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Hargarten JC, Vaughan MJ, Lampe AT, Jones RM, Ssebambulidde K, Nickerson KW, Williamson PR, Atkin AL, Brown DM. Farnesol remodels the peritoneal cavity immune environment influencing Candida albicans pathogenesis during intra-abdominal infection. Infect Immun 2023; 91:e0038423. [PMID: 37975682 PMCID: PMC10715096 DOI: 10.1128/iai.00384-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023] Open
Abstract
Candida albicans is a lifelong member of the mycobiome causing mucosal candidiasis and life-threatening, systemic, and intra-abdominal disease in immunocompromised and transplant patients. Despite the clinical importance of intra-abdominal candidiasis with mortality rates between 40% and 70%, the contribution of fungal virulence factors and host immune responses to disease has not been extensively studied. Secretion of the quorum-sensing molecule, farnesol, acts as a virulence factor for C. albicans during systemic infection, while inducing local, protective innate immune responses in oral models of infection. Previously, we reported that farnesol recruits macrophages to the peritoneal cavity in mice, suggesting a role for farnesol in innate immune responses. Here, we expand on our initial findings, showing that farnesol profoundly alters the peritoneal cavity microenvironment promoting innate inflammation. Intra-peritoneal injection of farnesol stimulates rapid local death of resident peritoneal cells followed by recruitment of neutrophils and inflammatory macrophages into the peritoneal cavity and peritoneal mesothelium associated with an early increase in chemokines followed by proinflammatory cytokines. These rapid inflammatory responses to farnesol significantly increase morbidity and mortality of mice with intra-abdominal candidiasis associated with increased formation of peritoneal adhesions, despite similar rates of fungal clearance from the peritoneal cavity and retro-peritoneal organs. C. albicans ddp3Δ/ddp3Δ knockout and reconstituted strains recapitulate these findings. This indicates that farnesol may be detrimental to the host during intra-abdominal infections. Importantly, our results highlight a need to understand how C. albicans virulence factors modulate the host immune response within the peritoneum, an exceedingly common site of Candida infection.
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Affiliation(s)
- Jessica C. Hargarten
- School of Biological Sciences, University of Nebraska—Lincoln, Lincoln, Nebraska, USA
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Malcolm J. Vaughan
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Anna T. Lampe
- School of Biological Sciences, University of Nebraska—Lincoln, Lincoln, Nebraska, USA
- Nebraska Center for Virology, University of Nebraska—Lincoln, Lincoln, Nebraska, USA
| | - Riley M. Jones
- School of Biological Sciences, University of Nebraska—Lincoln, Lincoln, Nebraska, USA
- College of Arts and Sciences, Doane University, Crete, Nebraska, USA
| | - Kenneth Ssebambulidde
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Kenneth W. Nickerson
- School of Biological Sciences, University of Nebraska—Lincoln, Lincoln, Nebraska, USA
| | - Peter R. Williamson
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Audrey L. Atkin
- School of Biological Sciences, University of Nebraska—Lincoln, Lincoln, Nebraska, USA
| | - Deborah M. Brown
- School of Biological Sciences, University of Nebraska—Lincoln, Lincoln, Nebraska, USA
- Nebraska Center for Virology, University of Nebraska—Lincoln, Lincoln, Nebraska, USA
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Lilly EA, Bender BE, Noverr MC, Fidel PL. Protection against lethal sepsis following immunization with Candida species varies by isolate and inversely correlates with bone marrow tissue damage. Infect Immun 2023; 91:e0025223. [PMID: 37702509 PMCID: PMC10580931 DOI: 10.1128/iai.00252-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 09/14/2023] Open
Abstract
Protection against lethal Candida albicans (Ca)/Staphylococcus aureus (Sa) intra-abdominal infection (IAI)-mediated sepsis can be achieved by a novel form of trained innate immunity (TII) involving Gr-1+ myeloid-derived suppressor cells (MDSCs) that are induced by inoculation (immunization) with low virulence Candida species [i.e., Candida dubliniensis (Cd)] that infiltrate the bone marrow (BM). In contrast, more virulent Candida species (i.e., C. albicans), even at sub-lethal inocula, fail to induce similar levels of protection. The purpose of the present study was to test the hypothesis that the level of TII-mediated protection induced by Ca strains inversely correlates with damage in the BM as a reflection of virulence. Mice were immunized by intraperitoneal inoculation with several parental and mutant strains of C. albicans deficient in virulence factors (hyphal formation and candidalysin production), followed by an intraperitoneal Ca/Sa challenge 14 d later and monitored for sepsis and mortality. Whole femur bones were collected 24 h and 13 d after immunization and assessed for BM tissue/cellular damage via ferroptosis and histology. While immunization with standard but not sub-lethal inocula of most wild-type C. albicans strains resulted in considerable mortality, protection against lethal Ca/Sa IAI challenge varied by strain was usually less than that for C. dubliniensis, with no differences observed between parental and corresponding mutants. Finally, levels of protection afforded by the Ca strains were inversely correlated with BM tissue damage (R 2 = -0.773). TII-mediated protection against lethal Ca/Sa sepsis induced by Candida strain immunization inversely correlates with BM tissue/cellular damage as a reflection of localized virulence.
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Affiliation(s)
- Elizabeth A. Lilly
- Department of Microbiology and Immunology, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Breah E. Bender
- Department of Microbiology and Immunology, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Mairi C. Noverr
- Department of Microbiology and Immunology, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Paul L. Fidel
- Center of Excellence in Oral and Craniofacial Biology, Louisiana State University Health Sciences Center School of Dentistry, New Orleans, Louisiana, USA
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Invasive Fungal Breakthrough Infections under Targeted Echinocandin Prophylaxis in High-Risk Liver Transplant Recipients. J Fungi (Basel) 2023; 9:jof9020272. [PMID: 36836384 PMCID: PMC9961099 DOI: 10.3390/jof9020272] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Invasive fungal infections (IFIs) are frequent and outcome-relevant complications in the early postoperative period after orthotopic liver transplantation (OLT). Recent guidelines recommend targeted antimycotic prophylaxis (TAP) for high-risk liver transplant recipients (HR-LTRs). However, the choice of antimycotic agent is still a subject of discussion. Echinocandins are increasingly being used due to their advantageous safety profile and the increasing number of non-albicans Candida infections. However, the evidence justifying their use remains rather sparse. Recently published data on breakthrough IFI (b-IFI) raise concerns about echinocandin efficacy, especially in the case of intra-abdominal candidiasis (IAC), which is the most common infection site after OLT. In this retrospective study, we analyzed 100 adult HR-LTRs undergoing first-time OLT and receiving echinocandin prophylaxis between 2017 and 2020 in a tertiary university hospital. We found a breakthrough incidence of 16%, having a significant impact on postoperative complications, graft survival, and mortality. The reasons for this may be multifactorial. Among the pathogen-related factors, we identified the breakthrough of Candida parapsilosis in 11% of patients and one case of persistent IFI due to the development of a secondary echinocandin resistance of an IAC caused by Candida glabrata. Consequently, the efficacy of echinocandin prophylaxis in liver transplantation should be questioned. Further studies are necessary to clarify the matter of breakthrough infections under echinocandin prophylaxis.
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Incidence of Invasive Fungal Infections in Liver Transplant Recipients under Targeted Echinocandin Prophylaxis. J Clin Med 2023; 12:jcm12041520. [PMID: 36836055 PMCID: PMC9960065 DOI: 10.3390/jcm12041520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
Invasive fungal infections (IFIs) are one of the most important infectious complications after liver transplantation, determining morbidity and mortality. Antimycotic prophylaxis may impede IFI, but a consensus on indication, agent, or duration is still missing. Therefore, this study aimed to investigate the incidence of IFIs under targeted echinocandin antimycotic prophylaxis in adult high-risk liver transplant recipients. We retrospectively reviewed all patients undergoing a deceased donor liver transplantation at the Medical University of Innsbruck in the period from 2017 to 2020. Of 299 patients, 224 met the inclusion criteria. We defined patients as being at high risk for IFI if they had two or more prespecified risk factors and these patients received prophylaxis. In total, 85% (190/224) of the patients were correctly classified according to the developed algorithm, being able to predict an IFI with a sensitivity of 89%. Although 83% (90/109) so defined high-risk recipients received echinocandin prophylaxis, 21% (23/109) still developed an IFI. The multivariate analysis identified the age of the recipient (hazard ratio-HR = 0.97, p = 0.027), split liver transplantation (HR = 5.18, p = 0.014), massive intraoperative blood transfusion (HR = 24.08, p = 0.004), donor-derived infection (HR = 9.70, p < 0.001), and relaparotomy (HR = 4.62, p = 0.003) as variables with increased hazard ratios for an IFI within 90 days. The fungal colonization at baseline, high-urgency transplantation, posttransplant dialysis, bile leak, and early transplantation showed significance only in a univariate model. Notably, 57% (12/21) of the invasive Candida infections were caused by a non-albicans species, entailing a markedly reduced one-year survival. The attributable 90-day mortality rate of an IFI after a liver transplant was 53% (9/17). None of the patients with invasive aspergillosis survived. Despite targeted echinocandin prophylaxis, there is still a notable risk for IFI. Consequently, the prophylactic use of echinocandins must be critically questioned regarding the high rate of breakthrough infections, the increased occurrence of fluconazole-resistant pathogens, and the higher mortality rate in non-albicans Candida species. Adherence to the internal prophylaxis algorithms is of immense importance, bearing in mind the high IFI rates in case algorithms are not followed.
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Caspofungin Population Pharmacokinetic Analysis in Plasma and Peritoneal Fluid in Septic Patients with Intra-Abdominal Infections: A Prospective Cohort Study. Clin Pharmacokinet 2021; 61:673-686. [PMID: 34931282 DOI: 10.1007/s40262-021-01062-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study was to report the pharmacokinetics (PK) of caspofungin in plasma and peritoneal fluid and to identify optimal dosing strategies in septic patients with intra-abdominal infections. METHODS Eleven patients with secondary peritonitis with septic shock received the standard dosing regimen of caspofungin. Total caspofungin plasma and peritoneal concentrations were subject to a population PK analysis using Pmetrics®. Monte Carlo simulations were performed considering the ratio of 24-h total drug exposure above the minimum inhibitory concentration (AUC24/MIC) in plasma and comparing simulated concentrations versus MIC in peritoneal fluid. RESULTS Fat-free mass (FFM) was retained in the final model of caspofungin, reporting a total clearance (standard deviation) of 0.78 (0.17) L/h and a central volume of distribution of 9.36 (2.61) L. The peritoneal fluid/plasma ratio of caspofungin was 33% on the first day of therapy (AUC24 73.92 (21.93) and 26.03 (9.88) mg*h/L for plasma and peritoneal data, respectively). Dosing simulations supported the use of standard dosing regimens for patients with an FFM < 50 kg for the most susceptible candida species (C. albicans and C. glabrata). For higher FFM, a loading dose of 70 or 100 mg, with a maintenance dose of 70 mg, reached AUC24/MIC ratios for these species. CONCLUSIONS There is moderate penetration of caspofungin into the peritoneal cavity (33%). For empirical treatment, a dose escalation of 100 mg loading dose on the first day is suggested for higher FFM to ensure adequate concentrations into the abdominal cavity for the most susceptible candida species.
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Prospective Cohort Study of Micafungin Population Pharmacokinetic Analysis in Plasma and Peritoneal Fluid in Septic Patients with Intra-abdominal Infections. Antimicrob Agents Chemother 2021; 65:e0230720. [PMID: 33846133 DOI: 10.1128/aac.02307-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The objective of this study was to describe the pharmacokinetics (PK) of micafungin in plasma and peritoneal fluid in septic patients with intra-abdominal infections. Twelve patients with secondary peritonitis in septic shock receiving 100 mg micafungin once daily were included. Total micafungin plasma and peritoneal fluid were subjected to a population pharmacokinetic analysis using Pmetrics. Monte Carlo simulations were performed considering the total area under the curve from 0 to 24 h (AUC0-24)/MIC ratios in plasma. Micafungin concentrations in both plasma and the peritoneal exudate were best described by a three-compartmental PK model with the fat-free mass (FFM) as a covariate of clearance (CL) and the volume of the central compartment (Vc). The mean parameter estimates (standard deviations [SD]) were 1.18 (0.40) liters/h for CL and 12.85 (4.78) liters for Vc. The mean peritoneal exudate/plasma ratios (SD) of micafungin were 25% (5%) on day 1 and 40% (8%) between days 3 and 5. Dosing simulations supported the use of standard 100-mg daily dosing for Candida albicans (FFM, <60 kg), C. glabrata (FFM, <50 kg), and C. tropicalis (FFM, <30 kg) on the second day of therapy. There is a moderate penetration of micafungin into the peritoneal cavity (25 to 40%). For empirical treatment, a dose escalation of at least a loading dose of 150 mg depending on the FFM of patients and the Candida species is suggested to be effective from the first day of therapy.
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Soulountsi V, Schizodimos T, Kotoulas SC. Deciphering the epidemiology of invasive candidiasis in the intensive care unit: is it possible? Infection 2021; 49:1107-1131. [PMID: 34132989 DOI: 10.1007/s15010-021-01640-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 06/08/2021] [Indexed: 12/12/2022]
Abstract
Invasive candidiasis (IC) has emerged in the last decades as an important cause of morbidity, mortality, and economic load in the intensive care unit (ICU). The epidemiology of IC is still a difficult and unsolved enigma for the literature. Accurate estimation of the true burden of IC is difficult due to variation in definitions and limitations inherent to available case-finding methodologies. Candidemia and intra-abdominal candidiasis (IAC) are the two predominant types of IC in ICU. During the last two decades, an increase in the incidence of candidemia has been constantly reported particularly in the expanding populations of elderly or immunosuppressed patents, with a parallel change in Candida species (spp.) distribution worldwide. Epidemiological shift in non-albicans spp. has reached worrisome trends. Recently, a novel, multidrug-resistant Candida spp., Candida auris, has globally emerged as a nosocomial pathogen causing a broad range of healthcare-associated invasive infections. Epidemiological profile of IAC remains imprecise. Though antifungal drugs are available for Candida infections, mortality rates continue to be high, estimated to be up to 50%. Increased use of fluconazole and echinocandins has been associated with the emergence of resistance to these drugs, which affects particularly C. albicans and C. glabrata. Crucial priorities for clinicians are to recognize the epidemiological trends of IC as well as the emergence of resistance to antifungal agents to improve diagnostic techniques and strategies, develop international surveillance networks and antifungal stewardship programmes for a better epidemiological control of IC.
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Affiliation(s)
- Vasiliki Soulountsi
- Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece.
| | - Theodoros Schizodimos
- Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece
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Antimicrobial Lessons From a Large Observational Cohort on Intra-abdominal Infections in Intensive Care Units. Drugs 2021; 81:1065-1078. [PMID: 34037963 DOI: 10.1007/s40265-021-01534-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
Severe intra-abdominal infection commonly requires intensive care. Mortality is high and is mainly determined by disease-specific characteristics, i.e. setting of infection onset, anatomical barrier disruption, and severity of disease expression. Recent observations revealed that antimicrobial resistance appears equally common in community-acquired and late-onset hospital-acquired infection. This challenges basic principles in anti-infective therapy guidelines, including the paradigm that pathogens involved in community-acquired infection are covered by standard empiric antimicrobial regimens, and second, the concept of nosocomial acquisition as the main driver for resistance involvement. In this study, we report on resistance profiles of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecalis and Enterococcus faecium in distinct European geographic regions based on an observational cohort study on intra-abdominal infections in intensive care unit (ICU) patients. Resistance against aminopenicillins, fluoroquinolones, and third-generation cephalosporins in E. coli, K. pneumoniae and P. aeruginosa is problematic, as is carbapenem-resistance in the latter pathogen. For E. coli and K. pneumoniae, resistance is mainly an issue in Central Europe, Eastern and South-East Europe, and Southern Europe, while resistance in P. aeruginosa is additionally problematic in Western Europe. Vancomycin-resistance in E. faecalis is of lesser concern but requires vigilance in E. faecium in Central and Eastern and South-East Europe. In the subcohort of patients with secondary peritonitis presenting with either sepsis or septic shock, the appropriateness of empiric antimicrobial therapy was not associated with mortality. In contrast, failure of source control was strongly associated with mortality. The relevance of these new insights for future recommendations regarding empiric antimicrobial therapy in intra-abdominal infections is discussed.
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Roccamatisi L, Gianotti L, Paiella S, Casciani F, De Pastena M, Caccialanza R, Bassi C, Sandini M. Preoperative standardized phase angle at bioimpedance vector analysis predicts the outbreak of antimicrobial-resistant infections after major abdominal oncologic surgery: A prospective trial. Nutrition 2021; 86:111184. [PMID: 33676330 DOI: 10.1016/j.nut.2021.111184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/30/2020] [Accepted: 01/21/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Infectious morbidity is the most common and costly among all surgery-related complications, and infections by multidrug-resistant microorganisms (MDR) are associated with poor outcomes. Derangements of body composition is a recognized risk factor for infections. The aim of this study was to investigate the potential association between specific traits of body composition and the risk of having MDR-related infections. METHODS This was a prospective study with patients scheduled for major abdominal surgery for gastrointestinal cancer. Bioimpedance vector analysis (BIVA), a reliable tool for body composition assessment, was performed the day before the operation. Postoperative complications were collected focusing on resistance patterns and site of infection. Patterns of resistance were compared with BIVA parameters. RESULTS Data from 182 patients suffering from pancreatic (n = 76, 41.7%), rectal (n = 38, 20.9%), gastric (n = 31, 17%), or hepatic (n = 37, 20.3%) malignancy were collected. Overall complications occurred in 108 patients (59%), and in 45 patients (28%) bacterial infections were proven at culture. Of these, 15 (8%) were multidrug-sensitive (MDS), 38 MDR, and 2 extended drug-resistant (XDR) infections. The standardized phase angle measured (SPA) at BIVA was significantly lower in the MDR/XDR infections (-0.02 ± 1.20) than for no infection/MDS (0.56 ± 1.53; P = 0.029). A multivariate analysis showed that SPA was the only independent variable for MDR/XDR infections with an odds ratio of 3.057 (95% confidence interval, 1.354-6903; P = 0.007). The predictive ability of SPA revealed an area under the receiver operating characteristic curve of 0.662, with an optimal threshold of -0.3. CONCLUSIONS In surgical cancer patients, preoperative value of SPA lower than -0.3 is associated with the outbreak of MDR bacterial infections.
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Affiliation(s)
- Linda Roccamatisi
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy Monza, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy Monza, Italy.
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, The Pancreas Institute, Policlinico GB Rossi, University of Verona Hospital Trust, Verona, Italy
| | - Fabio Casciani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, Policlinico GB Rossi, University of Verona Hospital Trust, Verona, Italy
| | - Matteo De Pastena
- Unit of General and Pancreatic Surgery, The Pancreas Institute, Policlinico GB Rossi, University of Verona Hospital Trust, Verona, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, Policlinico GB Rossi, University of Verona Hospital Trust, Verona, Italy
| | - Marta Sandini
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy Monza, Italy; Department of General Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Fungal Peritonitis Due to Gastroduodenal Perforation: Diagnostic and Treatment Challenges. ACTA MEDICA BULGARICA 2020. [DOI: 10.2478/amb-2020-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The gastrointestinal tract perforation is one of the leading causes of acute abdomen. Mycotic infections have become a significant clinical problem over the last few decades. Despite the advance in diagnostics and treatment of patients with fungal peritonitis, the mortality remains high.
Objective. The objective of the study was to determine the type and incidence of causative pathogens of acute peritonitis in patients with gastroduodenal perforation, and to estimate the impact of microbial flora on the disease outcome.
Materials and methods. We performed a retrospective study among 83 adult patients with acute peritonitis due to gastroduodenal perforation treated at our centre.
Results. A total of 40 mycotic agents were isolated in 39 of the abdominal samples. The primary mycotic isolates were Candida albicans (52.5%) and C. glabrata (64.3%); C. krusei (14.3%) and C. tropicalis (7.1%) predominated among non-albicans Candida species (35.0%). The most common bacterial agents were Escherichia coli (24.0%) and Enterococcus spp. (24.0%). 77.1% of all enrolled patients survived, and 19 of them deceased due to sepsis and multiple organ dysfunction syndrome.
Conclusion. Candida albicans is the most common mycotic pathogen in patients with acute peritonitis due to gastroduodenal perforation. It is obligatory to examine the peritoneal fluid samples for bacterial and fungal pathogens with determination of their antimicrobial susceptibility profile. Timely initiation of adequate treatment and multidisciplinary approach is crucial for the outcome of patients with fungal peritonitis.
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Eckmann C, Isenmann R, Kujath P, Pross A, Rodloff AC, Schmitz FJ. Calculated parenteral initial treatment of bacterial infections: Intra-abdominal infections. GMS INFECTIOUS DISEASES 2020; 8:Doc13. [PMID: 32373438 PMCID: PMC7186812 DOI: 10.3205/id000057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This is the seventh chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter deals with the empirical and targeted antimicrobial therapy of complicated intra-abdominal infections. It includes recommendations for antibacterial and antifungal treatment.
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Affiliation(s)
- Christian Eckmann
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Hannoversch-Münden, Germany
| | - Rainer Isenmann
- Allgemein- und Visceralchirurgie, St. Anna-Virngrund-Klinik Ellwangen, Germany
| | - Peter Kujath
- Chirurgische Klinik, Medizinische Universität Lübeck, Germany
| | - Annette Pross
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Germany
| | - Arne C. Rodloff
- Institut für Medizinische Mikrobiologie und Infektionsepidemiologie, Universitätsklinikum Leipzig, Germany
| | - Franz-Josef Schmitz
- Institut für Laboratoriumsmedizin, Mikrobiologie, Hygiene, Umweltmedizin und Transfusionsmedizin Johannes Wesling Klinikum Minden, Germany
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Fidel PL, Yano J, Esher SK, Noverr MC. Applying the Host-Microbe Damage Response Framework to Candida Pathogenesis: Current and Prospective Strategies to Reduce Damage. J Fungi (Basel) 2020; 6:jof6010035. [PMID: 32168864 PMCID: PMC7151217 DOI: 10.3390/jof6010035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 12/16/2022] Open
Abstract
Disease is a complex outcome that can occur as a result of pathogen-mediated damage, host-mediated damage or both. This has led to the revolutionary concept of the damage response framework (DRF) that defines microbial virulence as a function of host immunity. The DRF outlines six scenarios (classes) of host damage or beneficial outcomes, depending on the microbe and the strength of the immune response. Candida albicans is uniquely adapted to its human host and can exist as either a commensal, colonizing various anatomical sites without causing notable damage, or as a pathogen, with the ability to cause a diverse array of diseases, ranging from mucosal to invasive systemic infections that result in varying levels of microbe-mediated and/or host-mediated damage. We recently categorized six different forms of candidiasis (oropharyngeal, hematogenous, intra-abdominal, gastrointestinal, denture stomatitis, and vulvovaginitis) into independent DRF classes, supporting a contemporary view of unique mechanisms of pathogenesis for these Candida infections. In this review, we summarize the evidence for the pathogenesis of these various forms of candidiasis in the context of the DRF with the further intent to provide insights into strategies to achieve a level of host response or outcome otherwise, that limits host damage.
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Affiliation(s)
- Paul L. Fidel
- Center of Excellence in Oral and Craniofacial Biology, Louisiana State University Health Sciences Center School of Dentistry, New Orleans, LA 70119, USA;
- Correspondence: ; Tel.: +1-504-941-8425
| | - Junko Yano
- Center of Excellence in Oral and Craniofacial Biology, Louisiana State University Health Sciences Center School of Dentistry, New Orleans, LA 70119, USA;
| | - Shannon K. Esher
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA 70112, USA; (S.K.E.); (M.C.N.)
| | - Mairi C. Noverr
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA 70112, USA; (S.K.E.); (M.C.N.)
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Penetration of Ibrexafungerp (Formerly SCY-078) at the Site of Infection in an Intra-abdominal Candidiasis Mouse Model. Antimicrob Agents Chemother 2020; 64:AAC.02268-19. [PMID: 31871074 DOI: 10.1128/aac.02268-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/15/2019] [Indexed: 01/17/2023] Open
Abstract
Ibrexafungerp (IBX), formerly SCY-078, is a novel, oral and intravenous, semisynthetic triterpenoid glucan synthase inhibitor in clinical development for treating multiple fungal infections, including invasive candidiasis. Intra-abdominal candidiasis (IAC) is one of the most common types of invasive candidiasis associated with high mortality largely due to poor drug exposure in infected lesions. To better understand the potential of IBX to treat such infections, we investigated its penetration at the site of infection. Using matrix-assisted laser desorption ionization-mass spectrometry imaging (MALDI-MSI) and laser capture microdissection (LCM)-directed high-pressure liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS), we investigated tissue distribution and lesion-specific drug exposure of IBX in a clinically relevant IAC mouse model. After a single-dose treatment, IBX quickly distributed into tissues and efficiently accumulated within lesions. Drug concentrations of IBX within the liver abscesses were almost 100-fold higher than the serum concentration. In addition, drug penetration after repeated treatment of IBX was compared with micafungin. IBX exhibited robust and long-lasting lesion penetration after repeated treatment. These data indicate that IBX penetrates into intra-abdominal abscesses highly efficiently and holds promise as a potential therapeutic option for IAC patients.
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Lagunes L, Rey-Pérez A. What´s new in intraabdominal candidiasis in critically ill patients, a review. Hosp Pract (1995) 2019; 47:171-176. [PMID: 31585520 DOI: 10.1080/21548331.2019.1677032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A high prevalence of invasive candidiasis has been reported in recent years. Patients admitted to an intensive care unit are at the highest risk for invasive candidiasis, mostly due to the severity of their disease, immune-suppressive states, prolonged length of stay, broad-spectrum antibiotics, septic shock, and Candida colonization. Intraabdominal candidiasis comprises a range of clinical manifestations, from just the suspicion based on clinical scenario to fever, leukocytosis, increase in biomarkers to the isolation of the responsible microorganism. In critically ill patients with IAC prompt treatment and adequate source control remains the ultimate goal.
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Affiliation(s)
- L Lagunes
- Critical Care Department, Hospital Especialidades Medicas, San Luis Potosí, Mexico.,CRIPS, Vall d´Hebron Institut de Recerca, Vall d´Hebron, Barcelona, Spain
| | - A Rey-Pérez
- Burns and Neurotrauma Critical Care Department, Vall d´Hebron, Campus Hospitalari, Barcelona, Spain
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15
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Spectrum of Trained Innate Immunity Induced by Low-Virulence Candida Species against Lethal Polymicrobial Intra-abdominal Infection. Infect Immun 2019; 87:IAI.00348-19. [PMID: 31085710 PMCID: PMC6652762 DOI: 10.1128/iai.00348-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 12/14/2022] Open
Abstract
Polymicrobial intra-abdominal infections (IAI) are clinically prevalent and cause significant morbidity and mortality, especially those involving fungi. Our laboratory developed a mouse model of polymicrobial IAI and demonstrated that coinfection with Candida albicans and Staphylococcus aureus (C. albicans/S. aureus) results in 80 to 90% mortality in 48 to 72 h due to robust local and systemic inflammation. Polymicrobial intra-abdominal infections (IAI) are clinically prevalent and cause significant morbidity and mortality, especially those involving fungi. Our laboratory developed a mouse model of polymicrobial IAI and demonstrated that coinfection with Candida albicans and Staphylococcus aureus (C. albicans/S. aureus) results in 80 to 90% mortality in 48 to 72 h due to robust local and systemic inflammation. Surprisingly, inoculation with Candida dubliniensis and S. aureus resulted in minimal mortality, and rechallenge of mice with lethal C. albicans/S. aureus conferred >90% protection up to 60 days postinoculation. Protection was mediated by Gr-1+ polymorphonuclear leukocytes, indicating a novel form of trained innate immunity (TII). The purpose of this study was to determine the microbial requirements and spectrum of innate-mediated protection. In addition to Candida dubliniensis, several other low-virulence Candida species (C. glabrata, C. auris, and C. albicansefg1Δ/Δ cph1Δ/Δ) and Saccharomyces cerevisiae conferred significant protection with or without S. aureus. For C. dubliniensis-mediated protection, hyphal formation was not required, with protection conferred as early as 7 days after primary challenge but not at 120 days, and also following multiple lethal C. albicans/S. aureus rechallenges. This protection also extended to a lethal intravenous (i.v.) C. albicans challenge but had no effect in the C. albicans vaginitis model. Finally, studies revealed the ability of the low-virulence Candida species that conferred protection to invade the bone marrow by 24 h post-primary challenge, with a positive correlation between femoral bone marrow fungal infiltration at 48 h and protection upon rechallenge. These results support and further extend the characterization of this novel TII in protection against lethal fungal-bacterial IAI and sepsis.
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Esher SK, Fidel PL, Noverr MC. Candida/Staphylococcal Polymicrobial Intra-Abdominal Infection: Pathogenesis and Perspectives for a Novel Form of Trained Innate Immunity. J Fungi (Basel) 2019; 5:E37. [PMID: 31075836 PMCID: PMC6617080 DOI: 10.3390/jof5020037] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 01/10/2023] Open
Abstract
Polymicrobial sepsis is difficult to diagnose and treat and causes significant morbidity and mortality, especially when fungi are involved. In vitro, synergism between Candida albicans and various bacterial species has been described for many years. Our laboratory has developed a murine model of polymicrobial intra-abdominal infection with Candida albicans and Staphylococcus aureus, demonstrating that polymicrobial infections cause high levels of mortality, while monoinfections do not. By contrast, closely related Candida dubliniensis does not cause synergistic lethality and rather provides protection against lethal polymicrobial infection. This protection is thought to be driven by a novel form of trained innate immunity mediated by myeloid-derived suppressor cells (MDSCs), which we are proposing to call "trained tolerogenic immunity". MDSC accumulation has been described in patients with sepsis, as well as in in vivo sepsis models. However, clinically, MDSCs are considered detrimental in sepsis, while their role in in vivo models differs depending on the sepsis model and timing. In this review, we will discuss the role of MDSCs in sepsis and infection and summarize our perspectives on their development and function in the spectrum of trained innate immune protection against fungal-bacterial sepsis.
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Affiliation(s)
- Shannon K Esher
- Center of Excellence in Oral and Craniofacial Biology, School of Dentistry, Louisiana State University Health Sciences Center, New Orleans, LA 70119, USA.
- Department of Microbiology and Immunology, School of Medicine, Tulane University, New Orleans, LA 70112, USA.
| | - Paul L Fidel
- Center of Excellence in Oral and Craniofacial Biology, School of Dentistry, Louisiana State University Health Sciences Center, New Orleans, LA 70119, USA.
| | - Mairi C Noverr
- Center of Excellence in Oral and Craniofacial Biology, School of Dentistry, Louisiana State University Health Sciences Center, New Orleans, LA 70119, USA.
- Department of Microbiology and Immunology, School of Medicine, Tulane University, New Orleans, LA 70112, USA.
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17
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Blot S. Effect of antifungal exposure on the etiology of candidemia. Med Mal Infect 2019; 49:357. [PMID: 30871818 DOI: 10.1016/j.medmal.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 02/11/2019] [Indexed: 11/19/2022]
Affiliation(s)
- S Blot
- Department of Internal Medicine & Pediatrics, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Burns, Trauma, & Critical Care Research Centre, Faculty of Medicine, The University of Queensland, 4029 Herston, Queensland, Australia.
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18
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García J, Pemán J. [Microbiological diagnosis of invasive mycosis]. Rev Iberoam Micol 2018; 35:179-185. [PMID: 30471895 DOI: 10.1016/j.riam.2018.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 04/11/2018] [Accepted: 05/08/2018] [Indexed: 11/17/2022] Open
Abstract
The prognosis of invasive fungal infections (IFI) depends on the speed of diagnosis and treatment. Conventional diagnostic methods are of low sensitivity, laborious and too slow, leading to the need for new, faster, and more efficient diagnostic strategies. There are several techniques for diagnosing a candidemia that are faster than the conventional blood culture (BC). Once yeast growth in BC is detected, species identification can be speeded up by mass spectrometry (30minutes), commercialised molecular techniques (60-80minutes) or fluorescent in situ hybridization (90minutes). The combined detection of biomarkers (antimicellium, mannan and anti-mannan or β-glucan) has shown to be of greater use than their individual use. Commercialised nucleic acid amplification techniques (Septifast®, T2Candida®) are very reliable alternatives to BC. The detection of the capsular antigen of Cryptococcus, by means of latex agglutination or immuno-chromatography, is a valuable technique for cryptococcosis diagnosis. Direct microscopic examination and culture of representative specimens is used for the conventional diagnosis of IFI by filamentous fungi. Detection of galactomannan and β-glucan are considered diagnostic criteria for probable invasive aspergillosis and probable IFI, respectively, despite the lack of specificity of the latter. The detection of fungal volatile organic compounds in breath is an interesting diagnostic strategy in pulmonary infections. Although widely used, nucleic acid detection techniques are not considered diagnostic criteria for IFIs caused by moulds in consensus documents, due to their lack of standardisation. However, they are the only alternative to culture methods in invasive infections by Scedosporium/Lomentospora, Fusarium, zygomycetes, or dematiaceous fungi.
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Affiliation(s)
- Julio García
- Servicio de Microbiología, Hospital Universitario La Paz, Madrid, España
| | - Javier Pemán
- Servicio de Microbiología, Hospital Universitari i Politècnic La Fe, Valencia, España.
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19
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Anidulafungin increases the antibacterial activity of tigecycline in polymicrobial Candida albicans/Staphylococcus aureus biofilms on intraperitoneally implanted foreign bodies. J Antimicrob Chemother 2018; 73:2806-2814. [DOI: 10.1093/jac/dky246] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/30/2018] [Indexed: 11/14/2022] Open
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Yeoh SF, Lee TJ, Chew KL, Lin S, Yeo D, Setia S. Echinocandins for management of invasive candidiasis in patients with liver disease and liver transplantation. Infect Drug Resist 2018; 11:805-819. [PMID: 29881298 PMCID: PMC5985852 DOI: 10.2147/idr.s165676] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Candida species remains one of the most important causes of opportunistic infections worldwide. Invasive candidiasis (IC) is associated with considerable morbidity and mortality in liver disease (LD) patients if not treated promptly. Echinocandins are often recommended as a first-line empirical treatment for managing IC and can especially play a critical role in managing IC in LD patients. However, advanced LD patients are often immunocompromised and critically ill. Hence altered pharmacokinetics, drug interactions as well as tolerance issues of antifungal treatments are a concern in these patients. This comprehensive review examines the epidemiology, risk factors and diagnosis of IC in patients with LD and evaluates differences between three available echinocandins for treating this group of patients.
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Affiliation(s)
- Siang Fei Yeoh
- Department of Pharmacy, National University Health System, Singapore, Singapore
| | - Tae Jin Lee
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Ka Lip Chew
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Stephen Lin
- Global Medical Affairs, Asia-Pacific region, Pfizer, Hong Kong, People’s Republic of China
| | - Dennis Yeo
- Medical Affairs, Pfizer Pte. Ltd., Singapore, Singapore
| | - Sajita Setia
- Medical Affairs, Pfizer Pte. Ltd., Singapore, Singapore
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21
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Chen XP, Zheng H, Li WG, Chen GD, Lu JX. Bacteria-induced susceptibility to Candida albicans super-infection in mice via monocyte methyltransferase Setdb2. Cell Microbiol 2018; 20:e12860. [PMID: 29749709 DOI: 10.1111/cmi.12860] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/02/2018] [Accepted: 05/01/2018] [Indexed: 12/22/2022]
Abstract
Systemic bacterial infections are prone to secondary Candida albicans super-infection. However, the molecular mechanisms involved remain poorly understood. In this study, a model comprising sublethal cecal ligation and puncture plus C. albicans intravenous injection was applied to mimic the situation in super-infection. Compared with mice without systemic bacterial infection, mice with systemic bacterial infection had lower antifungal gene expression (including Il1b, Tnf, Il6, Ifnb, Ifng, Cxcl1, and Ccr2) in monocytes and less inflammatory monocytes and neutrophils infiltrating into the kidney when challenged with C. albicans. Further, lentivirus-mediated Setdb2-knockout and overexpression experiments verified that Setdb2 levels in monocytes correlated negatively with antifungal gene expression and survival rates. Transcriptional repression was probably achieved by Setdb2 through H3 methylation at lysine 9 in promoter regions of these antifungal genes.
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Affiliation(s)
- Xiao-Ping Chen
- State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Department of Nosocomial Infection, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hao Zheng
- State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Department of Nosocomial Infection, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Wen-Ge Li
- State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Department of Nosocomial Infection, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Guo-Dong Chen
- Department of Gastroenterology, Peking University People's Hospital, Beijing, China
| | - Jin-Xing Lu
- State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Department of Nosocomial Infection, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
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22
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Prostaglandin E 2 Receptor Antagonist with Antimicrobial Activity against Methicillin-Resistant Staphylococcus aureus. Antimicrob Agents Chemother 2018; 62:AAC.01920-17. [PMID: 29263068 DOI: 10.1128/aac.01920-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/13/2017] [Indexed: 11/20/2022] Open
Abstract
Polymicrobial intra-abdominal infections (IAI) involving Candida albicans and Staphylococcus aureus are associated with severe morbidity and mortality (∼80%). Our laboratory discovered that the immunomodulatory eicosanoid prostaglandin E2 (PGE2) plays a key role in the lethal inflammatory response during polymicrobial IAI using a mouse model of infection. In studies designed to uncover key PGE2 biosynthesis/signaling components involved in the response, selective eicosanoid enzyme inhibitors and receptor antagonists were selected and prescreened for antimicrobial activity against C. albicans or S. aureus Unexpectedly, we found that the EP4 receptor antagonist L-161,982 had direct growth-inhibitory effects on S. aureusin vitro at the physiological concentration required to block the PGE2 interaction with EP4 This antimicrobial activity was observed with methicillin-sensitive S. aureus and methicillin-resistant S. aureus (MRSA) strains, with the MIC and minimum bactericidal concentration values for planktonic cells being 50 μg/ml and 100 μg/ml, respectively. In addition, L-161,982 inhibited S. aureus biofilm formation and had activity against preformed mature biofilms. More importantly, treatment of mice with L-161,982 following intraperitoneal inoculation with a lethal dose of MRSA significantly reduced the bioburden and enhanced survival. Furthermore, L-161,982 protected mice against the synergistic lethality induced by coinfection with C. albicans and S. aureus The antimicrobial activity of L-161,982 is independent of EP4 receptor inhibitory activity; an alternative EP4 receptor antagonist exerted no antimicrobial or protective effects. Taken together, these findings demonstrate that L-161,982 has potent antimicrobial activity against MRSA and may represent a significant therapeutic alternative in improving the prognosis of mono- or polymicrobial infections involving MRSA.
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Abstract
Polymicrobial intra-abdominal infections (IAIs) are clinically prevalent and cause significant morbidity and mortality, especially those involving fungi. Our laboratory developed a mouse model of IAI and demonstrated that intraperitoneal inoculation with Candida albicans or other virulent non-albicans Candida (NAC) species plus Staphylococcus aureus resulted in 70 to 80% mortality in 48 to 72 h due to robust local and systemic inflammation (sepsis). Surprisingly, inoculation with Candida dubliniensis or Candida glabrata with S. aureus resulted in minimal mortality, and rechallenge of these mice with lethal C. albicans/S. aureus (i.e., coninfection) resulted in >90% protection. The purpose of this study was to define requirements for C. dubliniensis/S. aureus-mediated protection and interrogate the mechanism of the protective response. Protection was conferred by C. dubliniensis alone or by killed C. dubliniensis plus live S. aureus. S. aureus alone was not protective, and killed S. aureus compromised C. dubliniensis-induced protection. C. dubliniensis/S. aureus also protected against lethal challenge by NAC plus S. aureus and could protect for a long-term duration (60 days between primary challenge and C. albicans/S. aureus rechallenge). Unexpectedly, mice deficient in T and B cells (Rag-1 knockouts [KO]) survived both the initial C. dubliniensis/S. aureus challenge and the C. albicans/S. aureus rechallenge, indicating that adaptive immunity did not play a role. Similarly, mice depleted of macrophages prior to rechallenge were also protected. In contrast, protection was associated with high numbers of Gr-1hi polymorphonuclear leukocytes (PMNLs) in peritoneal lavage fluid within 4 h of rechallenge, and in vivo depletion of Gr-1+ cells prior to rechallenge abrogated protection. These results suggest that Candida species can induce protection against a lethal C. albicans/S. aureus IAI that is mediated by PMNLs and postulated to be a unique form of trained innate immunity. Polymicrobial intra-abdominal infections are clinically devastating infections with high mortality rates, particularly those involving fungal pathogens, including Candida species. Even in patients receiving aggressive antimicrobial therapy, mortality rates remain unacceptably high. There are no available vaccines against IAI, which is complicated by the polymicrobial nature of the infection. IAI leads to lethal systemic inflammation (sepsis), which is difficult to target pharmacologically, as components of the inflammatory response are also needed to control the infection. Our studies demonstrate that prior inoculation with low-virulence Candida species provides strong protection against subsequent lethal infection with C. albicans and S. aureus. Surprisingly, protection is long-lived but not mediated by adaptive (specific) immunity. Instead, protection is dependent on cells of the innate immune system (nonspecific immunity) and provides protection against other virulent Candida species. This discovery implies that a form of trained innate immunity may be clinically effective against polymicrobial IAI.
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Invasive Candida Infection after Upper Gastrointestinal Tract Surgery for Gastric Cancer. Int J Surg Oncol 2017; 2017:6058567. [PMID: 29234525 PMCID: PMC5695031 DOI: 10.1155/2017/6058567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 09/03/2017] [Accepted: 10/10/2017] [Indexed: 11/17/2022] Open
Abstract
Upper gastrointestinal tract (GIT) surgical procedures are more likely to cause nosocomial Candida peritonitis than lower GIT procedures and they thus constitute an independent risk factor for mortality. Because of the severity of postsurgical fungal infections complications, intensivists and surgeons need to be extremely aware of their clinical importance in critically ill postsurgical intensive care unit (ICU) patients. We analyzed the clinical and microbiological data of 149 oncologic patients who were hospitalized in the ICU at Soroka Medical Center between January 2010 and January 2015 after undergoing upper GIT surgery for gastric cancer. Invasive fungal infections related to secondary peritonitis following oncologic upper GIT surgery had a higher mortality rate than patients with nonfungal postoperative infectious complications. The presence of gastroesophageal junction leakage and advanced age were found to be independent risk factors for invasive fungal infection after oncologic upper GIT surgery.
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Posch W, Heimdörfer D, Wilflingseder D, Lass-Flörl C. Invasive candidiasis: future directions in non-culture based diagnosis. Expert Rev Anti Infect Ther 2017; 15:829-838. [PMID: 28829207 DOI: 10.1080/14787210.2017.1370373] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Delayed initial antifungal therapy is associated with high mortality rates caused by invasive candida infections, since accurate detection of the opportunistic pathogenic yeast and its identification display a diagnostic challenge. diagnosis of candida infections relies on time-consuming methods such as blood cultures, serologic and histopathologic examination. to allow for fast detection and characterization of invasive candidiasis, there is a need to improve diagnostic tools. trends in diagnostics switch to non-culture-based methods, which allow specified diagnosis within significantly shorter periods of time in order to provide early and appropriate antifungal treatment. Areas covered: within this review comprise novel pathogen- and host-related testing methods, e.g. multiplex-PCR analyses, T2 magnetic resonance, fungus-specific DNA microarrays, microRNA characterization or analyses of IL-17 as biomarker for early detection of invasive candidiasis. Expert commentary: Early recognition and diagnosis of fungal infections is a key issue for improved patient management. As shown in this review, a broad range of novel molecular based tests for the detection and identification of Candida species is available. However, several assays are in-house assays and lack standardization, clinical validation as well as data on sensitivity and specificity. This underscores the need for the development of faster and more accurate diagnostic tests.
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Affiliation(s)
- Wilfried Posch
- a Division of Hygiene and Medical Microbiology , Medical University of Innsbruck , Innsbruck , Austria
| | - David Heimdörfer
- a Division of Hygiene and Medical Microbiology , Medical University of Innsbruck , Innsbruck , Austria
| | - Doris Wilflingseder
- a Division of Hygiene and Medical Microbiology , Medical University of Innsbruck , Innsbruck , Austria
| | - Cornelia Lass-Flörl
- a Division of Hygiene and Medical Microbiology , Medical University of Innsbruck , Innsbruck , Austria
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Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, Chang PK, O'Neill PJ, Mollen KP, Huston JM, Diaz JJ, Prince JM. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt) 2017; 18:1-76. [PMID: 28085573 DOI: 10.1089/sur.2016.261] [Citation(s) in RCA: 321] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.
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Affiliation(s)
- John E Mazuski
- 1 Department of Surgery, Washington University School of Medicine , Saint Louis, Missouri
| | | | - Addison K May
- 3 Department of Surgery, Vanderbilt University , Nashville, Tennessee
| | - Robert G Sawyer
- 4 Department of Surgery, University of Virginia , Charlottesville, Virginia
| | - Evan P Nadler
- 5 Division of Pediatric Surgery, Children's National Medical Center , Washington, DC
| | - Matthew R Rosengart
- 6 Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Phillip K Chang
- 7 Department of Surgery, University of Kentucky , Lexington, Kentucky
| | | | - Kevin P Mollen
- 9 Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jared M Huston
- 10 Department of Surgery, Hofstra Northwell School of Medicine , Hempstead, New York
| | - Jose J Diaz
- 11 Department of Surgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jose M Prince
- 12 Departments of Surgery and Pediatrics, Hofstra-Northwell School of Medicine , Hempstead, New York
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Abstract
Secondary peritonitis remains associated with high mortality and morbidity rates. Treatment of secondary peritonitis is challenging even in modern medicine. Surgical intervention for source control remains the cornerstone of treatment, beside adequate antimicrobial therapy and resuscitation. A randomized clinical trial showed that relaparotomy on demand (ROD) after initial emergency surgery is the preferred treatment strategy, irrespective of the severity and extent of peritonitis. The effective and safe use of ROD requires intensive monitoring of the patient in a setting where diagnostic tests and decision making about relaparotomy are guaranteed round the clock. The lack of knowledge on timely and adequate patient selection, together with the lack of use of easy but reliable monitoring tools, seems to hamper full implementation of ROD. The accuracy of the relap decision tool is reasonable for prediction of ongoing peritonitis and selection for computer tomography (CT). The value of CT in an early postoperative phase is unclear. Future research and innovative technologies should focus on the additive value of CT in cases of operated secondary peritonitis and on the further optimization of bedside prediction tools to enhance adequate patient selection for intervention in a multidisciplinary setting.
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Affiliation(s)
- O van Ruler
- Department of Surgery, Academic Medical Center, 1100 DD, P.O. Box 22660, Amsterdam, The Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Center, 1100 DD, P.O. Box 22660, Amsterdam, The Netherlands.
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Majeed A, Ullah W, Zahid U, Al Mohajer M. Persistent spontaneous fungal peritonitis secondary to Candida albicans in a patient with alcoholic cirrhosis and review of the literature. BMJ Case Rep 2016; 2016:bcr-2016-216979. [PMID: 27873750 DOI: 10.1136/bcr-2016-216979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Candida albicans is a common human pathogen. Occasionally, it can cause peritonitis in immunocompromised and postsurgical patients. We report a case of a male patient who presented with abdominal pain and distention. He had a history of end-stage liver disease secondary to alcoholism. His peritoneal fluid culture revealed C albicans, and (1-3)-β-d glucan (BDG) level was elevated. His hospital course was complicated by sepsis and renal failure. He was treated with antifungals for spontaneous fungal peritonitis. Fungal peritonitis should be suspected in patients with chronic liver disease particularly with elevated BDG levels.
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Affiliation(s)
- Aneela Majeed
- Division of Infectious Disease, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Waqas Ullah
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Umar Zahid
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Mayar Al Mohajer
- Division of Infectious Disease, Department of Medicine, University of Arizona, Tucson, Arizona, USA
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Kashyap B, Kusumakar K, Kumar Sarin Y. Fatal Neonatal Peritoneal Candidiasis Mimicking Mucormycosis-A Case Report and Review of Literature. J Trop Pediatr 2016; 62:425-8. [PMID: 27185733 DOI: 10.1093/tropej/fmw028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Candida species have been implicated as significant contributors to morbidity in the neonatal period and are associated with 25-50% of mortality in invasive neonatal candidiasis. Peritoneal candidiasis, being paucisymptomatic, cannot often be correctly identified in a preterm neonate. The correct approach to diagnosis of neonatal peritoneal candidiasis is taking into account the epidemiology along with a strong clinical suspicion and appropriate timely diagnostic interventions. We report a case of fatal neonatal peritoneal candidiasis which was misdiagnosed as mucormycosis.
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Affiliation(s)
- Bineeta Kashyap
- Department of Microbiology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi 110002, India
| | - Kanupriya Kusumakar
- Department of Microbiology, Maulana Azad Medical College, New Delhi 110002, India
| | - Yogesh Kumar Sarin
- Department of Pediatric Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi 110002, India
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Mesini A, Bandettini R, Caviglia I, Fioredda F, Amoroso L, Faraci M, Mattioli G, Piaggio G, Risso FM, Moscatelli A, Loy A, Castagnola E. Candida infections in paediatrics: Results from a prospective single-centre study in a tertiary care children's hospital. Mycoses 2016; 60:118-123. [PMID: 27681940 DOI: 10.1111/myc.12570] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/28/2016] [Accepted: 09/01/2016] [Indexed: 12/21/2022]
Abstract
To describe the epidemiology of invasive Candida infection in a tertiary care paediatric hospital. Prospective single-centre survey on all Candida strains isolated from normally sterile fluids and urines in the period 2005-2015 . A total of 299 ICI were documented in 262 patients. Urinary tract infection represented the most frequent diagnosis (62%), followed by fungaemia (34%) and peritonitis (4%). Fungaemia was most frequent in children with cancer (59%) or in low birth weight neonates (61%), while urinary tract infections were more frequent in patients with urinary tract malformation. C.albicans was the most frequently isolated species (60%) compared with C. non-albicans, but differences were present according to the site of isolation and underlying conditions. Overall 90-day mortality was 7%, 13% in fungaemias, 8% in peritonitis and 2% in urinary tract infections. The rates of invasive Candida infection increased during the study period. Invasive Candida infection is diagnosed with increasing frequency in children. Site of isolation and aetiology are frequently related with the presence of underlying, favouring conditions. Mortality was not negligible, especially in the presence of more invasive infections and specific underlying conditions.
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Affiliation(s)
- Alessio Mesini
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Roberto Bandettini
- Laboratory of Analysis, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Ilaria Caviglia
- Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Francesca Fioredda
- Hematology Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Loredana Amoroso
- Oncology Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Maura Faraci
- Stem Cell Transplantation Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Girolamo Mattioli
- Pediatric Surgery, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Giorgio Piaggio
- Nephrology Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Francesco M Risso
- Neonatal Intensive Care Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric ICU, Critical Care and Perinatal Medicine, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Anna Loy
- Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Elio Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
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Candida albicans Pathogenesis: Fitting within the Host-Microbe Damage Response Framework. Infect Immun 2016; 84:2724-39. [PMID: 27430274 DOI: 10.1128/iai.00469-16] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Historically, the nature and extent of host damage by a microbe were considered highly dependent on virulence attributes of the microbe. However, it has become clear that disease is a complex outcome which can arise because of pathogen-mediated damage, host-mediated damage, or both, with active participation from the host microbiota. This awareness led to the formulation of the damage response framework (DRF), a revolutionary concept that defined microbial virulence as a function of host immunity. The DRF outlines six classifications of host damage outcomes based on the microbe and the strength of the immune response. In this review, we revisit this concept from the perspective of Candida albicans, a microbial pathogen uniquely adapted to its human host. This fungus commonly colonizes various anatomical sites without causing notable damage. However, depending on environmental conditions, a diverse array of diseases may occur, ranging from mucosal to invasive systemic infections resulting in microbe-mediated and/or host-mediated damage. Remarkably, C. albicans infections can fit into all six DRF classifications, depending on the anatomical site and associated host immune response. Here, we highlight some of these diverse and site-specific diseases and how they fit the DRF classifications, and we describe the animal models available to uncover pathogenic mechanisms and related host immune responses.
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Lagunes L, Borgatta B, Martín-Gomez MT, Rey-Pérez A, Antonelli M, Righi E, Merelli M, Brugnaro P, Dimopoulos G, Garnacho-Montero J, Colombo AL, Luzzati R, Menichetti F, Muñoz P, Nucci M, Scotton G, Viscoli C, Tumbarello M, Bassetti M, Rello J. Predictors of choice of initial antifungal treatment in intraabdominal candidiasis. Clin Microbiol Infect 2016; 22:719-24. [PMID: 27432766 DOI: 10.1016/j.cmi.2016.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 06/08/2016] [Accepted: 06/11/2016] [Indexed: 12/29/2022]
Abstract
Intraabdominal candidiasis (IAC) is the second most frequent form of invasive candidiasis, and is associated with high mortality rates. This study aims to identify current practices in initial antifungal treatment (IAT) in a real-world scenario and to define the predictors of the choice of echinocandins or azoles in IAC episodes. Secondary analysis was performed of a multinational retrospective cohort at 13 teaching hospitals in four countries (Italy, Greece, Spain and Brazil), over a 3-year period (2011-2013). IAC was identified in 481 patients, 323 of whom received antifungal therapy (classified as the treatment group). After excluding 13 patients given amphotericin B, the treatment group was further divided into the echinocandin group (209 patients; 64.7%) and the azole group (101 patients; 32.3%). Median APACHE II scores were significantly higher in the echinocandin group (p 0.013), but IAT did not differ significantly with regard to the Candida species involved. Logistic multivariate stepwise regression analysis, adjusted for centre effect, identified septic shock (adjusted OR (aOR) 1.54), APACHE II >15 (aOR 1.16) and presence in surgical ward at diagnosis (aOR 1.16) as the top three independent variables associated with an empirical echinocandin regimen. No differences in 30-day mortality were observed between groups. Echinocandin regimen was the first choice for IAT in patients with IAC. No statistical differences in mortality were observed between regimens, but echinocandins were administered to patients with more severe disease. Some disagreements were identified between current clinical guidelines and prescription of antifungals for IAC at the bedside, so further educational measures are required to optimize therapies.
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Affiliation(s)
- L Lagunes
- Critical Care Department, Vall d'Hebron University Hospital, Barcelona, Spain; Medicine Department, Universitat Autónoma de Barcelona, Spain.
| | - B Borgatta
- Critical Care Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - M T Martín-Gomez
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - A Rey-Pérez
- Critical Care Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - M Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli Hospital, Rome, Italy
| | - E Righi
- IAC Study Coordinator, Santa Maria Misericordia University Hospital, Infectious Diseases Division, Udine, Italy
| | - M Merelli
- IAC Study Coordinator, Santa Maria Misericordia University Hospital, Infectious Diseases Division, Udine, Italy
| | - P Brugnaro
- Venezia Hospital, Infectious Diseases Division, Venice, Italy
| | - G Dimopoulos
- Attikon University Hospital, Critical Care Department, Athens, Greece
| | - J Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena Instituto de Biomedicina de Sevilla, Seville, Spain
| | - A L Colombo
- Escola Paulista de Medicina UNIFESP, Sao Paulo, Brazil
| | - R Luzzati
- University Hospital of Trieste, Trieste, Italy
| | - F Menichetti
- Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - P Muñoz
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Medicine, Universidad Complutense, Madrid, Spain
| | - M Nucci
- University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - C Viscoli
- Azienda Ospedaliera Universitaria, Genoa, Italy
| | - M Tumbarello
- Sacro Cuore Catholic University Hospital, Rome, Italy
| | - M Bassetti
- IAC Study Coordinator, Santa Maria Misericordia University Hospital, Infectious Diseases Division, Udine, Italy
| | - J Rello
- Medicine Department, Universitat Autónoma de Barcelona, Spain; University Hospital of Trieste, Trieste, Italy
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Vergidis P, Clancy CJ, Shields RK, Park SY, Wildfeuer BN, Simmons RL, Nguyen MH. Intra-Abdominal Candidiasis: The Importance of Early Source Control and Antifungal Treatment. PLoS One 2016; 11:e0153247. [PMID: 27123857 PMCID: PMC4849645 DOI: 10.1371/journal.pone.0153247] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/27/2016] [Indexed: 01/28/2023] Open
Abstract
Intra-abdominal candidiasis (IAC) is poorly understood compared to candidemia. We described the clinical characteristics, microbiology, treatment and outcomes of IAC, and identified risk factors for mortality. We performed a retrospective study of adults diagnosed with IAC at our center in 2012–2013. Risk factors for mortality were evaluated using multivariable logistic regression. We identified 163 patients with IAC, compared to 161 with candidemia. Types of IAC were intra-abdominal abscesses (55%), secondary peritonitis (33%), primary peritonitis (5%), infected pancreatic necrosis (5%), and cholecystitis/cholangitis (3%). Eighty-three percent and 66% of secondary peritonitis and abscesses, respectively, stemmed from gastrointestinal (GI) tract sources. C. albicans (56%) and C. glabrata (24%) were the most common species. Bacterial co-infections and candidemia occurred in 67% and 6% of patients, respectively. Seventy-two percent of patients underwent an early source control intervention (within 5 days) and 72% received early antifungal treatment. 100-day mortality was 28%, and highest with primary (88%) or secondary (40%) peritonitis. Younger age, abscesses and early source control were independent predictors of survival. Younger age, abscesses and early antifungal treatment were independently associated with survival for IAC stemming from GI tract sources. Infectious diseases (ID) consultations were obtained in only 48% of patients. Consulted patients were significantly more likely to receive antifungal treatment. IAC is a common disease associated with heterogeneous manifestations, which result in poor outcomes. All patients should undergo source control interventions and receive antifungal treatment promptly. It is important for the ID community to become more engaged in treating IAC.
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Affiliation(s)
- Pascalis Vergidis
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- * E-mail:
| | - Cornelius J. Clancy
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Ryan K. Shields
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Seo Young Park
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Brett N. Wildfeuer
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Richard L. Simmons
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - M. Hong Nguyen
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
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van Ruler O, Boermeester MA. [Surgical treatment of secondary peritonitis: A continuing problem. German version]. Chirurg 2015; 87:13-9. [PMID: 26689581 DOI: 10.1007/s00104-015-0115-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Secondary peritonitis remains associated with high mortality and morbidity rates. Treatment of secondary peritonitis is still challenging even in the era of modern medicine. Surgical intervention for source control remains the cornerstone of treatment besides adequate antimicrobial therapy and when necessary intensive medical care measures and resuscitation. A randomized clinical trial showed that relaparotomy on demand (ROD) after initial emergency surgery was the preferred treatment strategy, irrespective of the severity and extent of peritonitis. RESULTS AND DISCUSSION The effective and safe use of ROD requires intensive monitoring of the patient in a setting where diagnostic tests and decision making about relaparotomy are guaranteed round the clock. The lack of knowledge on timely and adequate patient selection, together with the lack of use of easy but reliable monitoring tools seem to hamper full implementation of ROD. The accuracy of the relaparotomy decision tool is reasonable for prediction of the formation of peritonitis and necessary selection of patients for computed tomography (CT). The value of CT in the early postoperative phase is unclear. Future research and innovative technologies should focus on the additive value of CT after surgical treatment for secondary peritonitis and on the further optimization of bedside prediction tools to enhance adequate patient selection for interventions in a multidisciplinary setting.
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Affiliation(s)
- O van Ruler
- Department of Surgery, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, Niederlande
| | - M A Boermeester
- Department of Surgery, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, Niederlande.
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Morphology-Independent Virulence of Candida Species during Polymicrobial Intra-abdominal Infections with Staphylococcus aureus. Infect Immun 2015; 84:90-8. [PMID: 26483410 DOI: 10.1128/iai.01059-15] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/10/2015] [Indexed: 01/04/2023] Open
Abstract
Intra-abdominal polymicrobial infections cause significant morbidity and mortality. An experimental mouse model of Candida albicans-Staphylococcus aureus intra-abdominal infection (IAI) results in 100% mortality by 48 to 72 h postinoculation, while monomicrobial infections are avirulent. Mortality is associated with robust local and systemic inflammation without a requirement for C. albicans morphogenesis. However, the contribution of virulence factors coregulated during the yeast-to-hypha transition is unknown. This also raised the question of whether other Candida species that are unable to form hyphae are as virulent as C. albicans during polymicrobial IAI. Therefore, the purpose of this study was to evaluate the ability of non-albicans Candida (NAC) species with various morphologies and C. albicans transcription factor mutants (efg1/efg1 and cph1/cph1) to induce synergistic mortality and the accompanying inflammation. Results showed that S. aureus coinoculated with C. krusei or C. tropicalis was highly lethal, similar to C. albicans, while S. aureus-C. dubliniensis, S. aureus-C. parapsilosis, and S. aureus-C. glabrata coinoculations resulted in little to no mortality. Local and systemic interleukin-6 (IL-6) and prostaglandin E2 (PGE2) levels were significantly elevated during symptomatic and/or lethal coinfections, and hypothermia strongly correlated with mortality. Coinoculation with C. albicans strains deficient in the transcription factor Efg1 but not Cph1 reversed the lethal outcome. These results support previous findings and demonstrate that select Candida species, without reference to any morphological requirement, induce synergistic mortality, with IL-6 and PGE2 acting as key inflammatory factors. Mechanistically, signaling pathways controlled by Efg1 are critical for the ability of C. albicans to induce mortality from an intra-abdominal polymicrobial infection.
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Burgess HJ, Gaunt MC. Pathology in practice. Peritonitis caused by C albicans infection in a dog. J Am Vet Med Assoc 2015; 245:1107-9. [PMID: 25356710 DOI: 10.2460/javma.245.10.1107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Hilary J Burgess
- Department of Veterinary Pathology, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK S7N 5B4, Canada
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Bassetti M, Righi E, Ansaldi F, Merelli M, Scarparo C, Antonelli M, Garnacho-Montero J, Diaz-Martin A, Palacios-Garcia I, Luzzati R, Rosin C, Lagunes L, Rello J, Almirante B, Scotton PG, Baldin G, Dimopoulos G, Nucci M, Munoz P, Vena A, Bouza E, de Egea V, Colombo AL, Tascini C, Menichetti F, Tagliaferri E, Brugnaro P, Sanguinetti M, Mesini A, Sganga G, Viscoli C, Tumbarello M. A multicenter multinational study of abdominal candidiasis: epidemiology, outcomes and predictors of mortality. Intensive Care Med 2015; 41:1601-10. [PMID: 26077063 DOI: 10.1007/s00134-015-3866-2] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/04/2015] [Indexed: 01/17/2023]
Abstract
PURPOSE Clinical data on patients with intra-abdominal candidiasis (IAC) is still scarce. METHODS We collected data from 13 hospitals in Italy, Spain, Brazil, and Greece over a 3-year period (2011-2013) including patients from ICU, medical, and surgical wards. RESULTS A total of 481 patients were included in the study. Of these, 27% were hospitalized in ICU. Mean age was 63 years and 57% of patients were male. IAC mainly consisted of secondary peritonitis (41%) and abdominal abscesses (30%); 68 (14%) cases were also candidemic and 331 (69%) had concomitant bacterial infections. The most commonly isolated Candida species were C. albicans (n = 308 isolates, 64%) and C. glabrata (n = 76, 16%). Antifungal treatment included echinocandins (64%), azoles (32%), and amphotericin B (4%). Septic shock was documented in 40.5% of patients. Overall 30-day hospital mortality was 27% with 38.9% mortality in ICU. Multivariate logistic regression showed that age (OR 1.05, 95% CI 1.03-1.07, P < 0.001), increments in 1-point APACHE II scores (OR 1.05, 95% CI 1.01-1.08, P = 0.028), secondary peritonitis (OR 1.72, 95% CI 1.02-2.89, P = 0.019), septic shock (OR 3.29, 95% CI 1.88-5.86, P < 0.001), and absence of adequate abdominal source control (OR 3.35, 95% CI 2.01-5.63, P < 0.001) were associated with mortality. In patients with septic shock, absence of source control correlated with mortality rates above 60% irrespective of administration of an adequate antifungal therapy. CONCLUSIONS Low percentages of concomitant candidemia and high mortality rates are documented in IAC. In patients presenting with septic shock, source control is fundamental.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Piazzale Santa Maria della Misericordia 15, 33100, Udine, Italy,
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Morphogenesis is not required for Candida albicans-Staphylococcus aureus intra-abdominal infection-mediated dissemination and lethal sepsis. Infect Immun 2014; 82:3426-35. [PMID: 24891104 DOI: 10.1128/iai.01746-14] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Intra-abdominal polymicrobial infections cause significant morbidity and mortality. An established experimental mouse model of Staphylococcus aureus-Candida albicans intra-abdominal infection results in ∼60% mortality within 48 h postinoculation, concomitant with amplified local inflammatory responses, while monomicrobial infections are avirulent. The purpose of this study was to characterize early local and systemic innate responses during coinfection and determine the role of C. albicans morphogenesis in lethality, a trait involved in virulence and physical interaction with S. aureus. Local and systemic proinflammatory cytokines were significantly elevated during coinfection at early time points (4 to 12 h) compared to those in monoinfection. In contrast, microbial burdens in the organs and peritoneal lavage fluid were similar between mono- and coinfected animals through 24 h, as was peritoneal neutrophil infiltration. After optimizing the model for 100% mortality within 48 h, using 3.5 × 10(7) C. albicans (5× increase), coinfection with C. albicans yeast-locked or hypha-locked mutants showed similar mortality, dissemination, and local and systemic inflammation to the isogenic control. However, coinfection with the yeast-locked C. albicans mutant given intravenously (i.v.) and S. aureus given intraperitoneally (i.p.) failed to induce mortality. These results suggest a unique intra-abdominal interaction between the host and C. albicans-S. aureus that results in strong inflammatory responses, dissemination, and lethal sepsis, independent of C. albicans morphogenesis.
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Candida glabrata intra-abdominal candidiasis is characterized by persistence within the peritoneal cavity and abscesses. Infect Immun 2014; 82:3015-22. [PMID: 24799629 DOI: 10.1128/iai.00062-14] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The pathogenesis of Candida glabrata infections is poorly understood. We studied the pathogenesis of intra-abdominal candidiasis (IAC) in mice that were infected intraperitoneally with C. glabrata and sterile feces. C. glabrata BG2 (5 × 10(8) CFU) caused a 100% mortality rate. Sublethal inocula of BG2 (1 × 10(8) or 1 × 10(7) CFU) caused peritonitis that progressed to abscesses. Three clinical C. glabrata strains (5 × 10(8) CFU) caused 80 to 100% mortality rates, while a fourth (strain 346) caused a 29% mortality rate. Following sublethal inocula (1 × 10(7) CFU), the intra-abscess burdens of virulent strain 356 were ∼1 log greater than those of strain 346. A C. glabrata Δplb1-2 mutant (phospholipase B genes disrupted) killed mice as well as BG2 did. When sublethal inocula were used, however, the Δplb1-2 mutant was associated with more rapid abscess resolution and lower intra-abscess burdens; these findings were reversed by PLB1 and PLB2 reinsertion. The Δplb1-2 mutant was also more susceptible than BG2 to killing by human neutrophils in vitro. BG2 and the Δplb1-2 mutant were indistinguishable during hematogenously disseminated candidiasis. C. albicans SC5314 was more virulent than C. glabrata BG2 during IAC, causing a 100% mortality rate following a challenge with 5 × 10(7) CFU. In contrast, a sublethal inoculum (1 × 10(7) CFU) of BG2 caused less neutrophil infiltration and greater burdens in peritoneal fluid than SC5314 did and abscesses that persisted longer and contained greater burdens. In conclusion, a mouse model of C. glabrata IAC mimics disease in humans and distinguishes the relative virulence of clinical and gene disruption strains. C. glabrata differed from C. albicans during IAC by being less lethal and eliciting dampened neutrophil responses but resulting in more persistent peritonitis and abscesses.
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Glöckner A, Cornely O. Invasive Candida-Infektionen bei nichtneutropenischen Erwachsenen. Anaesthesist 2013; 62:1003-9. [DOI: 10.1007/s00101-013-2208-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts. Intensive Care Med 2013; 39:2092-106. [PMID: 24105327 DOI: 10.1007/s00134-013-3109-3] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 09/07/2013] [Indexed: 12/17/2022]
Abstract
INTRODUCTION intra-abdominal candidiasis (IAC) may include Candida involvement of peritoneum or intra-abdominal abscess and is burdened by high morbidity and mortality rates in surgical patients. Unfortunately, international guidelines do not specifically address this particular clinical setting due to heterogeneity of definitions and scant direct evidence. In order to cover this unmet clinical need, the Italian Society of Intensive Care and the International Society of Chemotherapy endorsed a project aimed at producing practice recommendations for the management of immune-competent adult patients with IAC. METHODS A multidisciplinary expert panel of 22 members (surgeons, infectious disease and intensive care physicians) was convened and assisted by a methodologist between April 2012 and May 2013. Evidence supporting each statement was graded according to the European Society of Clinical Microbiology and Infection Diseases (ESCMID) grading system. RESULTS Only a few of the numerous recommendations can be summarized in the Abstract. Direct microscopy examination for yeast detection from purulent and necrotic intra-abdominal specimens during surgery or by percutaneous aspiration is recommended in all patients with nonappendicular abdominal infections including secondary and tertiary peritonitis. Samples obtained from drainage tubes are not valuable except for evaluation of colonization. Prophylactic usage of fluconazole should be adopted in patients with recent abdominal surgery and recurrent gastrointestinal perforation or anastomotic leakage. Empirical antifungal treatment with echinocandins or lipid formulations of amphotericin B should be strongly considered in critically ill patients or those with previous exposure to azoles and suspected intra-abdominal infection with at least one specific risk factor for Candida infection. In patients with nonspecific risk factors, a positive mannan/antimannan or (1→3)-β-D-glucan (BDG) or polymerase chain reaction (PCR) test result should be present to start empirical therapy. Fluconazole can be adopted for the empirical and targeted therapy of non-critically ill patients without previous exposure to azoles unless they are known to be colonized with a Candida strain with reduced susceptibility to azoles. Treatment can be simplified by stepping down to an azole (fluconazole or voriconazole) after at least 5-7 days of treatment with echinocandins or lipid formulations of amphotericin B, if the species is susceptible and the patient has clinically improved. CONCLUSIONS Specific recommendations were elaborated on IAC management based on the best direct and indirect evidence and on the expertise of a multinational panel.
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Cheng S, Clancy CJ, Xu W, Schneider F, Hao B, Mitchell AP, Nguyen MH. Profiling of Candida albicans gene expression during intra-abdominal candidiasis identifies biologic processes involved in pathogenesis. J Infect Dis 2013; 208:1529-37. [PMID: 24006479 DOI: 10.1093/infdis/jit335] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The pathogenesis of intra-abdominal candidiasis is poorly understood. METHODS Mice were intraperitoneally infected with Candida albicans (1 × 10(6) colony-forming units) and sterile stool. nanoString assays were used to quantitate messenger RNA for 145 C. albicans genes within the peritoneal cavity at 48 hours. RESULTS Within 6 hours after infection, mice developed peritonitis, characterized by high yeast burdens, neutrophil influx, and a pH of 7.9 within peritoneal fluid. Organ invasion by hyphae and early abscess formation were evident 6 and 24 hours after infection, respectively; abscesses resolved by day 14. nanoString assays revealed adhesion and responses to alkaline pH, osmolarity, and stress as biologic processes activated in the peritoneal cavity. Disruption of the highly-expressed gene RIM101, which encodes an alkaline-regulated transcription factor, did not impact cellular morphology but reduced both C. albicans burden during early peritonitis and C. albicans persistence within abscesses. RIM101 influenced expression of 49 genes during intra-abdominal candidiasis, including previously unidentified Rim101 targets. Overexpression of the RIM101-dependent gene SAP5, which encodes a secreted protease, restored the ability of a rim101 mutant to persist within abscesses. CONCLUSIONS A mouse model of intra-abdominal candidiasis is valuable for studying pathogenesis and C. albicans gene expression. RIM101 contributes to persistence within intra-abdominal abscesses, at least in part through activation of SAP5.
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Brazilian guidelines for the management of candidiasis - a joint meeting report of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical. Braz J Infect Dis 2013; 17:283-312. [PMID: 23693017 PMCID: PMC9427385 DOI: 10.1016/j.bjid.2013.02.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 02/16/2013] [Indexed: 01/07/2023] Open
Abstract
Candida infections account for 80% of all fungal infections in the hospital environment, including bloodstream, urinary tract and surgical site infections. Bloodstream infections are now a major challenge for tertiary hospitals worldwide due to their high prevalence and mortality rates. The incidence of candidemia in tertiary public hospitals in Brazil is approximately 2.5 cases per 1000 hospital admissions. Due to the importance of this infection, the authors provide a review of the diversity of the genus Candida and its clinical relevance, the therapeutic options and discuss the treatment of major infections caused by Candida. Each topography is discussed with regard to epidemiological, clinical and laboratory diagnostic and therapeutic recommendations based on levels of evidence.
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Abstract
Intraabdominal infections are frequent and dangerous entity in intensive care units. Mortality and morbidity are high, causes are numerous, and treatment options are variable. The intensivist is challenged to recognize and treat intraabdominal infections in a timely fashion to prevent complications and death. Diagnosis of intraabdominal infection is often complicated by confounding underlying disease or masked by overall comorbidity. Current research describes a wide heterogeneity of patient populations, making it difficult to suggest a general treatment regimen and stressing the need of an individualized approach to decision making. Early focus-oriented intervention and antibiotic coverage tailored to the individual patient and hospital is warranted.
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Affiliation(s)
| | - Mitchell Cahan
- Department of Surgery, University of Massachusetts Medical School, MA, USA
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Hernández MJ, Balaguer J, Armero R, Baldó J, Gómez L, Solaz C. [Candida peritonitis: Prevalence and risk factors]. Rev Iberoam Micol 2012; 30:189-92. [PMID: 23174365 DOI: 10.1016/j.riam.2012.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 10/27/2012] [Accepted: 10/31/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A peritoneal fluid with a positive culture for Candida in patients with associated clinical symptoms enables peritoneal candidiasis (PC) to be diagnosed. This etiology is related to a poor prognosis, thus, it is important to know all the risk factors and to start early an empirical treatment. The risk factors associated with this kind of peritonitis are to receive prolonged antibiotic treatment, nosocomial infection, female gender, involvement of the upper gastro-intestinal (UGI) tract, and the ocurrence of an intraoperative cardiovascular failure (CVF). AIMS The principal aim was to determine the prevalence of PC in our hospital, and the secondary aims to determine the associated risk factors. METHODS We obtained samples from 74 patients diagnosed with peritonitis, consecutively from 2007 to 2010. Cultures were performed with the free peritoneal fluid aspirated during surgery. RESULTS The prevalence of PC obtained in our hospital was 17.6%, from which 46.15% corresponded to Candida albicans. The involvement of the UGI tract and the onset of CVF can be considered risk factors for the development of this pathology. Age, gender, nosocomial infection and previous antibiotic treatment were not related to this pathology. CONCLUSIONS Our prevalence of PC is 17.6%. The risk factors that could predispose are the involvement of the UGI tract as the cause of peritonitis, and CVF during surgical procedure.
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Affiliation(s)
- María José Hernández
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Dr. Peset, Valencia, España.
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Brazilian guidelines for the management of candidiasis: a joint meeting report of three medical societies – Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia, Sociedade Brasileira de Medicina Tropical. Braz J Infect Dis 2012. [DOI: 10.1016/s1413-8670(12)70336-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Abstract
Intra-abdominal infection (IAI) is a complex disease entity in which different aspects must be balanced in order to select the proper antimicrobial regimen and determine duration of therapy. A current classification indicates different faces of peritonitis. Primary peritonitis implies an intact gastrointestinal tract without overt barrier disruption. Secondary peritonitis refers to localized or diffuse peritoneal inflammation and abscess formation due to disruption of the anatomical barrier. Tertiary peritonitis includes cases that cannot be solved by a single or even sequential surgical intervention, often in combination with sequential courses of antimicrobial therapy. The most frequently used classification distinguishes ‘uncomplicated’ and ‘complicated’ IAI. In uncomplicated IAI, the infectious process is contained within a single organ, without anatomical disruption. In complicated IAI, disease is extended, with either localized or generalized peritonitis. However, there exists more than a single dimension of complexity in IAI, including severity of disease expression through systemic inflammation. As the currently used classifications of IAI often incite confusion by mixing elements of anatomical barrier disruption, severity of disease expression and (the likelihood of) resistance involvement, we propose an alternative for the current widely accepted classification. We suggest abandoning the terms ‘uncomplicated’ and ‘complicated’ IAI, as they merely confuse the issue. Furthermore, the term ‘tertiary peritonitis’ should likewise be discarded, as this simply refers to treatment failure of secondary peritonitis resulting in a state of persistent infection and/or inflammation. Hence, anatomical disruption and disease severity should be separated into different phenotypes for the same disease in combination with either presence or absence of risk factors for involvement of pathogens that are not routinely covered in first-line antimicrobial regimens (Pseudomonas aeruginosa, enterococci, Candida species and resistant pathogens). Generally, these risk factors can be brought back to recent exposure to antimicrobial agents and substantial length of stay in healthcare settings (5–7 days). As such, we developed a grid based on the different components of the classification: (i) anatomical disruption; (ii) severity of disease expression; and (iii) either community-acquired/early-onset healthcare-associated origin or healthcare-associated origin and/or recent antimicrobial exposure. The grid allows physicians to define the index case of IAI in a more unequivocal way and to select the most convenient empirical antimicrobial regimens. The grid advises on the necessity of covering nosocomial Gram-negative bacteria (including P. aeruginosa), enterococci and yeasts. The basis of antimicrobial therapy for IAI is that both Gram-negative and anaerobic bacteria should always be covered. In recent years, some newer agents such as doripenem, moxifloxacin and tigecycline have been added to the antimicrobial armamentarium for IAI. For patients in whom the source can be adequately controlled, antimicrobial therapy should be restricted to a short course (e.g. 3–7 days in peritonitis).
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Affiliation(s)
- Stijn Blot
- Faculty of Medicine & Health Sciences, Ghent University, Ghent, Belgium.
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León C, Ruiz-Santana S, Saavedra P, Castro C, Ubeda A, Loza A, Martín-Mazuelos E, Blanco A, Jerez V, Ballús J, Alvarez-Rocha L, Utande-Vázquez A, Fariñas O. Value of β-D-glucan and Candida albicans germ tube antibody for discriminating between Candida colonization and invasive candidiasis in patients with severe abdominal conditions. Intensive Care Med 2012; 38:1315-25. [PMID: 22752333 DOI: 10.1007/s00134-012-2616-y] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Accepted: 05/27/2012] [Indexed: 02/06/2023]
Abstract
PURPOSE To assess the value of (1→3)-β-D: -glucan (BDG), Candida albicans germ tube antibody (CAGTA), C-reactive protein (CRP), and procalcitonin (PCT) levels for the diagnosis of invasive candidiasis (IC) and for differentiating Candida spp. colonization from infection in ICU patients with severe abdominal conditions (SAC). METHODS Prospective study of 176 non-neutropenic patients, with SAC at ICU admission, and expected to stay at least 7 days. Surveillance cultures and BDG, CAGTA, CRP, and PCT levels were performed on the third day of ICU stay and twice a week for four consecutive weeks. Patients were grouped into invasive candidiasis (IC), Candida colonization, and neither colonized/nor infected. The classification and regression tree (CART) analysis was used to predict IC in colonized patients. The discriminatory ability of the obtained prediction rule was assessed by the area under the ROC curve (AUC). RESULTS The probabilities of IC were 59.3 % for the terminal node of BDG greater than 259 pg/mL and 30.8 % for BDG less than 259 pg/mL and CAGTA positivity, whereas there was a 93.9 % probability in predicting the absence of IC for BDG less than 259 pg/mL and negative CAGTA. Using a cutoff of 30 % for IC probability, the prediction rule showed 90.3 % sensitivity, 54.8 % specificity, 42.4 % positive predictive value, and 93.9 % negative predictive value with an AUC of 0.78 (95 % confidence interval 0.76-0.81). Significant differences in CRP (p = 0.411) and PCT (p = 0.179) among the studied groups were not found. CONCLUSIONS BDG with a positive test for CAGTA accurately differentiated Candida colonization from IC in patients with SAC, whereas CRP and PCT did not.
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Affiliation(s)
- Cristóbal León
- Intensive Care Unit, Hospital Universitario de Valme, Universidad de Sevilla, Carretera de Cádiz s/n, 41014 Seville, Spain.
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Peritonitis terciaria: tan difícil de definir como de tratar. Cir Esp 2012; 90:11-6. [DOI: 10.1016/j.ciresp.2010.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 09/10/2010] [Accepted: 11/01/2010] [Indexed: 12/17/2022]
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Carneiro HA, Mavrakis A, Mylonakis E. Candida Peritonitis: An Update on the Latest Research and Treatments. World J Surg 2011; 35:2650-9. [DOI: 10.1007/s00268-011-1305-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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