiology of invasive candidiasis with an emphasis on data from Taiwan. An increasing incidence of candidemia became apparent from 1980 to the end of the 1990s, followed by relative stability. Crude mortality rates of patients with candidemia were in the range of 35% to 60%. Candida albicans remains the predominant cause of invasive candidiasis in Taiwan and accounts for more than 50% of all cases. Candida tropicalis, Candida glabrata and Candida parapsilosis are the three most common non-albicans Candida species that cause invasive candidiasis. The above four Candida species account for more than 90% of invasive candidiasis in Taiwan. Overall, invasive Candida isolates have remained highly susceptible to fluconazole (> 90% susceptibility) over the past two decades. However, periodic surveillance is needed to monitor antifungal resistance because reduced fluconazole susceptibility in non-albicans Candida is not an uncommon trend. Voriconazole and echinocandins continue to exhibit excellent in vitro activity against invasive Candida isolates.

The changing face of epidemiology of invasive fungal disease in Europe

Invasive fungal diseases (IFDs) are an increasingly common complication in critically ill patients in Europe and are frequently fatal. Because of changes in treatment strategies and the increased use of antifungal prophylaxis, the epidemiology of IFDs has changed substantially in recent years and infections due to Candida species are no longer the majority in many institutions. In contrast, the emergence of non-Candida IFDs such as aspergillosis, zygomycosis and fusariosis has increased. European surveys indicate that Candida albicans is responsible for more than half the cases of invasive candidaemia; however, the occurrence of non-albicans-related IFDs appears to be increasing. Rates of IFD-related mortality in Europe depend on the pathogen, geographical location and underlying patient characteristics, with rates ranging from 28 to 59% for Candida infections and from 38 to 80% for invasive aspergillosis. Early initiation of antifungal therapy is critical for improving outcomes; however, this is complicated by the difficulty in diagnosing IFDs rapidly and accurately. The introduction of new extended-spectrum azole antifungal agents (e.g. voriconazole, posaconazole) and echinocandins (e.g. micafungin, caspofungin, anidulafungin) has increased the number of therapeutic options for early therapy. Choice between agents should be based on a variety of factors, including spectrum of activity, adverse events, drug interactions, route of administration, clinical efficacy of individual agents and local epidemiology.

Cost-effectiveness of micafungin as an alternative to fluconazole empiric treatment of suspected ICU-acquired candidemia among patients with sepsis: a model simulation

INTRODUCTION

Recent epidemiologic literature indicates that candidal species resistant to azoles are becoming more prevalent in the face of increasing incidence of hospitalizations with candidemia. Echinocandins, a new class of antifungal agents, are effective against resistant candidal species. As delaying appropriate antifungal coverage leads to increased mortality, we evaluated the cost-effectiveness of 100 mg daily empiric micafungin (MIC) vs. 400 mg daily fluconazole (FLU) for suspected intensive care unit-acquired candidemia (ICU-AC) among septic patients.

METHODS

We designed a decision model with inputs from the literature in a hypothetical 1000-patient cohort with suspected ICU-AC treated empirically with either MIC or FLU or no treatment accompanied by a watchful waiting strategy. We examined the differences in the number of survivors, acquisition costs of antifungals, and lifetime costs among survivors in the cohort under each scenario, and calculated cost per quality adjusted life year (QALY). We conducted Monte Carlo simulations and sensitivity analyses to determine the stability of our estimates.

RESULTS

In the base case analysis, assuming ICU-AC attributable mortality of 0.40 and a 52% relative risk reduction in mortality with appropriate timely therapy, compared with FLU (total deaths 31), treatment with MIC (total deaths 27) would result in four fewer deaths at an incremental cost/death averted of $61,446. Similarly, in reference case, incremental cost-effectiveness of MIC over FLU was $34,734 (95% confidence interval $26,312 to $49,209) per QALY. The estimates were most sensitive to the QALY adjustment factor and the risk of candidemia among septic patients.

CONCLUSIONS

Given the increasing likelihood of azole resistance among candidal isolates, empiric treatment of ICU-AC with 100 mg daily MIC is a cost-effective alternative to FLU.

A comparison of two sources of data on fungaemia in two hospitals

Fungal bloodstream infection (BSI) is of increasing concern in the hospital environment. This study compared routine hospital discharge data at two inner Sydney hospitals with a pathology database over a 6-year period. A high level of underreporting was found, with only 42% of the pathology database cases assigned an appropriate code in the hospital discharge data despite evidence of the infection being found in 97% of the medical records identified from the pathology database. The location of the evidence in the medical record had an impact on whether or not the infection was assigned a code. There was a greater likelihood that a code would be assigned if the infection was documented on the front sheet of the medical record. Improvements can be made to the reporting of fungal BSI if clinicians record it on the front sheet and if coders review the whole medical record before coding.