Risk factors for albicans and non-albicans candidemia in the intensive care unit. Crit Care Med. 2008;36:1993-1998. [PMID: 18552702 DOI: 10.1097/ccm.0b013e31816fc4cd]

Bloodstream infection caused by Wickerhamiella pararugosa in a patient with intestinal obstruction: A case report

The fungus Wickerhamiella pararugosa (Candida pararugosa) has been detected in various human organs but has rarely caused bloodstream infections. This report presents a case of central venous catheter-related bloodstream infection (CRBSI) of W. pararugosa in an adult. A female patient in her 80s was admitted to our facility for intestinal obstruction caused by colorectal cancer. The patient's ability to consume food was hindered, necessitating the insertion of a central venous catheter (CVC) into the internal jugular vein. On day 3 after admission, the patient developed a fever, prompting blood and CVC tip cultures to be performed. On day 5, yeast-like fungi were discovered in the blood cultures, and fosfluconazole (fluconazole [FLCZ] pro-drug) treatment was initiated. On day 8, yeast-like fungi were identified in both the blood and CVC tip cultures, leading to a diagnosis of CRBSI. The fungus was identified as W. pararugosa through biochemical and genetic characterization. This finding justified the use of micafungin (MCFG) for combination therapy. On day 17, the minimum inhibitory concentrations (MIC) for FLCZ and MCFG were 4-8 and 0.06 μg/mL, respectively. Accordingly, the treatment was changed to monotherapy with MCFG. After a 21-day treatment regimen, the patient was discharged on day 31. We present a case of CRBSI caused by W. pararugosa in an adult with intestinal obstruction. The notable increase in the MIC of FLCZ necessitated monotherapy with MCFG, which resulted in successful recovery of the patient.

The influence of continuous renal replacement therapy on 1,3-β-d-glucan levels in critically ill patients: a single-center retrospective propensity score study

1,3-β-d-Glucan (BDG) is commonly used for diagnosing invasive fungal infections (IFIs). While exposure to cellulose-based hemodialyzers is known to cause false-positive BDG results, the impact of modern hemofilters used in continuous renal replacement therapy (CRRT) remains unclear. This retrospective, single-center cohort study aimed to evaluate the effect of CRRT on BDG levels in critically ill patients. We included adult intensive care unit (ICU) patients with ≥1 BDG measurement between December 2019 and December 2020. The primary outcome was the rate of false-positive BDG results in patients exposed to CRRT compared to unexposed patients. Propensity score analysis was performed to control for confounding factors. A total of 103 ICU patients with ≥1 BDG level were identified. Most (72.8%) were medical ICU patients. Forty patients underwent CRRT using hemofilter membranes composed of sodium methallyl sulfonate copolymer (AN 69 HF) (82.5%) and of polyarylethersulfone (PAES) (17.5%). Among the 91 patients without proven IFI, 31 (34.1%) had false-positive BDG results. Univariable analysis showed an association between CRRT exposure and false-positive BDG results. However, the association between CRRT exposure and false-positive BDG results was no longer significant across three propensity score models employed: 1:1 match (n = 32) (odds ratio (OR) 1.65, p = .48), model-adjusted (n = 91) (OR 1.75, p = .38), quintile-adjusted (n = 91) (OR 1.78, p = .36). In this single-center retrospective analysis, exposure to synthetic CRRT membranes did not independently increase the risk of false-positive BDG results. Larger prospective studies are needed to further evaluate the association between CRRT exposure and false-positive BDG results in critically ill patients with suspected IFI.

Invasive Fungal Infections after Liver Transplantation

Invasive fungal infections represent a major challenge in patients who underwent organ transplantation. Overall, the most common fungal infections in these patients are candidiasis, followed by aspergillosis and cryptococcosis, except in lung transplant recipients, where aspergillosis is most common. Several risk factors have been identified, which increase the likelihood of an invasive fungal infection developing after transplantation. Liver transplant recipients constitute a high-risk category for invasive candidiasis and aspergillosis, and therefore targeted prophylaxis is favored in this patient population. Furthermore, a timely implemented therapy is crucial for achieving optimal outcomes in transplanted patients. In this article, we describe the epidemiology, risk factors, prophylaxis, and treatment strategies of the most common fungal infections in organ transplantation, with a focus on liver transplantation.

Can antibiotics affect the clinical features of patients with candidemia? The retrospective evaluation of 5 years of data in an intensive care unit

BACKGROUND

Candidemia is an opportunistic infection of intensive care units (ICUs) and causes morbidity and mortality. Multiple antibiotic exposure was found to be an independent risk factor for mortality and non-albicans candidemia (NAC) in candidemia patients.

AIM

The aim of this study was to determine the relationship between antibiotics and clinical features of patients with candidemia, and to determine the independent risk factors for hospital stay >50 days, 30-day mortality in hospital, candidemia types, and septic shock in candidemia patients.

METHODS

Patients were evaluated retrospectively for 5 years. A total of 148 candidemia cases were detected and included in the study. Characteristics of cases were defined and recorded. The relationship between qualitative data was determined by the χ² test. Logistic regression analysis was used to determine the independent risk factors for hospital stay >50 days, 30-day mortality in hospital, candidemia types, and septic shock in candidemia patients.

RESULTS

The incidence of candidemia for 5 years was 4.5%. Candida parapsilosis was the most reported species with 65% (n=97). Linezolid and central venous catheters (CVC) were found to be independent risk factors for NAC. Carbapenems and cephalosporins were found in association to lower mortality. No antibiotics or characteristics were found to be independent risk factors for mortality. Some broad spectrum antibiotics and antibiotic combinations were found in relationship with hospital stay >50 days; however, none of them were found to be independent risk factors. Metisilin resistant staphylococcus aureus (MRSA) antibiotics, meropenem+linezolid piperacillin-tazobactam+fluoroquinolones and comorbidity were found in association with septic shock, although only piperacillin-tazobactam+fluoroquinolones and comorbidity were found to be independent risk factors for septic shock.

CONCLUSIONS

This study concluded that many antibiotics were safe for candidemia patients. However, clinicians should pay attention when prescribing linezolid or piperacillin-tazobactam and flouroquinolons concomitantly or sequentially for patients with candidemia risk factors.

Yeast Bloodstream Infections in the COVID-19 Patient: A Multicenter Italian Study (FiCoV Study)

Fungemia is a co-infection contributing to the worsening of the critically ill COVID-19 patient. The multicenter Italian observational study FiCoV aims to estimate the frequency of yeast bloodstream infections (BSIs), to describe the factors associated with yeast BSIs in COVID-19 patients hospitalized in 10 hospitals, and to analyze the antifungal susceptibility profiles of the yeasts isolated from blood cultures. The study included all hospitalized adult COVID-19 patients with a yeast BSI; anonymous data was collected from each patient and data about antifungal susceptibility was collected. Yeast BSI occurred in 1.06% of patients, from 0.14% to 3.39% among the 10 participating centers. Patients were mainly admitted to intensive or sub-intensive care units (68.6%), over 60 years of age (73%), with a mean and median time from the hospitalization to fungemia of 29 and 22 days, respectively. Regarding risk factors for fungemia, most patients received corticosteroid therapy during hospitalization (61.8%) and had a comorbidity (25.3% diabetes, 11.5% chronic respiratory disorder, 9.5% cancer, 6% haematological malignancies, 1.4% organ transplantation). Antifungal therapy was administered to 75.6% of patients, mostly echinocandins (64.5%). The fatality rate observed in COVID-19 patients with yeast BSI was significantly higher than that of COVID-19 patients without yeast BSI (45.5% versus 30.5%). Candida parapsilosis (49.8%) and C. albicans (35.2%) were the most fungal species isolated; 72% of C. parapsilosis strains were fluconazole-resistant (range 0-93.2% among the centers). The FiCoV study highlights a high prevalence of Candida BSIs in critically ill COVID-19 patients, especially hospitalized in an intensive care unit, a high fatality rate associated with the fungal co-infection, and the worrying spread of azole-resistant C. parapsilosis.

Emerging and re-emerging fungal threats in Africa

The emergence of deadly fungal infections in Africa is primarily driven by a disproportionately high burden of human immunodeficiency virus (HIV) infections, lack of access to quality health care, and the unavailability of effective antifungal drugs. Immunocompromised people in Africa are therefore at high risk of infection from opportunistic fungal pathogens such as Cryptococcus neoformans and Pneumocystis jirovecii, which are associated with high morbidity, mortality, and related socioeconomic impacts. Other emerging fungal threats include Emergomyces spp., Histoplasma spp., Blastomyces spp., and healthcare-associated multi-drug resistant Candida auris. Socioeconomic development and the Covid-19 pandemic may influence shifts in epidemiology of invasive fungal diseases on the continent. This review discusses the epidemiology, clinical manifestations, and current management strategies available for these emerging fungal diseases in Africa. We also discuss gaps in knowledge, policy, and research to inform future efforts at managing these fungal threats.

Development of a Simple DNA Extraction Method and Candida Pan Loop-Mediated Isothermal Amplification Assay for Diagnosis of Candidemia

To reduce the morbidity and mortality of candidemia patients through rapid treatment, the development of a simple, rapid molecular diagnostic method that is based on nucleic acid extraction and is superior to conventional methods for detecting Candida in the blood is necessary. We developed a multiplex Candida Pan/internal control (IC) loop-mediated isothermal amplification (LAMP) assay and a simple DNA extraction boiling protocol using Chelex-100 that could extract yeast DNA in blood within 20 min. The Chelex-100/boiling method for DNA extraction showed comparable efficiency to that of the commercial QIAamp UCP Pathogen Mini Kit using Candida albicans qPCR. In addition, the Candida Pan/IC LAMP assay showed superior sensitivity to that of general Candida Pan and species qPCRs against clinical DNA samples extracted with the QIAamp UCP Pathogen Mini Kit and Chelex-100/boiling method. The Candida Pan/IC LAMP assay followed by Chelex-100/boiling-mediated DNA extraction showed high sensitivity (100%) and specificity (100%) against clinical samples infected with Candida. These results suggest that the Candida Pan/IC LAMP assay could be used as a rapid molecular diagnostic test for candidemia.

Epidemiological Characteristics and Drug Resistance of Fungemia in General Hospitals from 2010 to 2019

OBJECTIVE

This study intends to analyze the data of fungemia in a large tertiary hospital from 2010 to 2019, and is aimed at understanding its epidemic characteristics and drug resistance.

METHODS

The "Hospital Infection Real-Time Monitoring System" was used to retrieve the case information of patients who were hospitalized for more than 48 hours from 2010 to 2019. The questionnaire was designed to collect patients' basic information, infection situation, drug resistance, and other related information. Statistical software was used for analysis.

RESULTS

The fungi detection rate was in the range of 0.19%~0.75% in ten years, the average rate was 0.29%, and the rate 0.2%~0.3% since 2013, which was lower than that from 2010 to 2012. Non-Candida albicans was the main fungus, accounting for 62.50%. The drug resistance of non-C. albicans was higher than that of C. albicans, among which C. glabrata had the highest resistance rate. Data analysis showed that the patients with more serious basic diseases, combined with infection of other sites, surgery, long hospital stay, combination of antibiotics, and invasive catheterization, were more likely to occur fungemia.

CONCLUSION

We should pay more attention to the patients with high-risk factors of fungemia and focus on the drug resistance of non-C. albicans, choose the right antifungal drugs, so as to improve the level of diagnosis and treatment.

Invasive Fungal Infections Complicating COVID-19: A Narrative Review

Invasive fungal infections (IFIs) can complicate the clinical course of COVID-19 and are associated with a significant increase in mortality, especially in critically ill patients admitted to an intensive care unit (ICU). This narrative review concerns 4099 cases of IFIs in 58,784 COVID-19 patients involved in 168 studies. COVID-19-associated invasive pulmonary aspergillosis (CAPA) is a diagnostic challenge because its non-specific clinical/imaging features and the fact that the proposed clinically diagnostic algorithms do not really apply to COVID-19 patients. Forty-seven observational studies and 41 case reports have described a total of 478 CAPA cases that were mainly diagnosed on the basis of cultured respiratory specimens and/or biomarkers/molecular biology, usually without histopathological confirmation. Candidemia is a widely described secondary infection in critically ill patients undergoing prolonged hospitalisation, and the case reports and observational studies of 401 cases indicate high crude mortality rates of 56.1% and 74.8%, respectively. COVID-19 patients are often characterised by the presence of known risk factors for candidemia such as in-dwelling vascular catheters, mechanical ventilation, and broad-spectrum antibiotics. We also describe 3185 cases of mucormycosis (including 1549 cases of rhino-orbital mucormycosis (48.6%)), for which the main risk factor is a history of poorly controlled diabetes mellitus (>76%). Its diagnosis involves a histopathological examination of tissue biopsies, and its treatment requires anti-fungal therapy combined with aggressive surgical resection/debridement, but crude mortality rates are again high: 50.8% in case reports and 16% in observational studies. The presence of other secondary IFIs usually diagnosed in severely immunocompromised patients show that SARS-CoV-2 is capable of stunning the host immune system: 20 cases of Pneumocystis jirovecii pneumonia, 5 cases of cryptococcosis, 4 cases of histoplasmosis, 1 case of coccidioides infection, 1 case of pulmonary infection due to Fusarium spp., and 1 case of pulmonary infection due to Scedosporium.

Risk factors for invasive candida infection in critically ill patients - a systematic review and meta-analysis

Background

Current guidelines recommend empirical antifungal therapy in patients with sepsis with high risk of invasive Candida infection. However, many different risk factors have been derived from multiple studies. These risk factors lack specificity, and broad application would render most ICU patients eligible for empirical antifungal therapy.

Research Question

What risk factors for invasive Candida infection can be identified by a systematic review and meta-analysis?

Study Design and Methods

We searched PubMed, Web of Science, ScienceDirect, Biomed Central, and Cochrane and extracted the raw and adjusted OR for each risk factor associated with invasive Candida infection. We calculated pooled ORs for risk factors present in more than one study.

Results

We included 34 studies in our meta-analysis resulting in the assessment of 29 possible risk factors. Risk factors for invasive Candida infection included demographic factors, comorbid conditions, and medical interventions. Although demographic factors do not play a role for the development of invasive Candida infection, comorbid conditions (eg, HIV, Candida colonization) and medical interventions have a significant impact. The risk factors associated with the highest risk for invasive Candida infection were broad-spectrum antibiotics (OR, 5.6; 95% CI, 3.6-8.8), blood transfusion (OR, 4.9; 95% CI, 1.5-16.3), Candida colonization (OR, 4.7; 95% CI, 1.6-14.3), central venous catheter (OR, 4.7; 95% CI, 2.7-8.1), and total parenteral nutrition (OR, 4.6; 95% CI, 3.3-6.3). However, dependence between the various risk factors is probably high.

Interpretation

Our systematic review and meta-analysis identified patient- and treatment-related factors that were associated with the risk for the development of invasive Candida infection in the ICU. Most of the factors identified were either related to medical interventions during intensive care or to comorbid conditions.

Using Machine Learning Algorithms to Predict Candidaemia in ICU Patients With New-Onset Systemic Inflammatory Response Syndrome

Background: Distinguishing ICU patients with candidaemia can help with the precise prescription of antifungal drugs to create personalized guidelines. Previous prediction models of candidaemia have primarily used traditional logistic models and had some limitations. In this study, we developed a machine learning algorithm trained to predict candidaemia in patients with new-onset systemic inflammatory response syndrome (SIRS).

Methods: This retrospective, observational study used clinical information collected between January 2013 and December 2017 from three hospitals. The ICU patient data were used to train 4 machine learning algorithms–XGBoost, Support Vector Machine (SVM), Random Forest (RF), ExtraTrees (ET)–and a logistic regression (LR) model to predict patients with candidaemia.

Results: Of the 8,002 cases of new-onset SIRS (in 7,932 patients) included in the analysis, 137 new-onset SIRS cases (in 137 patients) were blood culture positive for candidaemia. Risk factors, such as fungal colonization, diabetes, acute kidney injury, the total number of parenteral nutrition days and renal replacement therapy, were important predictors of candidaemia. The XGBoost machine learning model outperformed the other models in distinguishing patients with candidaemia [XGBoost vs. SVM vs. RF vs. ET vs. LR; area under the curve (AUC): 0.92 vs. 0.86 vs. 0.91 vs. 0.90 vs. 0.52, respectively]. The XGBoost model had a sensitivity of 84%, specificity of 89% and negative predictive value of 99.6% at the best cut-off value.

Conclusions: Machine learning algorithms can potentially predict candidaemia in the ICU and have better efficiency than previous models. These prediction models can be used to guide antifungal treatment for ICU patients when SIRS occurs.

Risk factors of septic shock development and thirty-day mortality with a predictive model in adult candidemia patients in intensive care units

BACKGROUND

This study aimed to investigate factors associated with septic shock development and 30-day mortality outcome with a prediction model among adult candidemia patients in the intensive care unit (ICU).

METHODS

A retrospective study was conducted among patients admitted to the ICU from 2009 to 2018 at a tertiary care medical centre. The study subjects included adult patients ≥ 19 years with candidemia treated with antifungal agent for ≥ 3 days. Clinical variables were collected and analysed.

RESULTS

A total of 126 patients were included in the study. Of these patients, 32 patients (25.4%) had septic shock. Multivariate logistic regression analysis revealed that chronic liver disease was associated with septic shock (odds ratio [OR] 3.372, 95% confidence interval [CI] 1.057 - 10.057). The rate of 30-day mortality was 35.7% and the associated mortality risk factors were malignancy (OR 8.251, 95% CI 2.227 - 30.573), chronic liver disease (OR 3.605, 95% CI 0.913 - 14.227), haemodialysis (OR 8.479, 95% CI 1.801 - 39.924), mycological failure (OR 29.675, 95% CI 7.012 - 125.578), and septic shock (OR 3.980, 95% CI 1.238 - 12.796). A predictive model for 30-day mortality was created based on the mortality risk factor scores, which had an area of 0.862 under the receiver operating characteristic curve.

CONCLUSIONS

Adult candidemia patients in the ICU who have chronic liver disease may be at higher risk of developing septic shock. Furthermore, our predictive model for 30-day mortality based on the mortality risk factors may be useful for clinical assessment.

Candidemia in intensive care units over nine years at a large Italian university hospital: Comparison with other wards

Purpose

Candidemia is an alarming problem in critically ill patients including those admitted in intensive care units (ICUs). We aimed to describe the clinical and microbiological characteristics of bloodstream infections (BSIs) due to Candida spp. in patients admitted to ICUs of an italian tertiary referral university hospital over nine years.

Methods

A retrospective observational study of all cases of candidemia in adult patients was carried out from January 1, 2010 to December 31, 2018 at a 980-bedded University Hospital in Ancona, Italy, counting five ICUs. The incidence, demographics, clinical and microbiologic characteristics, therapeutic approaches and outcomes of ICU-patients with candidemia were collected. Non-ICU patients with candidemia hospitalized during the same time period were considered for comparison purposes. Early (7 days from the occurrence of the episode of Candida BSI) and late (30 days) mortality rates were calculated.

Results

During the study period, 188/505 (36%) episodes of candidemia occurred in ICU patients. Cumulative incidence was 9.9/1000 ICU admission and it showed to be stable over time. Candida albicans accounted for 52% of the cases, followed by C. parapsilosis (24%), and C. glabrata (14%). There was not a significant difference in species distribution between ICU and non-ICU patients. With the exception of isolates of C. tropicalis which showed to be fluconazole resistant in 25% of the cases, resistance to antifungals was not of concern in our patients. Early and late mortality rates, were 19% and 41% respectively, the latter being significantly higher than that observed in non-ICU patients. At multivariate analysis, factors associated with increased risk of death were septic shock, acute kidney failure, pulmonary embolism and lack of antifungal therapy. The type of antifungal therapy did not influence the outcome. Mortality did not increased significantly over time.

Conclusion

Neither cumulative incidence nor crude mortality of candidemia in ICU patients increased over time at our institution. However, mortality rate remained high and significantly associated with specific host-related factors in the majority of cases.

Comparative effectiveness of amphotericin B, azoles and echinocandins in the treatment of candidemia and invasive candidiasis: A systematic review and network meta-analysis

BACKGROUND + OBJECTIVES: The echinocandins, amphotericin B preparations, voriconazole and fluconazole are approved for the treatment of invasive candidiasis, though it remains unclear which agent is most effective. In order to answer this question, we performed a systematic review and network meta-analysis of the randomised controlled trials (RCTs) which evaluated these agents in comparison.

METHODS

Four electronic databases were searched from database inception to 8 October 2020. RCTs comparing triazoles, echinocandins or amphotericin B for the treatment of invasive candidiasis or candidemia were included. Random effect Bayesian network meta-analysis methods were used to compare treatment outcomes.

RESULTS

Thirteen RCTs met inclusion criteria. Of the 3528 patients included from these trials, 1531 were randomised to receive an echinocandin, 944 to amphotericin B and 1053 to a triazole. For all forms of invasive candidiasis, echinocandins were associated with the highest rate of treatment success when compared to amphotericin B (OR 1.41, 95% CI 1.04-1.92) and the triazoles (OR 1.82, 95% CI 1.35-2.51). Rank probability analysis favoured echinocandins as the most effective choice 98% of the time. Overall survival did not significantly differ between groups.

CONCLUSIONS

Among patients with invasive candidiasis, echinocandins had the best clinical outcomes and should remain the first-line agents in the treatment of invasive candidiasis.

Risk of invasive candidiasis with prolonged duration of ICU stay: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the duration of intensive care unit (ICU) stay prior to onset of invasive candidiasis (IC)/candidaemia.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Cochrane, Embase and Web of Science databases were searched through June 2019 to identify relevant studies.

ELIGIBILITY CRITERIA

Adult patients who had been admitted to the ICU and developed an IC infection.

DATA EXTRACTION AND SYNTHESIS

The following data were extracted from each article: length of hospital stay, length of ICU stay, duration of ICU admission prior to candidaemia onset, percentage of patients who received antibiotics and duration of their antibiotic therapy prior to candidaemia onset, and overall mortality. In addition to the traditional meta-analyses, meta-regression was performed to explore possible mediators which might have contributed to the heterogeneity.

RESULTS

The mean age of patients ranged from 28 to 76 years across selected studies. The pooled mean duration of ICU admission before onset of candidaemia was 12.9 days (95% CI 11.7 to 14.2). The pooled mean duration of hospital stay was 36.3±5.3 days (95% CI 25.8 to 46.7), and the pooled mean mortality rate was 49.3%±2.2% (95% CI 45.0% to 53.5%). There was no significant difference in duration of hospital stay (p=0.528) or overall mortality (p=0.111), but a significant difference was observed in the mean length of ICU stay (2.8 days, p<0.001), between patients with and without Candida albicans. Meta-regression analysis found that South American patients had longer duration of ICU admission prior to candidaemia onset than patients elsewhere, while those in Asia had the shortest duration.

CONCLUSIONS

Patients with IC are associated with longer ICU stay, with the shortest duration of ICU admission prior to the candidaemia onset in Asia. This shows a more proactive strategy in the diagnosis of IC should be considered in caring for ICU patients.

A multicenter retrospective analysis of the antifungal susceptibility patterns of Candida species and the predictive factors of mortality in South Korean patients with candidemia

As detection rates of non-albicans Candida species are increasing, determining their pathogen profiles and antifungal susceptibilities is important for antifungal treatment selection. We identified the antifungal susceptibility patterns and predictive factors for mortality in candidemia.A multicenter retrospective analysis of patients with at least 1 blood culture positive for Candida species was conducted. Candida species were classified into 3 groups (group A, Candia albicans; group B, Candida tropicalis, and Candida parasilosis; group C, Candida glabrata and Candida krusei ) to analyze the susceptibility patterns, first-line antifungal administered, and mortality. Univariate and multivariate comparisons between outcomes were performed to identify mortality risk factors.In total, 317 patients were identified, and 136 (42.9%) had recorded mortality. Echinocandin susceptibility was higher for group A than group B (111/111 [100%] vs 77/94 [81.9%], P < .001). Moreover, group A demonstrated higher fluconazole susceptibility (144/149 [96.6%] vs 39/55 [70.9%], P < .001) and lower mortality (68 [45.3%] vs 34 [61.8%], P = .036) than those of group C. In the multivariate analysis, the sequential organ failure assessment score (odds ratio OR 1.351, 95% confidence interval 1.067-1.711, p = 0.013) and positive blood culture on day 7 of hospitalization (odds ratio 5.506, 95% confidence interval, 1.697-17.860, P = .004) were associated with a higher risk of mortality.Patients with higher sequential organ failure assessment scores and sustained positive blood cultures have an increased risk of mortality.

Epidemiology of candidemia and impact of infectious disease consultation on survival and care

BACKGROUND

The aim of this study was to analyse temporal changes in the epidemiology of candidemia assessing patient's characteristics, risk factors, diagnostic management, treatment, and outcome in a tertiary care hospital in South Eastern Germany.

METHODS

In this retrospective cohort study patients with blood cultures positive for Candida spp. were identified from the microbiological database in the years 2006-2018. A detailed collection of patients' characteristics was obtained for the time periods 2006-2008 and 2016-2018. Risk factors for survival were analysed in a logistic regression analysis.

RESULTS

In the years 2006-2018, a total of 465 episodes of candidemia were identified. An increase in candidemia cases was evident in the period of 2016-2018 compared to 2006-2015 and to 2006-2008 in absolute numbers and adjusted to patient-days. C. albicans was responsible for 62.8% of cases in 2006-2008 and 51.2% of all cases in the years 2016-2018, respectively, whereas there was a significant increase of C. glabrata in the latter period (16.3-31.5%). Overall mortality was not significantly different in the two periods. Infectious diseases consultation led to a lower mortality of patients with candidemia and to a higher adherence to guidelines. In multivariate analysis, only complete change or extraction of intravascular indwelling material and female gender were independent predictors for survival.

CONCLUSION

We observed an increase in candidemia rates and rates of non-albicans spp. over time. A complete change of all catheters and/or indwelling devices improved survival. ID consultation led to a better guideline adherence.

Efficacy and safety of a comprehensive educational antimicrobial stewardship program focused on antifungal use

OBJECTIVE

Few data exist regarding the impact of antimicrobial stewardship programs on antifungal use. We evaluated the efficacy and safety of a comprehensive long-term antimicrobial stewardship program (ASP) focused on antifungal use.

METHODS

During a 9-year period, we quarterly assessed antifungal consumption, incidence density of hospital-acquired candidemia, Candida spp. distribution, antifungal resistance, and crude death rate per 1000 occupied bed days (OBDs) of hospital-acquired candidemia. We performed segmented regression analysis of interrupted time series.

RESULTS

A significant change in trend was observed for antifungal consumption, with a sustained reduction of -0.87% per quarter (95% confidence interval [CI], -1.36 -0.38, p < 0.001), accounting for a final reduction of -38.4%. The main reduction was produced in fluconazole, with a sustained reduction of -1.37% per quarter (95%CI, -1.96 -0.68, p<0.001). The incidence density of hospital-acquired candidemia decreased, with a change in slope of -5.06% cases per 1000 OBDs per year (95%CI, -8.23 -1.77, p = 0.009). The 14-day crude death rate per 1000 OBDs dropped from 0.044 to 0.017 (-6.36% deaths per 1000 OBDs per year; 95%CI, -13.45 -1.31, p = 0.09).

CONCLUSIONS

This ASP has succeeded in optimizing the use of antifungal with a long-lasting reduction without increasing the incidence, neither the mortality, of hospital-acquired candidemia.

Candida auris candidaemia in an intensive care unit - Prospective observational study to evaluate epidemiology, risk factors, and outcome

PURPOSE

To determine the prevalence of Candida auris candidaemia in our ICU patients and its molecular epidemiology.

METHODS

A prospective observational study was conducted on candidaemia in our ICU patients over 18 months during 2016-2017. Demographics, underlying disease, risk factors, antifungal therapy and outcome were studied. Risk factors of C. auris and non-auris candidaemia were compared.

RESULTS

During the study period, among 108 candidaemia cases recorded, the incidence was 6.75/1000 ICU bed days. C. auris topped the list (n = 42, 39.9%), followed by C. tropicalis (34.3%), and C. parapsilosis (15.7%). On bivariate analysis prior antibiotic therapy, long central line days, mechanical ventilation and length of ICU stay were significant risk factors for C. auris candidaemia compared to non-auris candidaemia. Multivariate analysis showed underlying respiratory and neurological diseases as significantly associated with risk of C. auris candidaemia. Fluconazole, amphotericin B, and caspofungin resistance were noted in 97.0%, 93.7% and 3% of C. auris isolates respectively.

CONCLUSION

Longer duration of central line days, prior antibiotic use, mechanical ventilation and prolonged ICU stay were important risk factors associated with C. auris candidaemia along with underlying respiratory or neurological disease. The isolates are non-clonal in origin, but they belong to a single clade.

Silver-Doped Hydroxyapatite Thin Layers Obtained by Sol-Gel Spin Coating Procedure

The main objective of this paper is to develop silver-doped hydroxyapatite suspensions (HApAg) with different concentrations of silver (?Ag = 0.05 and ?Ag = 0.2) in order to obtain uniform and homogenous layers by spin-coating procedure. The colloidal properties of HApAg suspensions are evaluated by dynamic light scattering (DLS) analysis, ζ-potential (ZP), and ultrasound measurements. The ultrasound studies show that the HApAg20 sample revealed better stability than the HApAg5 sample. The structural and morphological analysis on suspensions and thin layers is also conducted. It is observed that the particles of the two samples have a similar shape and are uniform. The layers obtained present a homogeneous appearance of the surface without evidence of cracks or interruption of the coatings. The in vitro antifungal studies conducted on the two thin layers at two different time intervals (24 and 48 h) show that both HApAg5 (?Ag = 0.05) and HApAg20 (?Ag = 0.05) nanoparticles suspensions and composite layers inhibit the development of colony forming units (CFU) even after 24 h of incubation comparative to the control, represented by the Candida albicans (C. albicans) culture in a proper medium. The fungicidal effect was evident after 48 h of incubation in the case of both HApAg20 nanoparticles suspensions and composite layers.

Candida Bloodstream Infection: Changing Pattern of Occurrence and Antifungal Susceptibility over 10 Years in a Tertiary Care Saudi Hospital

Background

Candida has emerged as one of the most important pathogens that cause bloodstream infection (BSI).Understanding the current Candida BSI trends, the dominant species causing disease and the mortality associated with this infection are crucial to optimize therapeutic and prophylaxis measures.

Objectives

To study the epidemiology and to evaluate the risk factors, prognostic factors, and mortality associated with candidemia and to compare these findings with previously published studies from Saudi Arabia.

Design

A retrospective medical record review.

Setting

Tertiary hospital in Riyadh.

Patients and Methods

The analysis included all cases of Candida blood stream infection who are >18 years old over the period from 2013 to 2018. Continuous variables were compared using the parametric T-test while categorical variables were compared using the Chi-squared test.

Main Outcome Measure

Incidence, resistance, and hospital outcomes in Candida blood stream infection.

Sample Size

324 patients.

Results

Three hundred and twenty-four episodes of Candida blood stream infections were identified. Median age of patients was 49.7 SD ± 28.1 years, and 53% of patients were males. More than half of the patients had an underlying disease involving the abdomen or laparotomy, 78% had an indwelling intravenous catheter, and 62% had suffered a bacterial infection within 2 weeks prior to candidemia. Candida albicans represents 33% of all isolates with decreasing trend overtime. There was an increase in the number of nonalbicans Candida overtime with Candida tropicalis in the lead (20%). Use of broad spectrum antibiotics (82%), prior ICU admission (60%) and use of central venous catheters (58%) were the most prevalent predisposing factors of candidemia. Azole resistance was variable overtime. Resistance to caspofungin remained very low (1.9%). Fourteen days crude mortality was 37% for ICU patients and 26.7% in non-ICU patients, while hospital crude mortality was 64.4% and 46.7%, respectively.

Conclusion

There is an increasing trend of nonalbicans Candida blood stream infection. Fluconazole resistance remained low to C. albicans. Most isolates remain susceptible to caspofungin, voriconazole, and amphotericin B. Candida bloodstream infection is associated with high 14-day hospital mortality.

Reemergence of Intravenous Drug Use as Risk Factor for Candidemia, Massachusetts, USA

The epidemic of illicit intravenous drug use (IVDU) in the United States has been accompanied by a surge in drug overdose deaths and infectious sequelae. Candida albicans infections were associated with injection of contaminated impure brown heroin in the 1970s-1990s; however, candidiasis accompanying IVDU became considerably rarer as the purity of the heroin supply increased. We reviewed cases of candidemia occurring over a recent 7-year period in persons >14 years of age at a tertiary care hospital in central Massachusetts. Of the 198 patients with candidemia, 24 cases occurred in patients with a history of IVDU. Compared with non-IVDU patients, those with a history of IVDU were more likely to have non-albicans Candida, be co-infected with hepatitis C, and have end-organ involvement, including endocarditis and osteomyelitis. Thus, IVDU appears to be reemerging as a risk factor for invasive candidiasis.

Septic shock due to Candida famata (Debaryomyces hansenii) candidemia in an ICU immunocompetent trauma-patient

Sepsis related to Candida famata (C. famata) fungemia is extremely rare in immunocompetent patients. Moreover, septic shock has not been reported due to this yeast. A previously healthy young multi-trauma male, presented septic shock from C. famata, after he had been admitted in the Intensive Care Unit (ICU) due to haemorrhagic shock. Risk factors for candidemia in ICU patients are the presence of a central venous catheter (CVC), Total Parenteral Nutrition (TPN), use of broad-spectrum antimicrobials, immunosuppression and the length of ICU stay. The presence of CVCs, prior use of antibiotics, prolonged hospitalization, disruption of skin flora and immunocompromised states have been identified as predisposing risk factors for C. famata fungemia. It is worth noting that the present case concerns a non-immunocompromised patient, but long ICU stay and brain injury may indicate a state of immunoparalysis. Identification of the yeast was performed by partial amplification and sequencing of the 26S ribosomal DNA gene [hypervariable region D1/D2; partial sequencing of the act1 gene confirmed the identity of the strain as Debaryomyces hansenii (GenBank submission ID: 1688297)] The patient quickly recovered from sepsis after initiation of amphotericin B and was discharged on the 60th day.

The Critical Role of Biliary Candidiasis in Development of Surgical Site Infections after Pancreatoduodenectomy: Results of Prospective Study Using a Selective Culture Medium for Candida Species

In accordance with previous reports, the incidence of biliary candidiasis (BC) after pancreaticoduodenectomy (PD) was reported to be 0 to 5%, and the clinical significance of BC still has been elusive. In this study, we prospectively evaluated the precise incidence of BC after PD using the CHROMagar Candida plate in an attempt to elucidate whether BC has a significant impact on the clinical outcomes after PD. Patients and Method. From November 2014 to March 2016, the consecutive 51 patients who underwent PD were enrolled for this study. The bile juice was prospectively collected through the biliary stent tube on postoperative days (POD) 3, 7, and 14 and directly incubated onto the CHROMagar Candida plate for the cultivation of various Candida species. In the presence or absence of BC, we compared the incidence of SSIs. Results. The incidence of postoperative BC was 15% on POD 3, 24% on POD 7, and 39% on POD 14, respectively. Taken together, 22 patients out of 51 (43.1%) developed BC after PD. Moreover, the incidence of SSIs was significantly higher in patients with BC than in those without it (71% versus 7%, p=0.005). BC was selected as the only significant risk factor of SSIs after PD among the various risk factors. Even though a cause of BC is unknown, high level of alkaline phosphatase (cut-off line >300 IU/L) was selected as the only preoperative risk factor of the development of BC. Conclusion. We elucidated new evidence in which BC could be the independent cause of SSIs after PD and should not be recognized as just contamination artifacts. Preoperative assessment for identifying carriers of Candida species might be essential for reducing the incidence of SSIs after PD.

Impact of supplemental parenteral nutrition early during critical illness on invasive fungal infections: a secondary analysis of the EPaNIC randomized controlled trial

OBJECTIVE

In the EPaNIC RCT (N=4640), postponing the administration of parenteral nutrition (PN) to beyond 1 week in the intensive care unit (ICU) (late-PN) reduced the number of ICU-acquired infections and the costs for antimicrobial drugs compared with initiation of PN within 24-48 hours of admission (early-PN). In a secondary analysis, we hypothesize that late-PN reduces the odds to acquire an invasive fungal infection (IFI) in the ICU.

METHODS

The impact of late-PN (N=2328) versus early-PN (N=2312) on acquired IFI and on the likelihood to acquire an IFI over time was assessed in univariable and multivariable analyses. Subsequently, we performed multivariable analyses to assess the effect of the mean total daily administered calories from admission until day 3, day 5, and day 7 on the likelihood over time of acquiring an IFI.

RESULTS

Fewer late-PN patients acquired an IFI compared with early-PN patients (77/2328 versus 112/2312) (p 0.008). After adjusting for risk factors, the odds to acquire an IFI and the likelihood of acquiring an IFI at any time were lower in late-PN (adjusted odds ratio 0.66, 95% CI 0.48-0.90, p 0.009; adjusted hazard ratio (HRadj) 0.70, 95% CI 0.52-0.93, p 0.02). Larger caloric amounts from admission until day 7 were associated with a higher likelihood to acquire an IFI over time (HRadj 1.09, 95% CI 1.02-1.16, p 0.009).

CONCLUSION

Postponing PN to beyond 1 week and smaller caloric amounts until day 7 in the ICU reduced ICU-acquired IFIs and the likelihood to develop an IFI over time.

Diabetes, malignancy and age as predictors of Candida glabrata bloodstream infection: A re-evaluation of the risk factors

OBJECTIVE

Echinocandins and azoles are widely used in the treatment of candidaemia. Guidelines of the Infectious Diseases Society of America recommend commencing treatment with an echinocandin in candidaemic patients with risk factors for Candida glabrata i.e. patients who are elderly, or who have diabetes or malignancy, or those with recent prescription of azoles. We attempted to validate whether age, diabetes and malignancy are associated with C. glabrata candidaemia.

PATIENTS, MATERIALS AND METHODS

Information in relation to demographics, patient associated risk factors, and laboratory parameters were collected from the casenotes and the laboratory information system. We then analysed the distribution of the risk factors (age, diabetes, and malignancy) in candidaemic patients with C. glabrata and patients with species other than C. glabrata (excluding Candida krusei).

RESULTS

Over a 42-month period (April 2011-September 2017), 124 patients had candidaemia. We analysed data for 119 patients of whom 33 (27.7%) had C. glabrata and the remaining 86 (72.2%) were infected with other species. Sixty-five patients were elderly (age≥65), 40 had some form of malignancy, 34 had diabetes, and 4 patients were prescribed azoles in the 30 days prior to candidaemia (many patients had multiple risk factors). Comparing patients with C. glabrata to patients infected with other species, we found no association with diabetes (39.3% vs. 24.4%, P=0.1), malignancy (36.3 vs. 32.5%, P=0.69), and age (54.5% vs. 54.6%, P=0.99).

CONCLUSIONS

Diabetes, malignancy and age are not reliable predictors of candidaemia due to C. glabrata.

Invasive Candidiasis in Critically Ill Patients: A Prospective Cohort Study in Two Tertiary Care Centers

Background:

Invasive candidiasis is not uncommon in critically ill patients but has variable epidemiology and outcomes between intensive care units (ICUs). This study evaluated the epidemiology, characteristics, management, and outcomes of patients with invasive candidiasis at 6 ICUs of 2 tertiary care centers.

Methods:

This was a prospective observational study of all adults admitted to 6 ICUs in 2 different hospitals between August 2012 and May 2016 and diagnosed to have invasive candidiasis by 2 intensivists according to predefined criteria. The epidemiology of isolated Candida and the characteristics, management, and outcomes of affected patients were studied. Multivariable logistic regression analyses were performed to identify the predictors of non-albicans versus albicans infection and hospital mortality.

Results:

Invasive candidiasis was diagnosed in 162 (age 58.4 ± 18.9 years, 52.2% males, 82.1% medical admissions, and admission Acute Physiology and Chronic Health Evaluation II score 24.1 ± 8.4) patients at a rate of 2.6 cases per 100 ICU admissions. On the diagnosis day, the Candida score was 2.4 ± 0.9 in invasive candidiasis compared with 1.6 ± 0.9 in Candida colonization (P < .01). The most frequent species were albicans (38.3%), tropicalis (16.7%), glabrata (16%), and parapsilosis (13.6%). In patients with candidemia, antifungal therapy was started on average 1 hour before knowing the culture result (59.6% of therapy initiated after). Resistance to fluconazole, caspofungin, and amphotericin B occurred in 27.9%, 2.9%, and 3.1%, respectively. The hospital mortality was 58.6% with no difference between albicans and non-albicans infections (61.3% and 54.9%, respectively; P = .44). The independent predictors of mortality were renal replacement therapy after invasive candidiasis diagnosis (odds ratio: 5.42; 95% confidence interval: 2.16-13.56) and invasive candidiasis leading/contributing to ICU admission versus occurring during critical illness (odds ratio: 2.87; 95% confidence interval: 1.22-6.74).

Conclusions:

In critically ill patients with invasive candidiasis, non-albicans was responsible for most cases, and mortality was high (58.6%). Antifungal therapy was initiated after culture results in 60% suggesting low preclinical suspicion. Study registration: NCT01490684; registered in ClinicalTrials.gov on February 11, 2012.

Epidemiology and prognosis of candidaemia in elderly patients

The aim of the study was to analyse the epidemiology and prognosis of candidaemia in elderly patients. We performed a comparison of clinical presentation of candidaemia according to age and a study of hazard factors within a prospective programme performed in 29 hospitals. One hundred and seventy-six episodes occurred in elderly patients (>75 years), 227 episodes in middle-aged patients (61-75 years) and 232 episodes in younger patients (16-60 years). Central venous catheter, parenteral nutrition, neutropenia, immunosuppressive therapy and candidaemia caused by Candida parapsilosis were less frequent in elderly patients. These patients received inadequate antifungal therapy (57.3%) more frequently than middle-aged and younger patients (40.5% P < .001). Mortality during the first week (20%) and 30 days (42%) was higher in elderly patients. The variables independently associated with mortality in elderly patients during the first 7 days were acute renal failure (OR: 2.64), Pitt score (OR: 1.57) and appropriate antifungal therapy (OR: 0.132). Primary candidaemia (OR: 2.93), acute renal failure (OR: 3.68), Pitt score (OR: 1.38), appropriate antifungal therapy (OR: 0.3) and early removal of the central catheter (OR: 0.47) were independently associated with 30-day mortality.In conclussion, inadequate antifungal treatment is frequently prescribed to elderly patients with candidaemia and is related with early and late mortality.

Risk factors and predictors of mortality of candidaemia among critically ill patients: role of antifungal prophylaxis in its development and in selection of non-albicans species

PURPOSE

The aim of the present study is to identify risk factors for development and predictors of mortality of candidaemia among critically ill patients.

METHODS

A 1:7 case-control study was conducted during a 4-year period (2012-2015) in a Greek Intensive Care Unit (ICU). Candidaemia was confirmed by positive blood cultures. All yeasts were identified using API 20C AUX System or Vitek 2 Advanced Expert System. Epidemiologic data were collected from the ICU computerized database and patients' chart reviews.

RESULTS

Fifty-three patients developed candidaemia with non-albicans species being the predominant ones (33 patients, 62.3%). Multivariate analysis found that prior emergency surgery, malignancy, hospitalization during summer months, prior septic shock by KPC-producing Klebsiella pneumoniae and number of antibiotics administered were independently associated with candidaemia, while, prior administration of azole was a protective factor. Non-albicans candidaemia was associated with number of antibiotics administered and prior administration of echinocandin. Mortality of 14 days was 28.3% (15 patients) and was associated with SOFA score upon infection onset and septic shock, while, appropriate empirical antifungal treatment was associated with better survival.

CONCLUSIONS

Prophylactic azole administration prevents development of candidaemia, while, echinocandin administration predisposes to non-albicans candidaemia. Empirical administration of an appropriate antifungal agent is associated with better survival.

Cross-resistance between voriconazole and fluconazole for non-albicans Candida infection: a case-case-control study

Cross-resistance (CR) between voriconazole and fluconazole for non-albicans Candida (NAC) species is not uncommon, but little is known about the risk factors and clinical consequences associated with this resistance phenotype. A case-case-control study was performed at a university-affiliated hospital in China between November 2012 and April 2016. The two case groups respectively comprised patients with a mono-resistance (MR) NAC infection (fluconazole or voriconazole resistance) and patients with a CR NAC infection (fluconazole and voriconazole resistance). Patients with a no-resistance (NR) NAC infection were included as the control group. Models were adjusted for demographic and clinical risk factors, and the risk of resistance associated with exposure to specific antibiotics or non-antibiotics were assessed. Of 259 episodes, 33 (12.7%) and 27 (10.4%) were identified as MR and CR NAC infections, respectively. The broad use of azoles was strongly associated with the emergence of MR and CR NAC infections (adjusted odds ratio [95% confidence interval] = 2.69 [1.10-6.58] and 2.53 [1.02-6.28], respectively). The time at risk (1.02 [1.00-1.03]) with 12 days as a breakpoint was also an independent risk factor for CR NAC infection. The number of species associated with a high minimum inhibitory concentration (≥128 μg/mL) of fluconazole was higher for CR NAC infections than for MR NAC infections. Different resistance phenotypes (CR vs. MR vs. NR) were associated with all-cause mortality rates. These findings indicate a worrisome propensity of CR NAC infections and emphasize the need for strict antifungal stewardship.

Epidemiology of Candida albicans and non-C.albicans of neonatal candidemia at a tertiary care hospital in western China

BACKGROUND

Although the majority of Candida infections occur in the developing world, candidemia epidemiology is poorly understood in these countries. The aim of this study was to investigate the epidemiology of non-Candida albicans (non-C. albicans) candidemia among neonates at Liuzhou Maternity and Child Healthcare Hospital in China.

METHODS

A retrospective review of all positive blood culture about Candida species in neonatal intensive care unit was conducted between January 2012 and November 2015. Information about demographics, risk factors and outcome of candidemia were collected. Univariate and multivariate logistic regression models were used to identify the risk factors associated with the development of non-C.albicans candidemia.

RESULTS

The prevalence of candidemia in infants was 1.4%. Non-C.albicans was responsible for 56.5% of neonatal candidemia. The predisposing factors for development of non-C.albicans candidemia among infants included mechanical ventilation [odds ratio (OR), 95% confidence interval (95%CI) = 3.13, 1.07-9.14; P = 0.037] and use of assisted reproductive technology (OR, 95%CI = 4.52, 1.39-14.77; P = 0.012). The overall mortality rate of candidemia was 8.7% and non-C.albicans attributed to 83.3% of all mortalities.

CONCLUSIONS

Non-C.albicans species are the major cause of candidemia in local neonatal group. The study highlights the urgent needs to evaluate the possibility of development of non-C.albicans candidemia in neonates exposed to these risk factors and much emphasis must be laid on the early implementation of medical intervention to reduce the incidences of candidemia in neonates.

Evaluation of epidemiological characteristics and risk factors affecting mortality in patients with candidemia

BACKGROUND/AIM

The aim of this study was to determine epidemiologic characters of patients with candidemia and to evaluate risk factors that can affect mortality rates among these patients.

MATERIALS AND METHODS

Patients admitted to the İstanbul Medeniyet University Göztepe Training Hospital between 2009 and 2011 who had a positive blood culture for Candida spp. during hospitalization were studied retrospectively for demographic characteristics and risk factors. Statistical comparisons were estimated with the Stata 12 package. Independent variables associated with mortality were estimated by Cox regression analyses.

RESULTS

A total of 89 patients were identified with a positive blood culture. Of the isolates, 72% (64/89) were C. albicans and 10% (9/89) were non-albicans Candida, while 18% (16/89) were unidentified. C. parapsilosis was the most frequently isolated species among non-albicans Candida. The crude mortality rate among candidemia cases was 30% (27/89). By univariate analysis, being in the ICU and age (≥50 or ≥60) were found to be statistically significant, whereas by multivariate analysis only age of ≥50 years was independently more associated with mortality (OR, 2.7; CI, 1.05-6.73).

CONCLUSION

Candidemia is associated with high mortality rates. Patients older than 50 years are found to be at considerable risk in terms of adverse outcomes.

The clinical outcomes and predictive factors for in-hospital mortality in non-neutropenic patients with candidemia

Recent epidemiologic studies have showed that candidemia is an important nosocomial infection in hospitalized patients. The majority of candidemia patients were non-neutropenic rather than neutropenic status. The aim of this study was to determine the clinical outcome of non-neutropenic patients with candidemia and to measure the contributing factors for mortality. A total of 163 non-neutropenic patients with candidemia during January 2010 to December 2013 were retrospectively enrolled. The patients' risk factors for mortality, clinical outcomes, treatment regimens, and Candida species were analyzed. The overall mortality was 54.6%. Candida albicans was the most frequent Candida species (n = 83; 50.9% of patients). Under multivariate analyses, hemodialysis (OR, 4.554; 95% CI, 1.464-14.164) and the use of amphotericin B deoxycholate (OR, 8.709; 95% CI, 1.587-47.805) were independent factors associated with mortality. In contrast, abdominal surgery (OR, 0.360; 95% CI, 0.158-0.816) was associated with a better outcome. The overall mortality is still high in non-neutropenic patients with candidemia. Hemodialysis and use of amphotericin B deoxycholate were independent factors associated with mortality, whereas prior abdominal surgery was associated with a better outcome.

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

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Risk factors for early invasive fungal disease in critically ill patients

BACKGROUND

The incidence of invasive fungal disease (IFD) is increasing worldwide in the past two to three decades. Critically ill patients in Intensive Care Units are more vulnerable to fungal infection. Early detection and treatment are important to decrease morbidity and mortality in critically ill patients.

OBJECTIVE

Our study aimed to assess factors associated with early IFD in critically ill patients.

MATERIALS AND METHODS

This prospective cohort study was conducted in critically ill patients, from March to September 2015. Total number of patients (74) in this study was drawn based on one of the risk factors (human immunodeficiency virus). Specimens were collected on day 5-7 of hospitalization. Multivariate analysis with logistic regression was performed for factors, with P < 0.25 in bivariate analysis.

RESULTS

Two hundred and six patients were enrolled in this study. Seventy-four patients were with IFD, majority were males (52.7%), mean age was 58 years (range 18-79), mean Leon's score was 3 (score range 2-5), majority group was nonsurgical/nontrauma (72.9%), and mean fungal isolation was positive on day 5. Candida sp. (92.2%) is the most frquently isolated fungal infection. Urine culture yielded the highest number of fungal isolates (70.1%). Mortality rate in this study was 50%. In multivariate analysis, diabetes mellitus (DM) (P = 0.018, odds ratio 2.078, 95% confidence interval 1.135-3.803) was found as an independent factor associated with early IFD critically ill patients.

CONCLUSION

DM is a significant factor for the incidence of early IFD in critically ill patients.

Antifungal antibiotics modulate the pro-inflammatory cytokine production and phagocytic activity of human monocytes in an in vitro sepsis model

AIMS

The incidence of secondary systemic fungal infections has sharply increased in bacterial septic patients. Antimycotics exhibit immunomodulatory properties, yet these effects are incompletely understood in secondary systemic fungal infections following bacterial sepsis. We investigated a model of systemic inflammation to determine whether antimycotics (liposomal amphotericin B (L-AMB), itraconazol (ITC), and anidulafungin (ANI)) modulate the gene and protein expression as well as the phagocytic activity of lipopolysaccharide (LPS)-stimulated human monocytes.

MAIN METHODS

THP-1 monocytes were incubated with L-AMB, ITC or ANI and LPS. Gene expression levels of cytokines (TNF-<alpha>, IL-1<beta>, IL-6, and IL-10) were measured after 2h, 6h, and 24h. Cytokine protein levels were evaluated after 24h and phagocytic activity was determined following co-incubation with Escherichia coli.

KEY FINDINGS

All antimycotics differentially modulated the gene and protein expression of cytokines in sepsis-like conditions. In the presence of LPS, we identified L-AMB as immunosuppressive, whereas ITC demonstrated pro-inflammatory properties. Both compounds induced remarkably less phagocytosis.

SIGNIFICANCE

Our study suggests that antimycotics routinely used in septic patients alter the immune response in sepsis-like conditions by modulating cytokine gene and protein expression levels and phagocytic activity. Future treatment strategies should consider the immune status of the host and apply antimycotics accordingly in bacterial septic patients with secondary fungal infections.

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.

Addition of lipids to parenteral nutrition does not cause fungal infections

Parenteral nutrition (PN) that includes lipid emulsion is considered to increase both bacterial and fungal central venous catheter-related bloodstream infections. This concept is based on several erroneous metrics: Reports in age-old literature at a time when preparing PN admixtures lacked stringent quality control, when its infusion, the techniques of insertion, maintenance of vascular access devices, and delivery systems were not well identified or enforced. Additionally, concepts of glucohomeostasis were different and higher glucose levels were accepted. We provide updated information with supporting literature to show that associating PN with lipids with an increase in bloodstream infections is not justified.

A case of Candida albicans fungus balls in the urinary tract appeared during the course of antifungal treatment for Candida endophthalmitis

Fungus balls have been rarely implicated as a cause of urinary tract obstruction. Here, we report a case of Candida albicans fungus balls in the urinary tract after the treatment of Candida endophthalmitis that has enough periods and adequate amount of antifungal agents. The patient completely recovered from this rare complication by irrigating through single-J stent and changing antifungal agents. Here we emphasize that we should take into account not only the susceptibility test results but also the difference in excretion route and tissue distribution of antifungal agents.

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.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Single-center retrospective study of the incidence of, and risk factors for, non-C. albicans invasive candidiasis in hospitalized patients in China

The aims of this study were to establish the incidence of invasive candidiasis (IC) in a Beijing hospital, to identify risk factors associated with IC caused by non-C. albicans Candida (NAC), and to determine risk factors for infection caused by NAC species not susceptible to fluconazole. Clinical data from 141 patients admitted to Beijing Chaoyang Hospital (from 2001-2010) diagnosed with IC were retrospectively analyzed. The incidence of IC increased during the 10-year period, but the proportion due to NAC did not change significantly in that of 141 cases, 55 (39%) were due to NAC and 86 (61%) to C. albicans (CA). The NAC species isolated included C. tropicalis (25 of 141, 18%), C. glabrata (14 of 141, 9.9%), C. parapsilosis (eight of 141, 5.7%), C. krusei (three of 141, 2.1%) and C. lusitaniae (one of 141, 0.71%); other Candida species accounted for four of the 141 cases (2.8%). Twenty-one isolates (38%) of NAC were not susceptible to fluconazole. Total parenteral nutrition (TPN) (OR 4.2; 95% CI 3.5-58; P < 0.001) and previous fluconazole therapy (OR 7.7; 95% CI 2.2-27; P = 0.001) were risk factors for invasive NAC candidiasis, whereas patient age ≥65 years (OR 0.37; CI 0.16-0.88; P = 0.025) and invasive mechanical ventilation (OR 0.22; CI 0.069-0.70; P =0.010) were connected with invasive CA candidiasis. Prior fluconazole therapy was a risk factor (P = 0.007) for infections caused by NAC not susceptible to fluconazole. In conclusion, TPN and prior fluconazole therapy are independent risk factors for NAC infection, while prior fluconazole therapy is a risk factor for infection due to NAC not susceptible to fluconazole.

Reliability of serum 1,3-beta-D-glucan assay in patients undergoing renal replacement therapy: a review of the literature

The serum 1,3-beta-D-glucan (BDG) test is a pan-fungal serum marker considered to detect the majority of pathogenic fungi, including Aspergillus spp. and Candida spp. For this review we searched for publications dealing with serum BDG levels in patients undergoing renal replacement therapy (RRT). The influence of various different membrane materials used for RRTs in these publications on serum BDG has been reviewed. We found that unmodified cellulose containing membranes increased the serum BDG levels highly, whereas conflicting results have been observed for modified cellulose containing materials. Synthetic materials (e.g. polysuflone) had no influence on serum BDG levels in the majority of the reviewed publications.

Prospective observational multicenter study to define a diagnostic algorithm for biliary candidiasis

AIM: To develop an algorithm to improve the diagnosis and treatment of patients with biliary candidiasis.

METHODS: We performed a prospective study of 127 patients who underwent endoscopic retrograde cholangiopancreatography, for various biliary disorders, at 3 tertiary referral centers in Germany from July 2011 through July 2012 (ClinicalTrials.gov: NCT01109550). Bile, buccal, and stool samples were collected. When indicated, endoscopic transpapillary bile duct biopsies were performed to clarify the etiology of bile duct strictures and to prove invasive fungal infections.

RESULTS: Candida species were detected in 38 of the 127 bile samples (29.9%). By multivariate analysis patients’ age and previous endoscopic sphincterotomy were independent risk factors for biliary candidiasis (P < 0.05). Patients with immunosuppression (P = 0.058) and recent long-term antibiotic therapy (> 7 d) (P = 0.089) tend to be at risk for biliary candidiasis. One patient was negative in mycological culture of bile fluid but invasive biliary candidiasis was diagnosed histologically. Of Candida subspecies detected, 36.7% were azole-resistant, such as C glabrata. Eight patients received anti-mycotic therapy, based on our algorithm. Of these, 3 had cancer with biliary tract involvement, 2 had secondary sclerosing cholangitis, 1 had retroperitoneal fibrosis, and 5 had septicemia. In all patients contamination was ruled out by smears of the endoscope channel.

CONCLUSION: Gastroenterologists should be aware of frequent candida colonization in patients with cholangitis and biliary disorders. Our suggested algorithm facilitates the further clinical management.