Candiduria in haematologic malignancy patients without a urinary catheter: nothing more than a frailty marker?

A 3-year study of Candida infections among patients with malignancy: etiologic agents and antifungal susceptibility profile

Objective

Opportunistic fungal infections by Candida species arise among cancer patients due to the weakened immune system following extensive chemotherapy. Prophylaxis with antifungal agents have developed the resistance of Candida spp. to antifungals. Accurate identification of yeasts and susceptibility patterns are main concerns that can directly effect on the treatment of patients.

Methods

Over a period of three years, 325 cancer patients suspected to Candida infections were included in the current investigation. The clinical isolates were molecularly identified by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). All strains, were examined for in vitro susceptibility to the amphotericin B, itraconazole, fluconazole, and anidulafungin according to the CLSI M27 document.

Results

Seventy-four cancer patients had Candida infections (22.7%). Candida albicans was the most common species (83.8%). Antifungal susceptibility results indicated that 100% of the Candida isolates were sensitive to amphotericin B; however, 17.6%, 9.4%, and 5.4% of clinical isolates were resistant to anidulafungin, fluconazole, and itraconazole, respectively.

Conclusion

The findings of the present work shows a warning increase in resistance to echinocandins. Since all fluconazole resistance isolates were obtained from candidemia, we recommend amphotericin B as the first line therapy for this potentially fatal infection.

Core Recommendations for Antifungal Stewardship: A Statement of the Mycoses Study Group Education and Research Consortium

In recent years, the global public health community has increasingly recognized the importance of antimicrobial stewardship (AMS) in the fight to improve outcomes, decrease costs, and curb increases in antimicrobial resistance around the world. However, the subject of antifungal stewardship (AFS) has received less attention. While the principles of AMS guidelines likely apply to stewarding of antifungal agents, there are additional considerations unique to AFS and the complex field of fungal infections that require specific recommendations. In this article, we review the literature on AMS best practices and discuss AFS through the lens of the global core elements of AMS. We offer recommendations for best practices in AFS based on a synthesis of this evidence by an interdisciplinary expert panel of members of the Mycoses Study Group Education and Research Consortium. We also discuss research directions in this rapidly evolving field. AFS is an emerging and important component of AMS, yet requires special considerations in certain areas such as expertise, education, interventions to optimize utilization, therapeutic drug monitoring, and data analysis and reporting.

Treatment of invasive fungal diseases in cancer patients-Revised 2019 Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO)

BACKGROUND

Invasive fungal diseases remain a major cause of morbidity and mortality in cancer patients undergoing intensive cytotoxic therapy. The choice of the most appropriate antifungal treatment (AFT) depends on the fungal species suspected or identified, the patient's risk factors (eg length and depth of granulocytopenia) and the expected side effects.

OBJECTIVES

Since the last edition of recommendations for 'Treatment of invasive fungal infections in cancer patients' of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) in 2013, treatment strategies were gradually moving away from solely empirical therapy of presumed or possible invasive fungal diseases (IFDs) towards pre-emptive therapy of probable IFD.

METHODS

The guideline was prepared by German clinical experts for infections in cancer patients in a stepwise consensus process. MEDLINE was systematically searched for English-language publications from January 1975 up to September 2019 using the key terms such as 'invasive fungal infection' and/or 'invasive fungal disease' and at least one of the following: antifungal agents, cancer, haematological malignancy, antifungal therapy, neutropenia, granulocytopenia, mycoses, aspergillosis, candidosis and mucormycosis.

RESULTS

AFT of IFDs in cancer patients may include not only antifungal agents but also non-pharmacologic treatment. In addition, the armamentarium of antifungals for treatment of IFDs has been broadened (eg licensing of isavuconazole). Additional antifungals are currently under investigation or in clinical trials.

CONCLUSIONS

Here, updated recommendations for the treatment of proven or probable IFDs are given. All recommendations including the levels of evidence are summarised in tables to give the reader rapid access to key information.

Candida urinary tract infections in adults

Candiduria is commonly seen in hospitalized patients and most of the patients are asymptomatic, but it may be due to cystitis, pyelonephritis, prostatitis, epididymo-orchitis or disseminated candidiasis. Major risk factors are diabetes mellitus, indwelling urinary catheters, use of broad-spectrum antibiotics, urinary obstruction, and admission to intensive care units. Candida urinary tract infections can be caused by hematogenous spread following candidemia, or retrograde route via the urethra. The presence of Candida species in urine in asymptomatic patients does not warrant antifungal therapy except neutropenic patients, very low-birth-weight infants and patients undergoing urologic procedures. Fluconazole is the treatment of choice for symptomatic infections, it achieves high urinary levels. The other azole antifungals and echinocandins do not reach sufficient urine levels. Amphotericin B deoxycholate is the alternative antifungal agent if fluconazole can not be used because of resistance, allergy or failure.

Candiduria; a review article with specific data from Iran

Although, several categories of nosocomial infections are presented during the recent years, urinary tract infections (UTIs) considered as one of the most important systemic infections. The presence of Candida species in the urinary tract system (Candiduria) is seen in only 10-15% of the cases with UTI, however candiduria has been considered as more problematic infection for patients, laboratory workers and physicians. Due to increasing numbers of several predisposing factors, such as antibacterial agents, urinary tract instrumentation, diabetes mellitus, invasive therapies, and prolonged hospital stay, candiduria develops among the hospitalized patients, especially hospitalized in intensive care units (ICUs) and neonatal intensive care units (NICUs). According to the epidemiological studies, Candida albicans is the most common isolated species from candiduric patients. However, during the recent years, due to increasing resistance to antifungal drugs, non-albicans Candida species including, C. glabrata, C. krusei, C. parapsilosis and C. tropicalis have been also implicated. We found that the mean prevalence of candiduria among Iranian patients was lower (16.5%) than worldwide ratio and also males were more frequently affected than females (M:F, 1.2:1). Similar to other countries, C. albicans was most common infectious agent followed by non-albicans Candida species including, C. glabrata, C. tropicalis and C. krusei.

Candiduria in kidney transplant recipients: Is antifungal therapy useful?

A French single-centre retrospective study between 2010 and 2014 was undertaken to assess candiduria's incidence in kidney transplant recipients (KTR), and the use and impact of antifungal treatment on outcome. Candiduria was defined as a urine culture with ≥10³  cfu/mL of Candida species. Candiduria clearance, severe complications and death rates were estimated by Kaplan-Meier methods and the effect of treatment by Cox models. 52/1223 (4.3%) KTR had ≥1 episode of candiduria, 42 (81%) were females, 18 (35%) had diabetes, with an incidence of 2.3/100 person-year of follow-up. Candiduria was asymptomatic in 51 (98%) patients. Candida glabrata was the most frequent pathogen identified. Overall fungal clearance rate was 89%. Antifungal therapy was initiated in only 14 episodes (12%), according to guidelines. Three patients (6%) developed severe complications in the first 2 weeks after transplantation, and 8 (15%) died. Antifungal treatment had no impact on candiduria clearance (HR, 0.6; 95% CI, 0.3-1.1; P = .10), on recurrence rate (HR, 0.5; 95% CI, 0.1-2.3; P = .41) and on the risk of severe complications or death (HR, 1.1; 95% CI, 0.3-4.8; P = .89). Candiduria is rare and usually asymptomatic among KTR. Candiduria management in the immediate post-transplant period deserves careful attention.

Nosocomial Candiduria in the Elderly: Microbiological Diagnosis

Candiduria is associated with high morbidity, mortality, and long hospitalization, involving high costs for the healthcare system. The use of increasingly aggressive treatments has prolonged the lives of patients susceptible to candiduria, namely the immunosuppressed, the premature, and the elderly. Our objective was to evaluate the incidence of nosocomial candiduria and the implicated species in hospitalized patients aged over 80 years old from three Spanish centers during 2012 and 2013. Urine samples received from these patients were cultured and analyzed by flow cytometry in search of leukocyturia, hematuria, proteinuria, and microbial nitrate reductase activity. The isolated yeast species were identified microscopically, by germ tube formation in serum, colony morphology after subculture onto CHROMagar Candida (Becton-Dickinson, UK), assimilation of carbon compounds ID32C (bioMérieux, France), matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDITOF) (Bruker Daltonics, Germany) and, in case of inconsistency, by sequencing of the ITS regions of ribosomal DNA (ITS1-5, 8S-ITS2). Susceptibility tests were also performed. The incidence of candiduria in the elderly population was 10.3%. A total of 155 strains of yeasts were isolated. The predominant species was Candida albicans, followed by Candida glabrata and then Candida tropicalis. Several infrequent species were found; among them, the first isolate of candiduria-producing Candida pulcherrima described in the literature. Our finding should raise concerns about the elderly population, which is probably the most important risk group for candiduria in the present moment, and the emergence of unusual yeast species producing candiduria, which are resistant against the commonly used antifungal agents.

Association Between Candiduria and Candidemia: A Clinical and Molecular Analysis of Cases

The risk of developing candidemia after candiduria is reportedly very low, but it has not been adequately investigated. The aim of this study was to examine the molecular relatedness between Candida strains isolated from adult patients with candidemia and concomitant candiduria in association with the clinical characteristics of the cases. All episodes of candidemia occurring in a tertiary care academic hospital during a 5-year period were recorded prospectively. Patients with episodes of candiduria occurring two weeks preceding to or one week following a positive for Candida blood culture were included in the study. The genotypic relatedness of Candida strains isolated from blood and urine was investigated by pulsed-field gel electrophoresis after digestion with the BssHII restriction endonuclease. We recorded 141 candidemia episodes, occurring in 134 patients. Twelve episodes of candidemia with concomitant candiduria occurred in 11 patients (8% of all candidemias). In six of these episodes, the strains in the blood-urine pairs belonged to different species. In two episodes, the isolates belonged to the same species but were not genetically related, and only in four (2.8% of all candidemias), the strains were related. All four patients were severely ill and had multiple risk factors for candidemia. These findings indicate that in hospitalized patients with candidemia, concomitant candiduria is rare and usually an independent event, confirming previous reports. In the critically ill, however, the existence of genetically related strains in blood and urine appears to be more frequent, with more probable the hematogenous dissemination.

2016 guidelines for the use of antifungal agents in patients with invasive fungal diseases in Taiwan

The Infectious Diseases Society of Taiwan, Medical Foundation in Memory of Dr. Deh-Lin Cheng, Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education, and CY Lee's Research Foundation for Pediatric Infectious Diseases and Vaccines have updated the guidelines for the use of antifungal agents in adult patients with invasive fungal diseases in Taiwan. This guideline replaces the 2009 version. Recommendations are provided for Candida, Cryptococcus, Aspergillus and Mucormycetes. The focus is based on up-to-date evidence on indications for treatment or prophylaxis of the most common clinical problems. To support the recommendations in this guideline, the committee considered the rationale, purpose, local epidemiology, and key clinical features of invasive fungal diseases to select the primary and alternative antifungal agents. This is the first guideline that explicitly describes the quality and strength of the evidence to support these recommendations. The strengths of the recommendations are the quality of the evidence, the balance between benefits and harms, resource and cost. The guidelines are not intended nor recommended as a substitute for bedside judgment in the management of individual patients, the advice of qualified health care professionals, and more recent evidence concerning therapeutic efficacy and emergence of resistance. Practical considerations for individualized selection of antifungal agents include patient factors, pathogen, site of infection and drug-related factors, such as drug-drug interaction, drug-food intervention, cost and convenience. The guidelines are published in the Journal of Microbiology, Immunology and Infection and are also available on the Society website.

The Frequency, Antifungal Susceptibility and Enzymatic Profiles of Candida Species Isolated from Neutropenic Patients

BACKGROUND

Neutropenia, as a predisposing factor for invasive candidiasis, is defined as a reduction in neutrophil count to less than 1500/mm³. It is a common condition in patients with hematological malignancy and cytostatic chemotherapy. Extensive chemotherapy and prophylaxis with antifungals have increased the resistance of Candida isolates to antifungal drugs. Although, Candida albicans is the most common causative agent among neutropenic patients, there is an increasing rate of non-albicans species. Extracellular enzymes activity pattern and antifungal agent sensitivity profiles are two important factors for spreading resistant strains.

OBJECTIVES

The aim of the present study was to identify the Candida strains isolated from hospitalized neutropenic patients. The patterns of antifungal susceptibility of the causative agents to antifungals and the extracellular enzymes activity of the isolates were also evaluated.

PATIENTS AND METHODS

In the present study, 243 urine and 243 oral swab samples were collected from neutropenic patients and inoculated on CHROMagar Candida. In addition, 100 blood samples were also inoculated in biphasic Brain Heart Infusion medium. Several yeast isolates were isolated from samples and identified by classical and molecular techniques. The profiles of extracellular enzymes and the susceptibility of recovered agents to amphotericin B, fluconazole and caspofungin were also evaluated.

RESULTS

A total of 110 yeast strains isolated from urine and oral cavities were identified as C. albicans (51.8%), C. krusei (25.5%), C. glabrata (6.4%) and other yeasts (16.3%). No yeast species was isolated from blood samples. Our result showed that in 90% of the isolates, the range of secretion of extracellular enzymes was medium (2+) and high (3+), however only a few isolates were negative for this characteristic. All isolates were sensitive to caspofungin and fluconazole, whereas 54.7% of isolates were resistant to amphotericin B.

CONCLUSIONS

We found a marked increase in the incidence of non-albicans species (48.2%) among neutropenic patients. Only a few strains failed to produce extracellular enzymes. Finally, in addition to fluconazole, caspofungin can be considered as the first line treatment against Candida species among neutropenic patients.

Characterization and identification of candiduria due to Candida species in diabetic patients

BACKGROUND AND PURPOSE

The presence of Candida yeasts in urine, known as candiduria, is an indicator of infection or colonization of the urinary tract by Candida species. This condition in diabetic patients can be hazardous due to diminished immune system response. The objective of this study was to investigate the incidence of candiduria in diabetic patients and to identify its causative agents. Furthermore, the demographic and laboratory (HbA_1c, urine glucose and pH, urine culture colony count, and fasting blood sugar) data and their possible associations with candiduria were investigated.

MATERIALS AND METHODS

This cross-sectional, descriptive study was performed on 305 diabetic patients referred to the diabetes research center, Hamedan, Iran, during April 2015 to September 2015. Urine and blood specimens were collected and urine analysis, urine culture, FBS, and HbA_1c tests were performed. Positive cases were subjected to colony count and the causative agents were subsequently identified through the routine identification tests, as well as colony color in CHROMagar Candida medium, and the assimilation patterns in API 20 C auxanographic method.

RESULTS

Among the 305 cases, 38 (%12.5) were positive for candiduria. Causative agents were identified as Candidaglabrata (n=19, 50%), C. albicans (n=12, 31.6%), C. krusei (n=4, 10.5%), C. tropicalis (n=2, 5.3%), andC. kefyr (n=1, 2.6%). According to the results of the statistical analyses, there were significant association between candiduria and female gender, high FBS and urine glucose, uncontrolled diabetes (HbA1c ≥8), and acidic urine pH (P<0.05).

CONCLUSION

Considering the high incidence rate of candiduria in diabetic patients, control of diabetes, predisposing factors, and causal relationships between diabetes and candiduria should be highlighted.

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

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