1
|
Jan HE, Lo CL, Lee JC, Li MC, Lin WL, Ko WC, Lee NY. Clinical impact of the combination of rapid species identification and antifungal stewardship intervention in adults with candidemia. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:1253-1260. [PMID: 37723015 DOI: 10.1016/j.jmii.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Candidemia is associated with a high mortality rate. This study aimed to evaluate the clinical impact of a diagnostic intervention and antifungal stewardship in adults with candidemia, including effectiveness in facilitating appropriate antifungals and improving patient outcomes. METHODS A pre-post quasi-experimental study was conducted to analyze the impact of the integrated workflow of rapid species identification and antifungal stewardship intervention provided by infectious disease specialists for adults with candidemia at a medical center in southern Taiwan from March 1st, 2014 to February 29th, 2016. The primary endpoint was 30-day crude mortality, and secondary outcomes included the time to species identification, time to initial antifungal modification, and length of hospital stay. RESULTS Total 303 patients with candidemia were included, including 152 adults in the pre-intervention period (Mar. 1st, 2014-Feb. 28th, 2015; control group) and 151 in the intervention period (Mar. 1st, 2015-Feb. 29th, 2016; case group). Demographic and clinical characteristics of patients in two groups were similar. The case group had a shorter time to species identification (72 vs. 96 h, P < 0.001) and earlier receipt of antifungals (47 vs. 59 h, P < 0.001) than the control group. Of note, the 30-day mortality rate (27.2% vs. 39.5%, P = 0.028) was lower and the hospital stay (43.5 vs. 46.0 days, P = 0.006) was shorter in the case group. CONCLUSION Rapid diagnostic workflow and antifungal stewardship provided by infectious disease specialists can promote early initiation of antifungal therapy and improve outcome for adults with candidemia.
Collapse
Affiliation(s)
- Hao-En Jan
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Lung Lo
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Chi Li
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Liang Lin
- Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Nan-Yao Lee
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| |
Collapse
|
2
|
Candida bloodstream infection in patients with cancer: A retrospective analysis of an 11-year period. Rev Iberoam Micol 2023; 40:3-9. [PMID: 36872132 DOI: 10.1016/j.riam.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 09/14/2022] [Accepted: 12/15/2022] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Candida bloodstream infection (CBSI) is a growing problem among patients with cancer. AIM To describe the main clinical and microbiological characteristics in patients with cancer who suffer CBSI. METHODS We reviewed the clinical and microbiological characteristics of all patients with CBSI diagnosed between January 2010 and December 2020, at a tertiary-care oncological hospital. Analysis was done according to the Candida species found. Multivariate logistic regression analysis was used to determine the risk factors associated with 30-day mortality. RESULTS There were 147 CBSIs diagnosed, 78 (53%) in patients with hematologic malignancies. The main Candida species identified were Candida albicans (n=54), Candida glabrata (n=40) and Candida tropicalis (n=29). C. tropicalis had been mainly isolated from patients with hematologic malignancies (79.3%) who had received chemotherapy recently (82.8%), and in patients with severe neutropenia (79.3%). Seventy-five (51%) patients died within the first 30 days, and the multivariate analysis showed the following risk factors: severe neutropenia, a Karnofsky Performance Scale score under 70, septic shock, and not receiving appropriate antifungal treatment. CONCLUSIONS Patients with cancer who develop CBSI had a high mortality related with factors associated with their malignancy. Starting an empirical antifungal therapy the soonest is essential to increase the survival in these patients.
Collapse
|
3
|
Tang Y, Hu W, Jiang S, Xie M, Zhu W, Zhang L, Sha J, Wang T, Ding M, Zeng J, Jiang J. Effect of empirical antifungal treatment on mortality in non-neutropenic critically ill patients: a propensity-matched retrospective cohort study. Eur J Clin Microbiol Infect Dis 2022; 41:1421-1432. [PMID: 36255537 DOI: 10.1007/s10096-022-04507-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/06/2022] [Indexed: 11/03/2022]
Abstract
To evaluate the effect of empirical antifungal treatment (EAFT) on mortality in critically ill patients without invasive fungal infections (IFIs). This was a single-center propensity score-matched retrospective cohort study involving non-transplanted, non-neutropenic critically ill patients with risk factors for invasive candidiasis (IC) in the absence of IFIs. We compared all-cause hospital mortality and infection-attributable hospital mortality in patients who was given EAFT for suspected IC as the cohort group and those without any systemic antifungal agents as the control group. Among 640 eligible patients, 177 patients given EAFT and 177 control patients were included in the analyses. As compared with controls, EAFT was not associated with the lower risks of all-cause hospital mortality [odds ratio (OR), 0.911; 95% CI, 0.541-1.531; P = 0.724] or infection-attributable hospital mortality (OR, 1.149; 95% CI, 0.632-2.092; P = 0.648). EAFT showed no benefit of improvement of infection at discharge, duration of mechanical ventilation, and antibiotic-free days. However, the later initiation of EAFT was associated with higher risks of all-cause hospital mortality (OR, 1.039; 95% CI, 1.003 to 1.076; P = 0.034) and infection-attributable hospital mortality (OR, 1.046; 95% CI, 1.009 to 1.085; P = 0.015) in patients with suspected IC. This effect was also found in infection-attributable hospital mortality (OR, 1.042; 95% CI, 1.005 to 1.081; P = 0.027) in septic patients with suspected IC. EAFT failed to decrease hospital mortality in non-neutropenic critically ill patients without IFIs. The timing may be critical for EAFT to improve mortality in these patients with suspected IC. ChiCTR2000038811, registered on Oct 3, 2020.
Collapse
Affiliation(s)
- Yue Tang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021, Shandong, People's Republic of China
| | - Wenjing Hu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021, Shandong, People's Republic of China
| | - Shuangyan Jiang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021, Shandong, People's Republic of China
| | - Maoyu Xie
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021, Shandong, People's Republic of China
| | - Wenying Zhu
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021, Shandong, People's Republic of China
| | - Lin Zhang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021, Shandong, People's Republic of China
| | - Jing Sha
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021, Shandong, People's Republic of China
| | - Tengfei Wang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021, Shandong, People's Republic of China
| | - Min Ding
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021, Shandong, People's Republic of China
| | - Juan Zeng
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021, Shandong, People's Republic of China.
| | - Jinjiao Jiang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, 250021, Shandong, People's Republic of China.
| |
Collapse
|
4
|
Zhang MK, Rao ZG, Ma T, Tang M, Xu TQ, He XX, Li ZP, Liu Y, Xu QJ, Yang KY, Gong YF, Xue J, Wu MQ, Xue XY. Appropriate empirical antifungal therapy is associated with a reduced mortality rate in intensive care unit patients with invasive fungal infection: A real-world retrospective study based on the MIMIC-IV database. Front Med (Lausanne) 2022; 9:952611. [PMID: 36203769 PMCID: PMC9530049 DOI: 10.3389/fmed.2022.952611] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe study aimed to determine the prevalence and pathogens of invasive fungal infection (IFI) among intensive care unit (ICU) patients. The next goal was to investigate the association between empirical antifungal treatment and mortality in ICU patients.MethodsUsing microbiological events, we identified all ICU patients with IFI and then retrieved electronic clinical data from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The data were statistically analyzed using t-tests, chi-square tests, log-rank tests, and Cox regression.ResultsThe most commonly reported fungi were Candida (72.64%) and Aspergillus (19.08%). The most frequently prescribed antifungal medication was fluconazole (37.57%), followed by micafungin (26.47%). In the survival study of ICU patients and patients with sepsis, survivors were more likely to receive empirical antifungal treatment. In contrast, non-empirical antifungal therapy was significantly associated with poor survival in patients with positive blood cultures. We found that the current predictive score makes an accurate prediction of patients with fungal infections challenging.ConclusionsOur study demonstrated that empirical antifungal treatment is associated with decreased mortality in ICU patients. To avoid treatment delays, novel diagnostic techniques should be implemented in the clinic. Until such tests are available, appropriate empirical antifungal therapy could be administered based on a model that predicts the optimal time to initiate antifungal therapy. Additional studies should be conducted to establish more accurate predictive models in the future.
Collapse
|
5
|
He Z, Liu JJ, Shu GF, Ma SL, Wu GQ. Diagnostic Utility of CD64 and CD38 Biomarkers for the Differential Diagnosis of Infections. Genet Test Mol Biomarkers 2022; 26:133-139. [PMID: 35230865 DOI: 10.1089/gtmb.2021.0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Identification of infection type in patients with fever is particularly important in the emergency departments (EDs) of hospitals. This study aimed to evaluate the performance of two biomarkers, namely the modified neutrophil CD64 (nCD64) index and CD38 present on T cells, using flow cytometry. Methods: A total of 305 potentially infected patients with fever were admitted to the ED of Zhongda Hospital (Nanjing, China) between March 2021 and August 2021. This study grouped 180, 30, and 65 patients as having bacterial (local, Gram-positive, and Gram-negative infections), viral, or no infections, respectively, based on their diagnostic outcomes and clinical records. Results: The expression level of traditional/modified nCD64 was significantly increased in the bacterial infection group, especially in case of patients infected with Gram-negative bacteria, and the main infectious strains were Staphylococcus and Escherichia coli. Similarly, CD3+CD38+ cell percentages were elevated in patients with viral infections, which were mostly caused by Epstein-Barr virus and cytomegalovirus. CD38 expression is age dependent, and high percentages of CD3+CD38+ cells were observed in children with viral infections. For the prediction of bacterial infections, the area under the curve (AUC) of modified nCD64 (AUC: 0.800) was significantly higher than that of C-reactive protein and heparin-binding protein but slightly lower than that of traditional nCD64 (AUC: 0.831). The AUC, specificity, and sensitivity values for the prediction of viral infections using CD3+CD38+ cells percentages in children were 0.899 (0.785-1.000), 96.2%, and 85.9%, respectively. Conclusion: nCD64 levels and CD3+CD38+ cell percentage are potential biomarkers that facilitate identification of patients with bacterial and viral infections.
Collapse
Affiliation(s)
- Zhi He
- Center of Clinical Laboratory Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jing-Jing Liu
- Center of Clinical Laboratory Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Guo-Fang Shu
- Center of Clinical Laboratory Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Shao-Lei Ma
- Department of Emergency and Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Guo-Qiu Wu
- Center of Clinical Laboratory Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| |
Collapse
|
6
|
Ylipalosaari P, Ala‐Kokko TI, Koskenkari J, Laurila JJ, Ämmälä S, Syrjälä H. Use and outcome of empiric echinocandins in critically ill patients. Acta Anaesthesiol Scand 2021; 65:944-951. [PMID: 33481252 DOI: 10.1111/aas.13783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 12/16/2020] [Accepted: 12/28/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Echinocandins are recommended as a first-line empiric treatment for fungal infections of patients in an intensive care unit (ICU) with critical illness. The primary aim of the study was to compare outcomes among ICU patients treated with empiric anidulafungin (ANI), caspofungin (CASPO), or micafungin (MICA). METHODS A retrospective cohort study in a mixed adult ICU. Patient demographics, reason for ICU admission, ICU risk scores and organ support therapies were analyzed. Outcome parameters included ICU and hospital stay, 30-day mortality and 1-year mortality. RESULTS Empiric echinocandin therapy was given to 367 patients (ANI; 73 patients, CASPO; 84 patients, and MICA; 210 patients) with a median duration of 3 days in an ICU. Patient median age was 60.7 years. As a first-line therapy, 52% of patients received fluconazole. Positive Candida cultures were found in the following samples: blood, 16 (4.4%); central line, 27 (7.4%); deep site, 92 (25.1%). Median ICU stay (ANI 6.4 days, CASPO 5.3 days, MICA 8.1 days), hospital stay (ANI 33 days, CASPO 30 days, MICA 30 days), 30-day mortality (ANI 27%, CASPO 32%, MICA 32%), and 1-year mortality (ANI 33%, CASPO 44%, MICA 45%) did not differ between the groups . The cost of antifungal therapy during the ICU period was similar in the three echinocandin groups (ANI; €1 872, CASPO; €1 799, and MICA; €1783). CONCLUSION Our results show that ICU, hospital stay, and mortality (hospital, 30-day and 1-year) did not differ among patients with empiric anidulafungin, caspofungin, or micafungin treatment in a mixed adult ICU.
Collapse
Affiliation(s)
- Pekka Ylipalosaari
- Department of Infection Control Oulu University Hospital Medical Research Center Oulu University of Oulu Oulu Finland
| | - Tero I. Ala‐Kokko
- Division of Intensive Care Medicine Research Group of Surgery, Anesthesiology and Intensive Care Medicine Oulu University Hospital Medical Research Center Oulu University of Oulu Oulu Finland
| | - Juha Koskenkari
- Division of Intensive Care Medicine Research Group of Surgery, Anesthesiology and Intensive Care Medicine Oulu University Hospital Medical Research Center Oulu University of Oulu Oulu Finland
| | - Jouko J. Laurila
- Division of Intensive Care Medicine Research Group of Surgery, Anesthesiology and Intensive Care Medicine Oulu University Hospital Medical Research Center Oulu University of Oulu Oulu Finland
| | - Sirpa Ämmälä
- Hospital Pharmacy Oulu University Hospital Oulu Finland
| | - Hannu Syrjälä
- Department of Infection Control Oulu University Hospital Medical Research Center Oulu University of Oulu Oulu Finland
| |
Collapse
|
7
|
Suh JW, Kim MJ, Kim JH. Risk factors of septic shock development and thirty-day mortality with a predictive model in adult candidemia patients in intensive care units. Infect Dis (Lond) 2021; 53:908-919. [PMID: 34330205 DOI: 10.1080/23744235.2021.1959052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND This study aimed to investigate factors associated with septic shock development and 30-day mortality outcome with a prediction model among adult candidemia patients in the intensive care unit (ICU). METHODS A retrospective study was conducted among patients admitted to the ICU from 2009 to 2018 at a tertiary care medical centre. The study subjects included adult patients ≥ 19 years with candidemia treated with antifungal agent for ≥ 3 days. Clinical variables were collected and analysed. RESULTS A total of 126 patients were included in the study. Of these patients, 32 patients (25.4%) had septic shock. Multivariate logistic regression analysis revealed that chronic liver disease was associated with septic shock (odds ratio [OR] 3.372, 95% confidence interval [CI] 1.057 - 10.057). The rate of 30-day mortality was 35.7% and the associated mortality risk factors were malignancy (OR 8.251, 95% CI 2.227 - 30.573), chronic liver disease (OR 3.605, 95% CI 0.913 - 14.227), haemodialysis (OR 8.479, 95% CI 1.801 - 39.924), mycological failure (OR 29.675, 95% CI 7.012 - 125.578), and septic shock (OR 3.980, 95% CI 1.238 - 12.796). A predictive model for 30-day mortality was created based on the mortality risk factor scores, which had an area of 0.862 under the receiver operating characteristic curve. CONCLUSIONS Adult candidemia patients in the ICU who have chronic liver disease may be at higher risk of developing septic shock. Furthermore, our predictive model for 30-day mortality based on the mortality risk factors may be useful for clinical assessment.
Collapse
Affiliation(s)
- Jin Woong Suh
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Ja Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jong Hun Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
8
|
Steinbrink JM, Myers RA, Hua K, Johnson MD, Seidelman JL, Tsalik EL, Henao R, Ginsburg GS, Woods CW, Alexander BD, McClain MT. The host transcriptional response to Candidemia is dominated by neutrophil activation and heme biosynthesis and supports novel diagnostic approaches. Genome Med 2021; 13:108. [PMID: 34225776 PMCID: PMC8259367 DOI: 10.1186/s13073-021-00924-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 06/11/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Candidemia is one of the most common nosocomial bloodstream infections in the United States, causing significant morbidity and mortality in hospitalized patients, but the breadth of the host response to Candida infections in human patients remains poorly defined. METHODS In order to better define the host response to Candida infection at the transcriptional level, we performed RNA sequencing on serial peripheral blood samples from 48 hospitalized patients with blood cultures positive for Candida species and compared them to patients with other acute viral, bacterial, and non-infectious illnesses. Regularized multinomial regression was utilized to develop pathogen class-specific gene expression classifiers. RESULTS Candidemia triggers a unique, robust, and conserved transcriptomic response in human hosts with 1641 genes differentially upregulated compared to healthy controls. Many of these genes corresponded to components of the immune response to fungal infection, heavily weighted toward neutrophil activation, heme biosynthesis, and T cell signaling. We developed pathogen class-specific classifiers from these unique signals capable of identifying and differentiating candidemia, viral, or bacterial infection across a variety of hosts with a high degree of accuracy (auROC 0.98 for candidemia, 0.99 for viral and bacterial infection). This classifier was validated on two separate human cohorts (auROC 0.88 for viral infection and 0.87 for bacterial infection in one cohort; auROC 0.97 in another cohort) and an in vitro model (auROC 0.94 for fungal infection, 0.96 for bacterial, and 0.90 for viral infection). CONCLUSIONS Transcriptional analysis of circulating leukocytes in patients with acute Candida infections defines novel aspects of the breadth of the human immune response during candidemia and suggests promising diagnostic approaches for simultaneously differentiating multiple types of clinical illnesses in at-risk, acutely ill patients.
Collapse
Affiliation(s)
- Julie M Steinbrink
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA.
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA.
| | - Rachel A Myers
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA
| | - Kaiyuan Hua
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA
| | - Melissa D Johnson
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Jessica L Seidelman
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Ephraim L Tsalik
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA
- Emergency Medicine Service, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Ricardo Henao
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA
| | - Geoffrey S Ginsburg
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA
| | - Christopher W Woods
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA
- Division of Infectious Diseases, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Barbara D Alexander
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Micah T McClain
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA
- Division of Infectious Diseases, Durham Veterans Affairs Health Care System, Durham, NC, USA
| |
Collapse
|
9
|
Chen F, Yao C, Feng Y, Yu Y, Guo H, Yan J, Chen J. The identification of neutrophils-mediated mechanisms and potential therapeutic targets for the management of sepsis-induced acute immunosuppression using bioinformatics. Medicine (Baltimore) 2021; 100:e24669. [PMID: 33761636 PMCID: PMC9282053 DOI: 10.1097/md.0000000000024669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 01/18/2021] [Indexed: 01/05/2023] Open
Abstract
Neutrophils have crucial roles in defensing against infection and adaptive immune responses. This study aimed to investigate the genetic mechanism in neutrophils in response to sepsis-induced immunosuppression.The GSE64457 dataset was downloaded from the Gene Expression Omnibus database and the neutrophil samples (D3-4 and D6-8 post sepsis shock) were assigned into two groups. The differentially expressed genes (DEGs) were identified. The Short Time-series Expression Miner (STEM) clustering analysis was conducted to select the consistently changed DEGs post sepsis shock. The overlapping genes between the DEGs and the deposited genes associated with immune, sepsis, and immunosuppression in the AmiGO2 and Comparative Toxicogenomics Database were screened out and used for the construction of the protein-protein interaction (PPI) network. The expression of several hub genes in sepsis patients was validated using the PCR analysis. The drugs targeting the hub genes and the therapy strategies for sepsis or immunosuppression were reviewed and used to construct the drug-gene-therapy-cell network to illustrate the potential therapeutic roles of the hub genes.A total of 357 overlapping DEGs between the two groups were identified and were used for the STEM clustering analysis, which generated four significant profiles with 195 upregulated (including annexin A1, ANXA1; matrix metallopeptidase 9, MMP9; and interleukin 15, IL-15) and 151 downregulated DEGs (including, AKT1, IFN-related genes, and HLA antigen genes). Then, a total of 34 of the 151 downregulated DEGs and 39 of the 195 upregulated DEGs were shared between the databases and above DEGs, respectively. The PPI network analysis identified a downregulated module including IFN-related genes. The deregulation of DEGs including AKT1 (down), IFN-inducible protein 6 (IFI6, down), IL-15 (up), and ANXA1 (up) was verified in the neutrophils from patients with sepsis-induced immunosuppression as compared with controls. Literature review focusing on the therapy showed that the upregulation of IL-15, IFN, and HLA antigens are the management targets. Besides, the AKT1 gene was targeted by gemcitabine.These findings provided additional clues for understanding the mechanisms of sepsis-induced immunosuppression. The drugs targeting AKT1 might provide now clues for the management strategy of immunosuppression with the intention to prevent neutrophil infiltration.
Collapse
Affiliation(s)
- Fang Chen
- Nursing Department, Zhejiang Hospital
| | - Chunyan Yao
- Institute of Health Food, Zhejiang Academy of Medical Sciences
| | - Yue Feng
- Radiology Department, Zhejiang Hospital
| | - Ying Yu
- Institute of Health Food, Zhejiang Academy of Medical Sciences
| | - Honggang Guo
- Zhejiang Experimental Animal Center, Zhejiang Academy of Medical Sciences
| | - Jing Yan
- Intensive Care Unit, Zhejiang Hospital
| | - Jin Chen
- General Practice Department, Zhejiang Hospital, Hangzhou, Zhejiang, China
| |
Collapse
|
10
|
Steuber TD, Butler L, Sawyer A, Chappell R, Edwards J. Comparison of blood cultures versus T2 Candida Panel in management of candidemia at a large community hospital. Eur J Clin Microbiol Infect Dis 2021; 40:997-1001. [PMID: 33387121 DOI: 10.1007/s10096-020-04144-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/27/2020] [Indexed: 11/25/2022]
Abstract
The T2 Candida Panel (T2CP) has high sensitivity and specificity to detect candidemia. Its role in the diagnosis and management of candidemia compared to blood cultures (BC) remains unclear. The purpose of this study was to evaluate the T2CP versus BC in detecting and treating candidemia. A retrospective, observational cohort study was conducted to compare clinical outcomes in patients with candidemia identified by BC versus T2CP. Patients with a positive BC or T2CP for Candida spp. from January 2012 to August 2020 were grouped by initial method of detection (BC vs T2CP). Co-primary endpoints assessed included time to detection of candidemia and time to antifungal therapy. Key secondary endpoints included length of stay (LOS), ICU LOS, and mortality. One hundred sixty-three patients with a positive BC and 89 patients with a positive T2CP were included in the evaluation. The average time to detection of candidemia was significantly shorter in the T2CP group compared to BC group (9 vs 41 h, p < 0.001). The time to antifungal was also significantly shorter in the T2CP group compared to the BC group (4 vs 37 h, p < 0.001). However, LOS was significantly shorter in the BC positive group than the T2CP group with no difference in ICU LOS. There was no difference in in-hospital or 30-day mortality between the two groups. Of patients diagnosed with candidemia at our large community hospital, identification by T2CP led to faster detection and initiation of antifungal compared to blood cultures without improvement in LOS or mortality.
Collapse
Affiliation(s)
- Taylor D Steuber
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, 301 Governors Drive SW, Huntsville, AL, 35801, USA.
- Department of Pharmacy, Huntsville Hospital, 101 Sivley Road, Huntsville, AL, 35801, USA.
| | - Lauren Butler
- Department of Pharmacy, Huntsville Hospital, 101 Sivley Road, Huntsville, AL, 35801, USA
| | - Adam Sawyer
- Department of Pharmacy, Huntsville Hospital, 101 Sivley Road, Huntsville, AL, 35801, USA
| | - Rachel Chappell
- Department of Pharmacy, DCH Regional Medical Center, 809 University Boulevard East, Tuscaloosa, AL, 35401, USA
| | - Jonathan Edwards
- Department of Pharmacy, Huntsville Hospital, 101 Sivley Road, Huntsville, AL, 35801, USA
| |
Collapse
|
11
|
Lee RA, Zurko JC, Camins BC, Griffin RL, Rodriguez JM, McCarty TP, Magadia J, Pappas PG. Impact of Infectious Disease Consultation on Clinical Management and Mortality in Patients With Candidemia. Clin Infect Dis 2020; 68:1585-1587. [PMID: 30281081 DOI: 10.1093/cid/ciy849] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 09/28/2018] [Indexed: 12/21/2022] Open
Abstract
Candidemia has a high attributable mortality. The objective of this study was to determine the impact of infectious disease consultation on mortality and clinical outcomes in candidemia. Infectious disease consultation was associated with better adherence to guidelines and improved survival, even in patients with high Acute Physiology and Chronic Health Evaluation II scores.
Collapse
Affiliation(s)
- Rachael A Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
| | - Joanna C Zurko
- Department of Medicine, University of Alabama at Birmingham
| | - Bernard C Camins
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
| | - Russell L Griffin
- Department of Epidemiology, University of Alabama School of Public Health, Birmingham
| | - J Martin Rodriguez
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
| | - Todd P McCarty
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
| | | | - Peter G Pappas
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
| |
Collapse
|
12
|
Cuervo G, Garcia-Vidal C, Puig-Asensio M, Merino P, Vena A, Martín-Peña A, Montejo JM, Ruiz A, Lázaro-Perona F, Fortún J, Fernández-Ruiz M, Suarez AI, Castro C, Cardozo C, Gudiol C, Aguado JM, Paño JR, Pemán J, Salavert M, Garnacho-Montero J, Cisneros JM, Soriano A, Muñoz P, Almirante B, Carratalà J. Usefulness of guideline recommendations for prognosis in patients with candidemia. Med Mycol 2020; 57:659-667. [PMID: 30418567 DOI: 10.1093/mmy/myy118] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 09/05/2018] [Accepted: 10/26/2018] [Indexed: 01/05/2023] Open
Abstract
We aimed to analyze whether the lack of inclusion of specific recommendations for the management of candidemia is an independent risk factor for early and overall mortality. Multicenter study of adult patients with candidemia in 13 hospitals. We assessed the proportion of patients on whom nine specific ESCMID and IDSA guidelines recommendations had been applied, and analyzed its impact on mortality. 455 episodes of candidemia were documented. Patients who died within the first 48 hours were excluded. Sixty-two percent of patients received an appropriate antifungal treatment. Either echinocandin or amphotericin B therapy were administered in 43% of patients presenting septic shock and in 71% of those with neutropenia. Sixty-one percent of patients with breakthrough candidemia underwent a change in antifungal drug class. Venous catheters were removed in 79% of cases. Follow-up blood cultures were performed in 72% of cases. Ophthalmoscopy and echocardiogram were performed in 48% and 50% of patients, respectively. Length of treatment was appropriate in 78% of cases. Early (2-7 days) and overall (2-30 days) mortality were 8% and 27.7%, respectively. Inclusion of less than 50% of the specific recommendations was independently associated with a higher early (HR = 7.02, 95% CI: 2.97-16.57; P < .001) and overall mortality (HR = 3.55, 95% CI: 2.24-5.64; P < .001). In conclusion, ESCMID and IDSA guideline recommendations were not performed on a significant number of patients. Lack of inclusion of these recommendations proved to be an independent risk factor for early and overall mortality.
Collapse
Affiliation(s)
- Guillermo Cuervo
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | | | - Mireia Puig-Asensio
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Antonio Vena
- Hospital General Universitario Gregorio Marañón e Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | | | | | - Alba Ruiz
- Hospital Universitari i Politecnic "La Fe", Valencia, Spain
| | | | | | - Mario Fernández-Ruiz
- Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | | | | | - Celia Cardozo
- Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Carlota Gudiol
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | - José María Aguado
- Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | | | - Javier Pemán
- Hospital Universitari i Politecnic "La Fe", Valencia, Spain
| | | | | | | | - Alex Soriano
- Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Patricia Muñoz
- Hospital General Universitario Gregorio Marañón e Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Benito Almirante
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Carratalà
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
13
|
Miljković N, Godman B, van Overbeeke E, Kovačević M, Tsiakitzis K, Apatsidou A, Nikopoulou A, Yubero CG, Portillo Horcajada L, Stemer G, Kuruc-Poje D, De Rijdt T, Bochenek T, Huys I, Miljković B. Risks in Antibiotic Substitution Following Medicine Shortage: A Health-Care Failure Mode and Effect Analysis of Six European Hospitals. Front Med (Lausanne) 2020; 7:157. [PMID: 32478082 PMCID: PMC7235345 DOI: 10.3389/fmed.2020.00157] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/08/2020] [Indexed: 01/23/2023] Open
Abstract
Introduction: Medicine shortages result in great risk for the continuity of patient care especially for antimicrobial treatment, potentially enhancing resistance rates and having a higher economic impact. This study aims to identify, describe, assess, and assign risk priority levels to potential failures following substitution of antimicrobial treatment due to shortages among European hospitals. Furthermore, the study investigated the impact of corrective actions on risk reduction so as to provide guidance and improve future patient care. Methods: Health-care failure mode and effect analysis (HFMEA) was applied to hospitals in Austria (H-AT), Belgium (H-BE), Croatia (H-CR), Greece (H-GR), Spain (H-SP), and Serbia (H-SR). Multidisciplinary teams identified processes, failure modes, causes, and corrective actions related to antibiotic substitution following medicine shortages. Characteristics of study hospitals as well as severity, probability, and hazard scores (HSs) of failure modes/causes were analyzed using Microsoft Office Excel 2010 and IBM SPSS Statistics® via descriptive and inferential statistics. Results: Through HFMEA, 74 failure modes were identified, with 53 of these scoring 8 or above on the basis of assigned severity and probability for a failure. Severity of failure modes differed before and after corrective actions in H-CR, H-GR, and H-SR (p < 0.005). Their probability differed in all study hospitals (p < 0.005) when compared before and after corrective actions aimed to be implemented. The highest number of failure-mode causes was detected in H-CR (46) and the lowest in H-SP (16). Corrective actions can address failure modes and lower HSs; therein, all teams proposed the following: structuring communication among stakeholders, introducing electronic prescribing, strengthening pharmacists' involvement, and increasing effectiveness of the ward stock assessment. These proposed actions led to HS reductions up to 83%. Conclusion: There is a lack of structure in addressing risks associated with antibiotic substitution following shortages. Furthermore, lack of communication, data scarcity on availability of antibiotics, non-supportive information technology (IT) systems, and lack of internal substitution protocols hinder quick assessment of alternatives addressing patient needs. Nevertheless, the study shows that health-care professionals manage to secure optimal antimicrobial treatment for patients using available IT and human resources.
Collapse
Affiliation(s)
- Nenad Miljković
- Institute for Orthopaedic Surgery "Banjica", University of Belgrade, Belgrade, Serbia
| | - Brian Godman
- Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, United Kingdom.,Department of Public Health and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | | | - Milena Kovačević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Karyofyllis Tsiakitzis
- General Hospital of Thessaloniki "G. Papanikolaou", Hospital Pharmacy Department, Thessaloniki, Greece
| | - Athina Apatsidou
- General Hospital of Thessaloniki "G. Papanikolaou", Hospital Pharmacy Department, Thessaloniki, Greece
| | - Anna Nikopoulou
- General Hospital of Thessaloniki "G. Papanikolaou", Hospital Pharmacy Department, Thessaloniki, Greece
| | | | | | - Gunar Stemer
- Gunar Stemer, Medicines Information and Clinical Pharmacy Services, Vienna General Hospital, Vienna, Austria
| | - Darija Kuruc-Poje
- General Hospital "Dr. Tomislav Bardek", Hospital Pharmacy Department, Koprivnica, Croatia
| | - Thomas De Rijdt
- Pharmacy Department, University Hospitals Leuven, UZ Herestraat, Leuven, Belgium
| | - Tomasz Bochenek
- Department of Drug Management, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Isabelle Huys
- Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
14
|
Higashi Y, Niimi H, Sakamaki I, Yamamoto Y, Kitajima I. Rapid Identification of Candida Species in Candidemia Directly from Blood Samples Using Imperfect Match Probes. Sci Rep 2020; 10:5828. [PMID: 32242033 PMCID: PMC7118160 DOI: 10.1038/s41598-020-62276-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 03/11/2020] [Indexed: 01/05/2023] Open
Abstract
Candidemia is associated with a high mortality rate, and initial adequate antifungal therapy results in a significant decrease in the crude mortality. We herein report a rapid method that can identify eight Candida species in candidemia using imperfect match quenching probes (IM Q-probes) within three and a half hours of whole blood sample collection. Furthermore, employing the D value, which reflects the difference between the Tm signature from a clinical isolate and that registered in the database, it is possible to quickly identify samples suitable for IM Q-probe identification. We first evaluated the method using 34 Candida colonies collected from different patients, and 100% (34/34) of the identification results matched the preidentified Candida species. We then performed blind tests using eight whole blood samples artificially mixed with eight different Candida species respectively, and all identification results correctly matched the preidentified Candida species. Finally, using 16 whole blood samples collected from candidemia patients, we compared the IM Q-probe method with the culture/sequencing method. Of a total of 16 patient samples, 100% (16/16) matched the culture and sequencing results. The IM Q-probe method is expected to contribute not only to the life expectancy of candidemia patients but also to antifungal stewardship.
Collapse
Affiliation(s)
- Yoshitsugu Higashi
- Department of Clinical Infectious Diseases, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, 930-0194, Japan
| | - Hideki Niimi
- Department of Clinical Laboratory and Molecular Pathology, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, 930-0194, Japan.
| | - Ippei Sakamaki
- Department of Clinical Infectious Diseases, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, 930-0194, Japan
| | - Yoshihiro Yamamoto
- Department of Clinical Infectious Diseases, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, 930-0194, Japan
| | - Isao Kitajima
- Department of Clinical Laboratory and Molecular Pathology, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, 930-0194, Japan
| |
Collapse
|
15
|
Bassetti M, Vena A, Meroi M, Cardozo C, Cuervo G, Giacobbe DR, Salavert M, Merino P, Gioia F, Fernández-Ruiz M, López-Cortés LE, Almirante B, Escolà-Vergé L, Montejo M, Aguilar-Guisado M, Puerta-Alcalde P, Tasias M, Ruiz-Gaitán A, González F, Puig-Asensio M, Marco F, Pemán J, Fortún J, Aguado JM, Soriano A, Carratalá J, Garcia-Vidal C, Valerio M, Sartor A, Bouza E, Muñoz P. Factors associated with the development of septic shock in patients with candidemia: a post hoc analysis from two prospective cohorts. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:117. [PMID: 32216822 PMCID: PMC7099832 DOI: 10.1186/s13054-020-2793-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 02/17/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Almost one third of the patients with candidemia develop septic shock. The understanding why some patients do and others do not develop septic shock is very limited. The objective of this study was to identify variables associated with septic shock development in a large population of patients with candidemia. METHODS A post hoc analysis was performed on two prospective, multicenter cohort of patients with candidemia from 12 hospitals in Spain and Italy. All episodes occurring from September 2016 to February 2018 were analyzed to assess variables associated with septic shock development defined according to The Third International Consensus Definition for Sepsis and Septic Shock (Sepsis-3). RESULTS Of 317 candidemic patients, 99 (31.2%) presented septic shock attributable to candidemia. Multivariate logistic regression analysis identifies the following factors associated with septic shock development: age > 50 years (OR 2.57, 95% CI 1.03-6.41, p = 0.04), abdominal source of the infection (OR 2.18, 95% CI 1.04-4.55, p = 0.04), and admission to a general ward at the time of candidemia onset (OR 0.21, 95% CI, 0.12-0.44, p = 0.001). Septic shock development was independently associated with a greater risk of 30-day mortality (OR 2.14, 95% CI 1.08-4.24, p = 0.02). CONCLUSIONS Age and abdominal source of the infection are the most important factors significantly associated with the development of septic shock in patients with candidemia. Our findings suggest that host factors and source of the infection may be more important for development of septic shock than intrinsic virulence factors of organisms.
Collapse
Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata, Piazzale Santa Maria della Misericordia 15, 33010, Udine, Italy. .,Department of Health Sciences, University of Genoa, Genoa, Italy. .,Clinica Malattie Infettive, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy.
| | - Antonio Vena
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata, Piazzale Santa Maria della Misericordia 15, 33010, Udine, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Marco Meroi
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata, Piazzale Santa Maria della Misericordia 15, 33010, Udine, Italy
| | - Celia Cardozo
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Guillermo Cuervo
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | - Daniele Roberto Giacobbe
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | | | - Paloma Merino
- Hospital Universitario Clínico "San Carlos", Madrid, Spain
| | | | - Mario Fernández-Ruiz
- Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología Clínica, Hospital Universitario Virgen Macarena/Instituto de Biomedicina de Sevilla (IBiS)/Universidad de Sevilla/Centro Superior de Investigaciones Científicas, Seville, Spain
| | - Benito Almirante
- Hospital Universitari Vall d'Hebron, VHIR (Vall d'Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Escolà-Vergé
- Hospital Universitari Vall d'Hebron, VHIR (Vall d'Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Pedro Puerta-Alcalde
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Mariona Tasias
- Hospital Universitari I Politecnic "La Fe", Valencia, Spain
| | | | | | - Mireia Puig-Asensio
- Hospital Universitari Vall d'Hebron, VHIR (Vall d'Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesc Marco
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Javier Pemán
- Hospital Universitari I Politecnic "La Fe", Valencia, Spain
| | - Jesus Fortún
- Hospital Universitario "Ramón y Cajal", Madrid, Spain
| | - Jose Maria Aguado
- Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | - Alejandro Soriano
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Jordi Carratalá
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | - Carolina Garcia-Vidal
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Maricela Valerio
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, Spain
| | - Assunta Sartor
- Microbiology Unit, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, Spain.,Medicine Department School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Udine, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, Spain.,Medicine Department School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Udine, Spain
| |
Collapse
|
16
|
Cardozo C, Cuervo G, Salavert M, Merino P, Gioia F, Fernández-Ruiz M, López-Cortés LE, Escolá-Vergé L, Montejo M, Muñoz P, Aguilar-Guisado M, Puerta-Alcalde P, Tasias M, Ruiz-Gaitán A, González F, Puig-Asensio M, Vena A, Marco F, Pemán J, Fortún J, Aguado JM, Almirante B, Soriano A, Carratalá J, Garcia-Vidal C, Martínez JA, Morata L, Rodríguez-Nuñez O, Guerrero MA, Ayats J, Grau I, Calabuig E, Castro I, Cuéllar S, Martín-Dávila P, Gómez-García de la Pedrosa E, Pérez-Ayala A, Losada I, Navarro MD, Suarez AI, Martin-Gomez MT, Rodríguez-Alvarez R, López-Soira L, Bouza E, Guinea J, Martín C. An evidence-based bundle improves the quality of care and outcomes of patients with candidaemia. J Antimicrob Chemother 2019; 75:730-737. [DOI: 10.1093/jac/dkz491] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 10/05/2019] [Accepted: 10/25/2019] [Indexed: 12/31/2022] Open
Abstract
AbstractBackgroundCandidaemia is a leading cause of bloodstream infections in hospitalized patients all over the world. It remains associated with high mortality.ObjectivesTo assess the impact of implementing an evidence-based package of measures (bundle) on the quality of care and outcomes of candidaemia.MethodsA systematic review of the literature was performed to identify measures related to better outcomes in candidaemia. Eight quality-of-care indicators (QCIs) were identified and a set of written recommendations (early treatment, echinocandins in septic shock, source control, follow-up blood culture, ophthalmoscopy, echocardiography, de-escalation, length of treatment) was prospectively implemented. The study was performed in 11 tertiary hospitals in Spain. A quasi-experimental design before and during bundle implementation (September 2016 to February 2018) was used. For the pre-intervention period, data from the prospective national surveillance were used (May 2010 to April 2011).ResultsA total of 385 and 263 episodes were included in the pre-intervention and intervention groups, respectively. Adherence to all QCIs improved in the intervention group. The intervention group had a decrease in early (OR 0.46; 95% CI 0.23–0.89; P = 0.022) and overall (OR 0.61; 95% CI 0.4–0.94; P = 0.023) mortality after controlling for potential confounders.ConclusionsImplementing a structured, evidence-based intervention bundle significantly improved patient care and early and overall mortality in patients with candidaemia. Institutions should embrace this objective strategy and use the bundle as a means to measure high-quality medical care of patients.
Collapse
Affiliation(s)
- Celia Cardozo
- Hospital Clínic, IDIBAPS (Institut d’Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Guillermo Cuervo
- Hospital Universitari de Bellvitge, IDIBELL (Institut D’Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | | | - Paloma Merino
- Hospital Universitario Clínico ‘San Carlos’, Madrid, Spain
| | | | - Mario Fernández-Ruiz
- Hospital Universitario ‘12 de Octubre’, Instituto de Investigación Hospital ‘12 de Octubre’ (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | - Luis E López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología Clínica, Hospital Universitario Virgen Macarena/Instituto de Biomedicina de Sevilla (IBiS)/Universidad de Sevilla/Centro Superior de Investigaciones Científicas, Sevilla, Spain
| | - Laura Escolá-Vergé
- Hospital Universitari Vall d’Hebron, VHIR (Vall d’Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Patricia Muñoz
- Hospital General Universitario Gregorio Marañón e Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Pedro Puerta-Alcalde
- Hospital Clínic, IDIBAPS (Institut d’Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Mariona Tasias
- Hospital Universitari I Politecnic ‘La Fe’, Valencia, Spain
| | | | | | - Mireia Puig-Asensio
- Hospital Universitari Vall d’Hebron, VHIR (Vall d’Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Vena
- Hospital General Universitario Gregorio Marañón e Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Francesc Marco
- Hospital Clínic, IDIBAPS (Institut d’Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Javier Pemán
- Hospital Universitari I Politecnic ‘La Fe’, Valencia, Spain
| | - Jesús Fortún
- Hospital Universitario ‘Ramón y Cajal’, Madrid, Spain
| | - José María Aguado
- Hospital Universitario ‘12 de Octubre’, Instituto de Investigación Hospital ‘12 de Octubre’ (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | - Benito Almirante
- Hospital Universitari Vall d’Hebron, VHIR (Vall d’Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alejandro Soriano
- Hospital Clínic, IDIBAPS (Institut d’Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Jordi Carratalá
- Hospital Universitari de Bellvitge, IDIBELL (Institut D’Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | - Carolina Garcia-Vidal
- Hospital Clínic, IDIBAPS (Institut d’Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Samuel L. Direct Detection of Pathogens in Bloodstream During Sepsis: Are We There Yet? J Appl Lab Med 2019; 3:631-642. [DOI: 10.1373/jalm.2018.028274] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 11/07/2018] [Indexed: 12/22/2022]
Abstract
Abstract
Background
Advances in medicine have improved our understanding of sepsis, but it remains a major cause of morbidity and mortality. The detection of pathogens that cause sepsis remains a challenge for clinical microbiology laboratories.
Content
Routine blood cultures are time-consuming and are negative in a large proportion of cases, leading to excessive use of broad-spectrum antimicrobials. Molecular testing direct from patient blood without the need for incubation has the potential to fill the gaps in our diagnostic armament and complement blood cultures to provide results in a timely manner. Currently available platforms show promise but have yet to definitively address gaps in sensitivity and specificity.
Summary
Significant strides have been made in the detection of pathogens directly from blood. A number of hurdles, however, remain before this technology can be adapted for routine use.
Collapse
Affiliation(s)
- Linoj Samuel
- Department of Pathology and Laboratory Medicine, Clinical Microbiology Division, Henry Ford Health System, Detroit, MI
| |
Collapse
|
18
|
Abstract
The role of biomarkers for detection of sepsis has come a long way. Molecular biomarkers are taking front stage at present, but machine learning and other computational measures using bigdata sets are promising. Clinical research in sepsis is hampered by lack of specificity of the diagnosis; sepsis is a syndrome with no uniformly agreed definition. This lack of diagnostic precision means there is no gold standard for this diagnosis. The final conclusion is expert opinion, which is not bad but not perfect. Perhaps machine learning will displace expert opinion as the final and most accurate definition for sepsis.
Collapse
Affiliation(s)
- Steven M Opal
- Infectious Disease Division, Alpert Medical School of Brown University, Ocean State Clinical Coordinating Center at Rhode Island Hospital, 1 Virginia Avenue Suite 105, Providence, RI 02905, USA.
| | - Xavier Wittebole
- Critical Care Department, (Pr Laterre), Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
| |
Collapse
|
19
|
Righi E, Carnelutti A, Baccarani U, Sartor A, Cojutti P, Bassetti M, Pea F. Treatment of Candida infections with fluconazole in adult liver transplant recipients: Is TDM-guided dosing adaptation helpful? Transpl Infect Dis 2019; 21:e13113. [PMID: 31106504 DOI: 10.1111/tid.13113] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 04/24/2019] [Accepted: 05/02/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Fluconazole represents a common antifungal option for the treatment of Candida infections in liver transplant recipients. Although adequate antifungal exposure is known to correlate with favorable outcomes in patients with invasive candidiasis, therapeutic drug monitoring (TDM) of fluconazole is currently not recommended. METHODS We conducted a retrospective study including adult liver transplant recipients receiving fluconazole for invasive candidiasis and undergoing TDM. We assessed the correlation between clinical variables, fluconazole trough plasma levels (Cmin ), and outcome. RESULTS Twenty-seven patients (74% males; median age 57 years) were included. Abdominal candidiasis was the most frequent infection (56%). Median duration of fluconazole therapy was 17 days (IQR 9-21). Fluconazole median Cmin was 11.0 mg/L (range 2.4-30.6 mg/L). Five (19%) patients required TDM-guided fluconazole dose increase. All-cause in hospital mortality was 33%. Fluconazole Cmin >11 mg/L significantly correlated with clinical success (OR 8.78, 95% CI 1.13-67.8, P = 0.04). CONCLUSIONS Our study identified decreased fluconazole Cmin as a factor associated with negative outcomes in liver transplant recipients with Candida infection. TDM of fluconazole may be advisable in this patient population.
Collapse
Affiliation(s)
- Elda Righi
- Infectious Diseases Division, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy.,Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Alessia Carnelutti
- Infectious Diseases Division, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| | - Umberto Baccarani
- General Surgery and Transplantation Unit, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Assunta Sartor
- Microbiology Unit, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| | - Piergiorgio Cojutti
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Clinical Pharmacology, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| | - Matteo Bassetti
- Infectious Diseases Division, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Federico Pea
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Clinical Pharmacology, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| |
Collapse
|
20
|
Epidemiology of antifungal susceptibility: Review of literature. J Mycol Med 2019; 28:574-584. [PMID: 29773435 DOI: 10.1016/j.mycmed.2018.04.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 11/24/2022]
Abstract
Fungal infections are a major cause of morbidity and mortality despite the latest developments of diagnostic tools and therapeutic options. Early initiation of the appropriate antifungal therapy has been demonstrated to have a direct impact on the patient's outcome. Antifungal susceptibility testing methods are available to detect antifungal resistance and to determine the best treatment for a specific fungus. American and European standards have been developed, as well as equivalent commercial systems, which are more appropriate for clinical laboratories. These studies have allowed the development of interpretative breakpoints against the most frequent agents of fungal infections in the world. Surveillance of antifungal susceptibility patterns can provide the local drug resistance data to the clinicians, which can further aid better management of patients. Antifungal susceptibility tests have become essential tools to identify resistance to antifungals, to know the local and global disease epidemiology and to guide the treatment of fungal diseases. The distribution of species and the prevalence of antifungal resistance in fungi isolates varied among different areas. Here we summarize the epidemiology of antifungal susceptibility pattern of different fungal species.
Collapse
|
21
|
Candida sp. Infections in Patients with Diabetes Mellitus. J Clin Med 2019; 8:jcm8010076. [PMID: 30634716 PMCID: PMC6352194 DOI: 10.3390/jcm8010076] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 12/27/2018] [Accepted: 01/03/2019] [Indexed: 02/07/2023] Open
Abstract
Candidiasis has increased substantially worldwide over recent decades and is a significant cause of morbidity and mortality, especially among critically ill patients. Diabetes mellitus (DM) is a metabolic disorder that predisposes individuals to fungal infections, including those related to Candida sp., due to a immunosuppressive effect on the patient. This review aims to discuss the latest studies regarding the occurrence of candidiasis on DM patients and the pathophysiology and etiology associated with these co-morbidities. A comprehensive review of the literature was undertaken. PubMed, Scopus, Elsevier’s ScienceDirect, and Springer’s SpringerLink databases were searched using well-defined search terms. Predefined inclusion and exclusion criteria were applied to classify relevant manuscripts. Results of the review show that DM patients have an increased susceptibility to Candida sp. infections which aggravates in the cases of uncontrolled hyperglycemia. The conclusion is that, for these patients, the hospitalization periods have increased and are commonly associated with the prolonged use of indwelling medical devices, which also increase the costs associated with disease management.
Collapse
|
22
|
The Role of Antifungals in Pediatric Critical Care Invasive Fungal Infections. Crit Care Res Pract 2018; 2018:8469585. [PMID: 30595916 PMCID: PMC6282141 DOI: 10.1155/2018/8469585] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/20/2018] [Accepted: 10/30/2018] [Indexed: 12/11/2022] Open
Abstract
Invasive fungal infections (IFIs) have seen considerable increase in pediatric intensive care units over the past several decades. IFIs are predominantly caused by Candida species, and candidemia is the third most common cause of healthcare-associated bloodstream infections (BSIs) in children. IFIs are opportunistic infections that affect pediatric patients in critical care resulting in significant morbidity and mortality especially in those with a compromised immune system. IFIs are the leading cause of death in children with comorbidities such as immunosuppression, and pediatric ICU admission has been shown to be an independent risk factor for mortality. Management of IFI and fungal sepsis is broad and encompasses several key components that include prompt initiation of therapy and rapid source identification and control. This study reviews important antifungals in the pediatric critical care setting including the pharmacologic properties, antifungal spectrum, adverse effects, and clinical uses of agents belonging to the four major classes of antifungals—the polyenes, azoles, echinocandins, and pyrimidine analogue flucytosine. The polyenes and azoles are the most often used classes of antifungals. The echinocandins are a relatively newer class of antifungal agents that offer excellent Candida activity and are currently recommended as the first-line therapy for invasive candidiasis.
Collapse
|
23
|
Beganovic M, McCreary EK, Mahoney MV, Dionne B, Green DA, Timbrook TT. Interplay between Rapid Diagnostic Tests and Antimicrobial Stewardship Programs among Patients with Bloodstream and Other Severe Infections. J Appl Lab Med 2018; 3:601-616. [PMID: 31639729 DOI: 10.1373/jalm.2018.026450] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/04/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) aim to provide optimal antimicrobial therapy to patients quickly to improve the likelihood of overcoming infection while reducing the risk of adverse effects. Rapid diagnostic tests (RDTs) for infectious diseases have become an integral tool for ASPs to achieve these aims. CONTENT This review explored the demonstrated clinical value of longer-standing technologies and implications of newer RDTs from an antimicrobial stewardship perspective. Based on available literature, the focus was on the use of RDTs in bloodstream infections (BSIs), particularly those that perform organism identification and genotypic resistance detection, phenotypic susceptibility testing, and direct specimen testing. Clinical implications of rapid testing among respiratory, central nervous system, and gastrointestinal infections are also reviewed. SUMMARY Coupling RDTs with ASPs facilitates the appropriate and timely use of test results, translating into improved patient outcomes through optimization of antimicrobial use. These benefits are best demonstrated in the use of RDT in BSIs. Rapid phenotypic susceptibility testing offers the potential for early pharmacokinetic/pharmacodynamic optimization, and direct specimen testing on blood may allow ASPs to initiate appropriate therapy and/or tailor empiric therapy even sooner than other RDTs. RDTs for respiratory, central nervous system, and gastrointestinal illnesses have also shown significant promise, although more outcome studies are needed to evaluate their full impact.
Collapse
Affiliation(s)
- Maya Beganovic
- Advocate Lutheran General Hospital, Department of Pharmacy, Park Ridge, IL
| | - Erin K McCreary
- University of Pittsburgh Medical Center, Department of Pharmacy, Pittsburgh, PA
| | - Monica V Mahoney
- Beth Israel Deaconess Medical Center, Department of Pharmacy, Boston, MA
| | - Brandon Dionne
- Northeastern University, School of Pharmacy, Bouvé College of Health Sciences, Boston, MA.,Brigham and Women's Hospital, Department of Pharmacy, Boston, MA
| | - Daniel A Green
- Columbia University College of Physicians and Surgeons, New York, NY
| | | |
Collapse
|
24
|
Timbrook TT, Spivak ES, Hanson KE. Current and Future Opportunities for Rapid Diagnostics in Antimicrobial Stewardship. Med Clin North Am 2018; 102:899-911. [PMID: 30126579 DOI: 10.1016/j.mcna.2018.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Rapid diagnostic testing has improved clinical care of patients with infectious syndromes when combined with antimicrobial stewardship. The authors review the current data on antimicrobial stewardship and rapid diagnostic testing in bloodstream, respiratory tract, and gastrointestinal tract infections. Evidence for the potential benefit of rapid tests in bloodstream infections seems strong, respiratory tract infections mixed, and gastrointestinal tract infections still evolving. The authors also review future directions in rapid diagnostic testing and suggest areas of focus for antimicrobial stewardship efforts.
Collapse
Affiliation(s)
- Tristan T Timbrook
- Department of Pharmacy, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA
| | - Emily S Spivak
- Department of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - Kimberly E Hanson
- Department of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA; Institute for Clinical and Experimental Pathology, ARUP Laboratories, 500 Chipeta Way, Salt Lake City, UT 84108, USA; Department of Pathology, University of Utah, 15 North Medical Drive East, Salt Lake City, UT 84112, USA.
| |
Collapse
|
25
|
The application of UV resonance Raman spectroscopy for the differentiation of clinically relevant Candida species. Anal Bioanal Chem 2018; 410:5839-5847. [DOI: 10.1007/s00216-018-1196-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/30/2018] [Accepted: 06/13/2018] [Indexed: 01/21/2023]
|
26
|
|
27
|
Micafungin Plasma Levels Are Not Affected by Continuous Renal Replacement Therapy: Experience in Critically Ill Patients. Antimicrob Agents Chemother 2017; 61:AAC.02425-16. [PMID: 28584142 DOI: 10.1128/aac.02425-16] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 05/21/2017] [Indexed: 01/08/2023] Open
Abstract
Critically ill patients often experience acute kidney injury and the need for renal replacement therapy in the course of their treatment in an intensive care unit (ICU). These patients are at an increased risk for candidiasis. Although there have been several reports of micafungin disposition during renal replacement therapy, to this date there are no data describing the elimination of micafungin during high-dose continuous venovenous hemodiafiltration with modified AN69 membranes. The aim of this prospective open-label pharmacokinetic study was to assess whether micafungin plasma levels are affected by continuous hemodiafiltration in critical ill patients using the commonly employed AN69 membrane. A total of 10 critically ill patients with micafungin treatment due to suspected or proven candidemia were included in this trial. Prefilter/postfilter micafungin clearance was measured to be 46.0 ml/min (±21.7 ml/min; n = 75 individual time points), while hemofilter clearance calculated by the sieving coefficient was 0.0038 ml/min (±0.002 ml/min; n = 75 individual time points). Total body clearance was measured to be 14.0 ml/min (±7.0 ml/min; n = 12). The population area under the curve from 0 to 24 h (AUC0-24) was calculated as 158.5 mg · h/liter (±79.5 mg · h/liter; n = 13). In spite of high protein binding, no dose modification is necessary in patients receiving continuous venovenous hemodiafiltration with AN69 membranes. A dose elevation may, however, be justified in certain cases. (This study has been registered at ClinicalTrials.gov under identifier NCT02651038.).
Collapse
|
28
|
Rapid and Accurate Molecular Identification of the Emerging Multidrug-Resistant Pathogen Candida auris. J Clin Microbiol 2017; 55:2445-2452. [PMID: 28539346 PMCID: PMC5527423 DOI: 10.1128/jcm.00630-17] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 05/22/2017] [Indexed: 11/24/2022] Open
Abstract
Candida auris is an emerging multidrug-resistant fungal pathogen causing nosocomial and invasive infections associated with high mortality. C. auris is commonly misidentified as several different yeast species by commercially available phenotypic identification platforms. Thus, there is an urgent need for a reliable diagnostic method. In this paper, we present fast, robust, easy-to-perform and interpret PCR and real-time PCR assays to identify C. auris and related species: Candida duobushaemulonii, Candida haemulonii, and Candida lusitaniae. Targeting rDNA region nucleotide sequences, primers specific for C. auris only or C. auris and related species were designed. A panel of 140 clinical fungal isolates was used in both PCR and real-time PCR assays followed by electrophoresis or melting temperature analysis, respectively. The identification results from the assays were 100% concordant with DNA sequencing results. These molecular assays overcome the deficiencies of existing phenotypic tests to identify C. auris and related species.
Collapse
|
29
|
Alastruey-Izquierdo A, Melhem MSC, Bonfietti LX, Rodriguez-Tudela JL. SUSCEPTIBILITY TEST FOR FUNGI: CLINICAL AND LABORATORIAL CORRELATIONS IN MEDICAL MYCOLOGY. Rev Inst Med Trop Sao Paulo 2016; 57 Suppl 19:57-64. [PMID: 26465371 PMCID: PMC4711191 DOI: 10.1590/s0036-46652015000700011] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
During recent decades, antifungal susceptibility testing has become standardized and nowadays has the same role of the antibacterial susceptibility testing in microbiology laboratories. American and European standards have been developed, as well as equivalent commercial systems which are more appropriate for clinical laboratories. The detection of resistant strains by means of these systems has allowed the study and understanding of the molecular basis and the mechanisms of resistance of fungal species to antifungal agents. In addition, many studies on the correlation of in vitro results with the outcome of patients have been performed, reaching the conclusion that infections caused by resistant strains have worse outcome than those caused by susceptible fungal isolates. These studies have allowed the development of interpretative breakpoints for Candida spp. and Aspergillus spp., the most frequent agents of fungal infections in the world. In summary, antifungal susceptibility tests have become essential tools to guide the treatment of fungal diseases, to know the local and global disease epidemiology, and to identify resistance to antifungals.
Collapse
|
30
|
Paiva JA, Pereira JM, Tabah A, Mikstacki A, de Carvalho FB, Koulenti D, Ruckly S, Çakar N, Misset B, Dimopoulos G, Antonelli M, Rello J, Ma X, Tamowicz B, Timsit JF. Characteristics and risk factors for 28-day mortality of hospital acquired fungemias in ICUs: data from the EUROBACT study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:53. [PMID: 26956367 PMCID: PMC4784333 DOI: 10.1186/s13054-016-1229-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 02/10/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND To characterize and identify prognostic factors for 28-day mortality among patients with hospital-acquired fungemia (HAF) in the Intensive Care Unit (ICU). METHODS A sub-analysis of a prospective, multicenter non-representative cohort study conducted in 162 ICUs in 24 countries. RESULTS Of the 1156 patients with hospital-acquired bloodstream infections (HA-BSI) included in the EUROBACT study, 96 patients had a HAF. Median time to its diagnosis was 20 days (IQR 10.5-30.5) and 9 days (IQR 3-15.5) after hospital and ICU admission, respectively. Median time to positivity of blood culture was longer in fungemia than in bacteremia (48.7 h vs. 38.1 h; p = 0.0004). Candida albicans was the most frequent fungus isolated (57.1%), followed by Candida glabrata (15.3%) and Candida parapsilosis (10.2%). No clear source of HAF was detected in 33.3% of the episodes and it was catheter-related in 21.9% of them. Compared to patients with bacteremia, HAF patients had a higher rate of septic shock (39.6% vs. 21.6%; p = 0.0003) and renal dysfunction (25% vs. 12.4%; p = 0.0023) on admission and a higher rate of renal failure (26% vs. 16.2%; p = 0.0273) at diagnosis. Adequate treatment started within 24 h after blood culture collection was less frequent in HAF patients (22.9% vs. 55.3%; p < 0.001). The 28-day all cause fatality was 40.6%. According to multivariate analysis, only liver failure (OR 14.35; 95% CI 1.17-175.6; p = 0.037), need for mechanical ventilation (OR 8.86; 95% CI 1.2-65.24; p = 0.032) and ICU admission for medical reason (OR 3.87; 95% CI 1.25-11.99; p = 0.020) were independent predictors of 28-day mortality in HAF patients. CONCLUSIONS Fungi are an important cause of hospital-acquired BSI in the ICU. Patients with HAF present more frequently with septic shock and renal dysfunction on ICU admission and have a higher rate of renal failure at diagnosis. HAF are associated with a significant 28-day mortality rate (40%), but delayed adequate antifungal therapy was not an independent risk factor for death. Liver failure, need for mechanical ventilation and ICU admission for medical reason were the only independent predictors of 28-day mortality.
Collapse
Affiliation(s)
- José-Artur Paiva
- Grupo de Infecção e Sepsis; Emergency and Intensive Care Department, Centro Hospitalar S. João, EPE; Faculty of Medicine, University of Porto, Porto, Portugal.
| | - José Manuel Pereira
- Grupo de Infecção e Sepsis; Emergency and Intensive Care Department, Centro Hospitalar S. João, EPE; Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Alexis Tabah
- Université Grenoble 1, U 823, Albert Bonniot Institute; Team 11: Outcome of mechanically ventilated patients and respiratory cancers, Grenoble, France. .,Burns, Trauma, and Critical Care Research Center, The University of Queensland, Butterfield Street, Brisbane, Australia. .,Outcomerea Organization, Paris, France.
| | - Adam Mikstacki
- Department of Anaesthesiology and Intensive Therapy, Regional Hospital in Poznan, Poznan University of Medical Sciences, Poznan, Poland.
| | - Frederico Bruzzi de Carvalho
- Infectious and Tropical Diseases Intensive Care Unit, Hospital Eduardo de Menezes, Fundação Hospitalar do Estado de Minas Gerais, Belo Horizonte, MG, Brazil.
| | - Despoina Koulenti
- Burns, Trauma, and Critical Care Research Center, The University of Queensland, Butterfield Street, Brisbane, Australia. .,Department of Critical Care, University Hospital ATTIKON, Medical School University of Athens, Athens, Greece.
| | - Stéphane Ruckly
- Outcomerea Organization, Paris, France. .,Decision Sciences in Infectious Disease (DescID) Prevention, Control and Care, UMR 1137 Paris Diderot University, Sorbonne, Paris, France.
| | - Nahit Çakar
- Department of Anaesthesiology and Intensive Care, Istanbul University and Istanbul Medical School, Istanbul, Turkey.
| | - Benoit Misset
- Université Paris Descartes, Paris Sorbonne Cité, Medical-surgical ICU, Groupe hospitalier Paris Saint-Joseph, Paris, France.
| | - George Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, Medical School University of Athens, Athens, Greece.
| | - Massimo Antonelli
- Department of Intensive Care and Anaesthesiology, Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Jordi Rello
- Critical Care Department, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Xiaochun Ma
- Department of Critical Care Medicine, The First Affiliated Hospital Of China Medical University, Shenyang, China.
| | - Barbara Tamowicz
- Department of Anaesthesiology and Intensive Therapy, Regional Hospital in Poznan, Poznan University of Medical Sciences, Poznan, Poland.
| | - Jean-François Timsit
- Université Grenoble 1, U 823, Albert Bonniot Institute; Team 11: Outcome of mechanically ventilated patients and respiratory cancers, Grenoble, France. .,Outcomerea Organization, Paris, France. .,Decision Sciences in Infectious Disease (DescID) Prevention, Control and Care, UMR 1137 Paris Diderot University, Sorbonne, Paris, France. .,Medical and Infectious Diseases Intensive Care Unit, Bichat University Hospital, Paris Diderot University, Paris, 75018, France.
| |
Collapse
|
31
|
Bernal-Martínez L, Alastruey-Izquierdo A, Cuenca-Estrella M. Diagnostics and susceptibility testing in Aspergillus. Future Microbiol 2016; 11:315-28. [PMID: 26848512 DOI: 10.2217/fmb.15.140] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
UNLABELLED Invasive aspergillosis is a major cause of morbidity and mortality in immunosuppressed patients. Early diagnosis and correct antifungal treatment have a direct impact on patient survival. A number of newer diagnostic procedures have been developed as alternatives to conventional microbiological methods. The detection of fungal components, largely antigens and DNA, are used in clinical laboratories to diagnose invasive aspergillosis. Other rapid diagnostic tests have been recently developed with promising results. However, antifungal resistance is becoming an emerging problem. The detection of this resistance is important to administer the proper antifungal agent. This text reviews the novelties on new diagnostics Aspergillus spp. PROCEDURES Intrinsic antifungal resistance and mechanisms of secondary resistance to triazoles in A. fumigatus are also reviewed.
Collapse
Affiliation(s)
- Leticia Bernal-Martínez
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain; Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain; Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Cuenca-Estrella
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain; Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
32
|
Pfaller MA, Castanheira M. Nosocomial Candidiasis: Antifungal Stewardship and the Importance of Rapid Diagnosis. Med Mycol 2015; 54:1-22. [PMID: 26385381 DOI: 10.1093/mmy/myv076] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/20/2015] [Indexed: 01/12/2023] Open
Abstract
Candidemia and other forms of candidiasis are associated with considerable excess mortality and costs. Despite the addition of several new antifungal agents with improved spectrum and potency, the frequency of Candida infection and associated mortality have not decreased in the past two decades. The lack of rapid and sensitive diagnostic tests has led to considerable overuse of antifungal agents resulting in increased costs, selection pressure for resistance, unnecessary drug toxicity, and adverse drug interactions. Both the lack of timely diagnostic tests and emergence of antifungal resistance pose considerable problems for antifungal stewardship. Whereas antifungal stewardship with a focus on nosocomial candidiasis should be able to improve the administration of antifungal therapy in terms of drug selection, proper dose and duration, source control and de-escalation therapy, an important parameter, timeliness of antifungal therapy, remains a victim of slow and insensitive diagnostic tests. Fortunately, new proteomic and molecular diagnostic tools are improving the time to species identification and detection. In this review we will describe the potential impact that rapid diagnostic testing and antifungal stewardship can have on the management of nosocomial candidiasis.
Collapse
Affiliation(s)
- Michael A Pfaller
- T2Biosystems, Lexington, Massachusetts JMI Laboratories, North Liberty, Iowa University of Iowa College of Medicine College of Public Health, Iowa City, Iowa
| | | |
Collapse
|
33
|
Liang SY, Kumar A. Empiric antimicrobial therapy in severe sepsis and septic shock: optimizing pathogen clearance. Curr Infect Dis Rep 2015; 17:493. [PMID: 26031965 PMCID: PMC4581522 DOI: 10.1007/s11908-015-0493-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Mortality and morbidity in severe sepsis and septic shock remain high despite significant advances in critical care. Efforts to improve outcome in septic conditions have focused on targeted, quantitative resuscitation strategies utilizing intravenous fluids, vasopressors, inotropes, and blood transfusions to correct disease-associated circulatory dysfunction driven by immune-mediated systemic inflammation. This review explores an alternate paradigm of septic shock in which microbial burden is identified as the key driver of mortality and progression to irreversible shock. We propose that clinical outcomes in severe sepsis and septic shock hinge upon the optimized selection, dosing, and delivery of highly potent antimicrobial therapy.
Collapse
Affiliation(s)
- Stephen Y. Liang
- Division of Infectious Diseases, Division of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8051, St. Louis, MO 63110, USA,
| | - Anand Kumar
- Section of Critical Care Medicine, Section of Infectious Diseases, JJ399d, Health Sciences Centre, 700 William Street, Winnipeg, Manitoba, Canada R3A-1R9,
| |
Collapse
|
34
|
Miyazaki T, Kohno S. Current recommendations and importance of antifungal stewardship for the management of invasive candidiasis. Expert Rev Anti Infect Ther 2015; 13:1171-83. [DOI: 10.1586/14787210.2015.1058157] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
35
|
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.
Collapse
Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Piazzale Santa Maria della Misericordia 15, 33100, Udine, Italy,
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Ng K, Schorr C, Reboli AC, Zanotti S, Tsigrelis C. Incidence and mortality of sepsis, severe sepsis, and septic shock in intensive care unit patients with candidemia. Infect Dis (Lond) 2015; 47:584-7. [PMID: 25811137 DOI: 10.3109/23744235.2015.1028100] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In this incidence study, of 16 074 patients admitted to the intensive care unit (ICU) from 1/1/2003 to 7/31/2011, 161 cases of candidemia were identified. The incidence of sepsis (27%), severe sepsis (31%), and septic shock (40%) was remarkably high in these cases of candidemia, as was the all-cause in-hospital mortality for sepsis (30%), severe sepsis (44%), and septic shock (65%).
Collapse
Affiliation(s)
- Kevin Ng
- From the Division of Infectious Diseases, Department of Medicine, Cooper Medical School of Rowan University and Cooper University Hospital , Camden, NJ , USA
| | | | | | | | | |
Collapse
|
37
|
Clinical and epidemiological characteristics and risk factors for mortality in patients with candidemia in hospitals from Bogotá, Colombia. Braz J Infect Dis 2014; 18:631-7. [PMID: 25181401 PMCID: PMC9425269 DOI: 10.1016/j.bjid.2014.06.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 05/29/2014] [Accepted: 06/27/2014] [Indexed: 11/25/2022] Open
Abstract
Background Bloodstream infection by Candida species has a high mortality in Latin American countries. The aim of this study was to describe the characteristics of patients with documented bloodstream infections caused by Candida species in third level hospitals and determine the risk factors for in-hospital-mortality. Methods Patients from seven tertiary-care hospitals in Bogotá, Colombia, with isolation of a Candida species from a blood culture were followed prospectively from March 2008 to March 2009. Epidemiologic information, risk factors, and mortality were prospectively collected. Isolates were sent to a reference center, and fluconazole susceptibility was tested by agar-based E-test. The results of susceptibility were compared by using 2008 and 2012 breakpoints. A multivariate analysis was used to determinate risk factors for mortality. Results We identified 131 patients, with a median age of 41.2 years. Isolates were most frequently found in the intensive care unit (ICU). Candida albicans was the most prevalent species (66.4% of the isolates), followed by C. parapsilosis (14%). Fluconazole resistance was found in 3.2% and 17.6% of the isolates according to the 2008 and 2012 breakpoints, respectively. Fluconazole was used as empirical antifungal therapy in 68.8% of the cases, and amphotericin B in 22%. Hospital crude mortality rate was 35.9%. Mortality was associated with age and the presence of shock at the time of Candida detection. Fluconazole therapy was a protective factor for mortality. Conclusions Candidemia is associated with a high mortality rate. Age and shock increase mortality, while the use of fluconazole was shown to be a protective factor. A higher resistance rate with new breakpoints was noted.
Collapse
|
38
|
Candidemia and non-candidemia related septic shock: are there differences between them? Intensive Care Med 2014; 40:1046-8. [PMID: 24832565 DOI: 10.1007/s00134-014-3332-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 05/02/2014] [Indexed: 10/25/2022]
|
39
|
Surveillance of Candida spp bloodstream infections: epidemiological trends and risk factors of death in two Mexican tertiary care hospitals. PLoS One 2014; 9:e97325. [PMID: 24830654 PMCID: PMC4022628 DOI: 10.1371/journal.pone.0097325] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 04/17/2014] [Indexed: 01/09/2023] Open
Abstract
Introduction Larger populations at risk, broader use of antibiotics and longer hospital stays have impacted on the incidence of Candida sp. bloodstream infections (CBSI). Objective To determine clinical and epidemiologic characteristics of patients with CBSI in two tertiary care reference medical institutions in Mexico City. Design Prospective and observational laboratory-based surveillance study conducted from 07/2008 to 06/2010. Methods All patients with CBSI were included. Identification and antifungal susceptibility were performed using CLSI M27-A3 standard procedures. Frequencies, Mann-Whitney U test or T test were used as needed. Risk factors were determined with multivariable analysis and binary logistic regression analysis. Results CBSI represented 3.8% of nosocomial bloodstream infections. Cumulative incidence was 2.8 per 1000 discharges (incidence rate: 0.38 per 1000 patient-days). C. albicans was the predominant species (46%), followed by C. tropicalis (26%). C. glabrata was isolated from patients with diabetes (50%), and elderly patients. Sixty-four patients (86%) received antifungals. Amphotericin-B deoxycholate (AmBD) was the most commonly used agent (66%). Overall mortality rate reached 46%, and risk factors for death were APACHE II score ≥16 (OR = 6.94, CI95% = 2.34–20.58, p<0.0001), and liver disease (OR = 186.11, CI95% = 7.61–4550.20, p = 0.001). Full susceptibility to fluconazole, AmBD and echinocandins among C. albicans, C. tropicalis, and C. parapsilosis was observed. Conclusions The cumulative incidence rate in these centers was higher than other reports from tertiary care hospitals from Latin America. Knowledge of local epidemiologic patterns permits the design of more specific strategies for prevention and preemptive therapy of CBSI.
Collapse
|
40
|
|
41
|
Cortegiani A, Russotto V, Montalto F, Foresta G, Accurso G, Palmeri C, Raineri SM, Giarratano A. Procalcitonin as a marker of Candida species detection by blood culture and polymerase chain reaction in septic patients. BMC Anesthesiol 2014; 14:9. [PMID: 24559080 PMCID: PMC3936855 DOI: 10.1186/1471-2253-14-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 02/12/2014] [Indexed: 12/25/2022] Open
Abstract
Background The aim of our study is to test procalcitonin (PCT) as surrogate marker of identification of Candida spp. by blood culture (BC) and real-time-polymerase chain reaction (PCR), whether alone or in association with bacteria, in septic patients. Methods We performed a single-centre retrospective study. We reviewed the clinical charts of patients with a diagnosis of severe sepsis or septic shock treated at our general intensive care unit from March 2009 to March 2013. We analysed all diagnostic episodes consisting of BC, real-time PCR assay and dosage of PCT. We registered age, sex, white blood count, sequential organ failure assessment score and type of admission between medical or surgical. When inclusion criteria were met more than once, we registered the new diagnostic episode as subsequent diagnostic episode. The diagnostic performance of PCT to predict Candida spp. identification alone or in mixed infections by either BC or PCR was tested using the receiver-operative characteristic curve. Logistic regression was constructed using presence of Candida spp. as the dependent variable. Results A total of 260 diagnostic episodes met the inclusion criteria. According to BC results classification, a significantly lower value of PCT was observed in Candida spp. BSI (0.99 ng/ml, 0.86 - 1.34) than in BSI caused by bacteria (16.7 ng/ml, 7.65 - 50.2) or in mixed infections (4.76 ng/ml, 2.98 - 6.08). Similar findings were observed considering PCR results. A cut-off of ≤ 6.08 ng/ml for PCT yielded a sensitivity of 86.8%, a specificity of 87.4%, a positive predictive value of 63.9%, a negative predictive value (NPV) of 96.3% and an area under the curve of 0.93 for Candida spp. identification by BC. A similar high NPV for a cut-off ≤ 6.78 ng/ml was observed considering the classification of diagnostic episodes according to PCR results, with an AUC of 0.85. A subsequent diagnostic episode was independently associated with Candida spp. detection either by BC or PCR. Conclusion PCT could represent a useful diagnostic tool to exclude the detection of Candida spp. by BC and PCR in septic patients.
Collapse
Affiliation(s)
- Andrea Cortegiani
- Department of Biopathology, Medical and Forensic Biotechnologies (DIBIMEF), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico "P, Giaccone", University of Palermo, Palermo, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Kumar A. An alternate pathophysiologic paradigm of sepsis and septic shock: implications for optimizing antimicrobial therapy. Virulence 2013; 5:80-97. [PMID: 24184742 PMCID: PMC3916387 DOI: 10.4161/viru.26913] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The advent of modern antimicrobial therapy following the discovery of penicillin during the 1940s yielded remarkable improvements in case fatality rate of serious infections including septic shock. Since then, pathogens have continuously evolved under selective antimicrobial pressure resulting in a lack of significant improvement in clinical effectiveness in the antimicrobial therapy of septic shock despite ever more broad-spectrum and potent drugs. In addition, although substantial effort and money has been expended on the development novel non-antimicrobial therapies of sepsis in the past 30 years, clinical progress in this regard has been limited. This review explores the possibility that the current pathophysiologic paradigm of septic shock fails to appropriately consider the primacy of the microbial burden of infection as the primary driver of septic organ dysfunction. An alternate paradigm is offered that suggests that has substantial implications for optimizing antimicrobial therapy in septic shock. This model of disease progression suggests the key to significant improvement in the outcome of septic shock may lie, in great part, with improvements in delivery of existing antimicrobials and other anti-infectious strategies. Recognition of the role of delays in administration of antimicrobial therapy in the poor outcomes of septic shock is central to this effort. However, therapeutic strategies that improve the degree of antimicrobial cidality likely also have a crucial role.
Collapse
Affiliation(s)
- Anand Kumar
- Section of Critical Care Medicine; Section of Infectious Diseases; Health Sciences Centre; Winnipeg, MB Canada
| |
Collapse
|
43
|
Clinical impact of time to positivity for Candida species on mortality in patients with candidaemia. J Antimicrob Chemother 2013; 68:2890-7. [DOI: 10.1093/jac/dkt256] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
|
44
|
Pemán J, Zaragoza R. [Towards an early diagnosis of invasive candidiasis in the critically ill patient]. Rev Iberoam Micol 2013; 29:71-5. [PMID: 22463780 DOI: 10.1016/j.riam.2012.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The management of invasive fungal infections in critically ill patients, from diagnosis to selection of the therapeutic protocol, is often a challenge. Early diagnosis and treatment are associated with a better prognosis, but apart from cases with positive cultures from blood or fluid/tissue biopsy, diagnosis is neither sensitive nor specific, and there is a need for specific markers in these diseases. Serodiagnostic assays such as mannan antigen, mannan antibodies, Candida albicans germ-tube antibodies or (1→3)-β-D-glucan detection, and molecular techniques for the detection of fungal-specific DNA have been developed with promising results in critical care settings. One of the main features in diagnosis is the evaluation of risk factors for infection, which will identify patients in need of preemptive or empirical treatment. Clinical scores were built from those risk factors. The combination of prediction rules and non-culture microbiological tools could be currently be the key to improving the diagnosis and prognosis of invasive fungal infections in critically ill patients.
Collapse
Affiliation(s)
- Javier Pemán
- Servicio de Microbiología, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | | |
Collapse
|
45
|
Cortés JA, Prada G. Protocolo de estudio y manejo de pacientes con candidiasis sistémica en adultos. INFECTIO 2012. [DOI: 10.1016/s0123-9392(12)70037-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
46
|
Attributable costs of patients with candidemia and potential implications of polymerase chain reaction-based pathogen detection on antifungal therapy in patients with sepsis. J Crit Care 2012; 28:2-8. [PMID: 22999484 DOI: 10.1016/j.jcrc.2012.07.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 07/06/2012] [Accepted: 07/08/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE The purposes of this study were to calculate attributable costs of candidemia in patients with severe sepsis and to obtain preliminary data regarding the potential effects of polymerase chain reaction-based pathogen detection on antifungal therapy for these patients. METHODS Patients treated between 2004 and 2010 because of severe sepsis were included into this retrospective analysis. The hospital management provided annual fixed costs per patient-day; data for variable intensive care unit costs were taken from the literature. Multiplex polymerase chain reaction (PCR) was used (VYOO, SIRS-Lab, Jena, Germany) for pathogen detection in the blood. RESULTS Thirty-two patients with candidemia were identified. Of 874 patients with sepsis, propensity score matching found 32 corresponding patients with sepsis but without candida infection but similar risk factors for developing candidemia. Attributable costs of candidemia were 7713.79 Euro (cost increase, 19.4%). Initiation of antifungal therapy was reduced from 67.5 (52.4, 90) hours in the group, where candida infection was determined by blood culture, to 31.0 (28.0, 37.5; P < .01) hours after detection by multiplex PCR. CONCLUSIONS Candidemia increases costs of care in patients with septic shock. Polymerase chain reaction-based pathogen detection significantly reduces the time to initiation of antifungal therapy. This might impact on the clinical course of the disease but need to be confirmed in further trials.
Collapse
|
47
|
Glöckner A, Cornely OA. Practical considerations on current guidelines for the management of non-neutropenic adult patients with candidaemia. Mycoses 2012; 56:11-20. [DOI: 10.1111/j.1439-0507.2012.02208.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
|
48
|
Griffith MM, Gross AE, Sutton SH, Bolon MK, Esterly JS, Patel JA, Postelnick MJ, Zembower TR, Scheetz MH. The impact of anti-infective drug shortages on hospitals in the United States: trends and causes. Clin Infect Dis 2012; 54:684-91. [PMID: 22267747 DOI: 10.1093/cid/cir954] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Anti-infective shortages pose significant logistical and clinical challenges to hospitals and may be considered a public health emergency. Anti-infectives often represent irreplaceable life-saving treatments. Furthermore, few new agents are available to treat increasingly prevalent multidrug-resistant pathogens. Frequent anti-infective shortages have substantially altered patient care and may lead to inferior patient outcomes. Because many of the shortages stem from problems with manufacturing and distribution, federal legislation has been introduced but not yet enacted to provide oversight for the adequate supply of critical medications. At the local level, hospitals should develop strategies to anticipate the impact and extent of shortages, to identify therapeutic alternatives, and to mitigate potential adverse outcomes. Here we describe the scope of recent anti-infective shortages in the United States and explore the reasons for inadequate drug supply.
Collapse
Affiliation(s)
- Milena M Griffith
- Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois 60515, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Abstract
Despite the availability of newer antifungal drugs, outcomes for patients with invasive fungal infections (IFIs) continue to be poor, in large part due to delayed diagnosis and initiation of appropriate antifungal therapy. Standard histopathologic diagnostic techniques are often untenable in at-risk patients, and culture-based diagnostics typically are too insensitive or nonspecific, or provide results after too long a delay for optimal IFI management. Newer surrogate markers of IFIs with improved sensitivity and specificity are needed to enable earlier diagnosis and, ideally, to provide prognostic information and/or permit therapeutic monitoring. Surrogate assays should also be accessible and easy to implement in the hospital. Several nonculture-based assays of newer surrogates are making their way into the medical setting or are currently under investigation. These new or up-and-coming surrogates include antigens/antibodies (mannan and antimannan antibodies) or fungal metabolites (d-arabinitol) for detection of invasive candidiasis, the Aspergillus cell wall component galactomannan used to detect invasive aspergillosis, or the fungal cell wall component and panfungal marker β-glucan. In addition, progress continues with use of polymerase chain reaction- or other nucleic acid- or molecular-based assays for diagnosis of either specific or generic IFIs, although the various methods must be better standardized before any of these approaches can be more fully implemented into the medical setting. Investigators are also beginning to explore the possibility of combining newer surrogate markers with each other or with more standard diagnostic approaches to improve sensitivity, specificity, and capacity for earlier diagnosis, at a time when fungal burden is still relatively low and more responsive to antifungal therapy.
Collapse
|
50
|
Abstract
Effective management of invasive fungal infections (IFIs) depends on early individualized therapy that optimizes efficacy and safety. Considering the negative consequences of IFI, for some high-risk patients the potential benefits of prophylactic therapy may outweigh the risks. When using a prophylactic, empiric, or preemptive therapeutic approach, clinicians must take into account the local epidemiology, spectrum of activity, pharmacokinetic and pharmacodynamic parameters, and safety profile of different antifungal agents, together with unique host-related factors that may affect antifungal efficacy or safety. Therapeutic drug monitoring is increasingly recognized as important or necessary when employing lipophilic triazoles (itraconazole, voriconazole, posaconazole) or flucytosine. Because early diagnostics remain limited for uncommon, yet emerging opportunistic molds (e.g., Mucorales), and treatment delay is associated with increased mortality, early effective management often depends on a high index of suspicion, taking into account predisposing factors, host cues favoring mucormycosis, and local epidemiology. Antifungal options for mucormycosis are limited, and optimal management depends on a multimodal approach that includes early diagnosis/clinical suspicion, correction of underlying predisposing factors, radical debridement of affected tissues, and extended antifungal therapy. This article discusses strategies for the effective management of invasive mycoses, with a particular focus on antifungal hepatotoxicity.
Collapse
Affiliation(s)
- Dimitrios P Kontoyiannis
- Division of Internal Medicine, Department of Infectious Diseases Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
| |
Collapse
|