Management of invasive candidiasis in nonneutropenic ICU patients

Serological biomarkers of candidemia: a retrospective evaluation of three assays

PURPOSE

Serologic testing allows for rapid detection of candidemia. More data are needed for the Virion\Serion ELISA antigen test (Ag), Hemkit Candida IHA antibody test (Ab), and Wako β-1,3-D-glucan assay (BDG).

METHODS

Tests were performed on serum samples from 120 cases of culture-confirmed candidemia and 44 Candida-negative controls. Sensitivities and specificities of individual tests as well as combinations were assessed.

RESULTS

The overall sensitivity of Ag, Ab, and Ag/Ab testing was 30, 40, and 54%, respectively, while in transplant patients it significantly dropped to 16, 26, and 40% (p = 0.02). For BDG testing it was 67%, both overall and in transplant patients. Especially Ag testing performed poorly among women ≤ 65 years with a significantly reduced sensitivity of 9% (p < 0.002). While the sensitivity of Ag/Ab testing was somewhat higher at 67% for C. albicans, it was significantly lower for non-albicans species at 42% (p = 0.006). The sensitivity of BDG testing for C. albicans and non-albicans species was not significantly different at 64 and 69%, respectively. Both Ag/Ab and BDG testing had a high specificity of 93%, for Ag testing it was 100%. Similar sensitivities were calculated for sera sampled on the day of and 4-6 days before sampling of positive blood cultures.

CONCLUSIONS

Serological markers are valuable tools for the early diagnosis of candidemia. Ab, Ag, and BDG testing are all characterized by high specificity. The Wako BDG test is significantly more sensitive compared to combined Candida-Ag/Ab testing, particularly in the setting of non-albicans species and specific host factors.

A dedicated fungal culture medium is useful in the diagnosis of fungemia: a retrospective cross-sectional study

Background

Mortality for candidemia ranges from 15% to 35%. Current guidelines recommend inoculating blood into three aerobic and three anaerobic blood culture bottles when candidemia is suspected, without mention of a fungal blood culture bottle.

Objective

To determine the value of the BACTEC Myco/F Lytic blood culture media in the diagnosis of fungemia.

Methods

A two-year retrospective cross-sectional study was performed for patients who had fungemia with submitted BACTEC Plus Aerobic/F (Aer), BACTEC Plus Anaerobic/F (Anaer) or Myco/F Lytic (Myco) blood culture bottles.

Results

The detection rate of fungemia was 77.4% in 93 patients with contemporaneously submitted blood culture bottles when limited to only Aer/Anaer culture results. The detection rate improved significantly with the addition of the Myco culture bottle results (p<0.0001). A logistic regression model showed that Myco culture bottle submissions were less useful for patients with appropriate anti-fungal therapy administered within 48 hours [OR = 0.18, 95% CI = (0.06, 0.49), p = 0.001] and those with fungal growth detected within 48 hours [OR = 0.33, 95% CI = (0.12, 0.89), p = 0.001]. Among a subset of patients with concordant blood culture results, those with Myco culture bottles submission allowed earlier fungal detection and speciation by at least one day in 27.5% and 25.0% of the cases respectively.

Conclusion

Our study highlights the importance of a dedicated fungal blood culture when fungemia is clinically suspected. Nearly a quarter of fungemias may be missed if a fungal blood culture is not performed.

MEDical wards Invasive Candidiasis ALgorithms (MEDICAL):Consensus proposal for management

INTRODUCTION

A majority of invasive Candida infections occur in medical wards; however, evidence for management in this setting is scarce and based primarily on the intensive care or surgical setting. On behalf of the Italian Society for Anti-Infective Therapy (SITA) and the Italian Federation of Associations of Hospital Doctors on Internal Medicine (FADOI), the MEDICAL group produced practical management algorithms for patients in internal medicine wards.

METHODS

The MEDICAL group panel, composed of 30 members from internal medicine, infectious disease, clinical pharmacology, clinical microbiology and clinical epidemiology, provided expert opinion through the RAND/UCLA method.

RESULTS

Seven clinical scenarios were constructed based on clinical severity and probability of invasive candidiasis. For each scenario, the appropriateness of 63 different diagnostic, imaging, management, or therapeutic procedures was determined in two Delphi rounds. The necessity for performing each appropriate procedure, was then determined in a third Delphi round. Results were summarized in algorithms.

DISCUSSION

The proposed algorithms provide internal medicine physicians and managers with an easy to interpret tool that is exhaustive, clear and suitable for adaption to individual local settings. Attention was paid to individual patient management and resource allocation.