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Kamath S, Hammad Altaq H, Abdo T. Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades? Microorganisms 2023; 11:2231. [PMID: 37764075 PMCID: PMC10537306 DOI: 10.3390/microorganisms11092231] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.
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Affiliation(s)
| | | | - Tony Abdo
- Section of Pulmonary, Critical Care and Sleep Medicine, The University of Oklahoma Health Sciences Center, The Oklahoma City VA Health Care System, Oklahoma City, OK 73104, USA; (S.K.); (H.H.A.)
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2
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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.
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3
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Zou ZY, Sun KJ, Fu G, Huang JJ, Yang ZJ, Zhou ZP, Ma SL, Zhu F, Wu M. Impact of early empirical antifungal therapy on prognosis of sepsis patients with positive yeast culture: A retrospective study from the MIMIC-IV database. Front Microbiol 2022; 13:1047889. [PMID: 36466647 PMCID: PMC9712452 DOI: 10.3389/fmicb.2022.1047889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/26/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Mortality and other clinical outcomes of culture-negative and culture-positive among patients with fungal sepsis have not been documented, and whether antifungal therapy prior to fungal culture reports is related to decreased mortality among patients remains largely controversial. This study aimed to determine the mortality and other clinical outcomes of patients with positive yeast cultures and further investigate the effects of initial empiric antifungal therapy. METHODS A retrospective study was conducted among septic patients using the Medical Information Mart for Intensive Care (MIMIC)-IV database. Patients with sepsis were divided into two groups based on first fungal culture status during intensive care unit (ICU) stay, and initial empirical antifungal therapy was prescribed based on physician's experience prior to fungal culture reports within 48 h. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30-day all-cause mortality, 60-day all-cause mortality, length of ICU stay and length of hospital stay. Multivariate logistic regression, propensity score matching (PSM), subgroup analyses and survival curve analyses were performed. RESULTS This study included 18,496 sepsis patients, of whom 3,477 (18.8%) had positive yeast cultures. Patients with positive yeast cultures had higher in-hospital all-cause mortality, 60-day all-cause mortality, and longer lengths of ICU stay and hospital stay than those with negative yeast cultures after PSM (all p < 0.01). Multivariate logistic regression analysis revealed that positive yeast culture was a risk factor for in-hospital mortality in the extended model. Subgroup analyses showed that the results were robust among the respiratory infection, urinary tract infection, gram-positive bacterial infection and bacteria-free culture subgroups. Interestingly, empiric antifungal therapy was not associated with lower in-hospital mortality among patients with positive yeast cultures, mainly manifested in stratification analysis, which showed that antifungal treatment did not improve outcomes in the bloodstream infection (odds ratio, OR 2.12, 95% CI: 1.16-3.91, p = 0.015) or urinary tract infection groups (OR 3.24, 95% CI: 1.48-7.11, p = 0.003). CONCLUSION Culture positivity for yeast among sepsis patients was associated with worse clinical outcomes, and empiric antifungal therapy did not lower in-hospital all-cause mortality in the bloodstream infection or urinary tract infection groups in the ICU.
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Affiliation(s)
- Zhi-ye Zou
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
| | - Kai-jun Sun
- Department of Cardiovascular Medicine, Weifang People's Hospital, Weifang, China
| | - Guang Fu
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Jia-jia Huang
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
- Shantou University Medical College, Shantou, China
| | - Zhen-jia Yang
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
- Shantou University Medical College, Shantou, China
| | - Zhi-peng Zhou
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
| | - Shao-lin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Shao-lin Ma,
| | - Feng Zhu
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Burn and Trauma ICU, The First Affiliated Hospital, Naval Medical University, Shanghai, China
- Feng Zhu,
| | - Ming Wu
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
- Shantou University Medical College, Shantou, China
- Ming Wu,
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4
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 944] [Impact Index Per Article: 314.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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5
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Nakada-Motokawa N, Miyazaki T, Ueda T, Yamagishi Y, Yamada K, Kawamura H, Kakeya H, Mukae H, Mikamo H, Takesue Y, Kohno S. Modified Pitt bacteremia score for predicting mortality in patients with candidaemia: A multicentre seven-year retrospective study conducted in Japan. Mycoses 2021; 64:1498-1507. [PMID: 34655487 PMCID: PMC9297953 DOI: 10.1111/myc.13380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/11/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several severity indexes have been reported for critically ill patients. The Pitt bacteremia score (PBS) is commonly used to predict the risk of mortality in patients with bacteraemia. OBJECTIVES To develop a scoring system for predicting mortality in candidaemia patients. METHODS Medical records at five Japanese tertiary hospitals were reviewed. Factors associated with mortality were analysed using logistic regression modelling. The discriminatory power of scoring models was evaluated by assessing the area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS In total, 422 candidaemia patients were included. Higher PBS, dialysis and retainment of central venous catheter were independent risk factors for all-cause 30-day mortality. However, among the five PBS components, fever was not associated with mortality; therefore, we developed a modified version of the PBS (mPBS) by replacing fever with dialysis. AUC for PBS and mPBS were 0.74 (95% confidence interval [CI]: 0.68-0.80) and 0.76 (95% CI: 0.71-0.82), respectively. The increase in predictive ability of mPBS for 30-day mortality was statistically significant as assessed by NRI (0.24, 95% CI: 0.01-0.46, p = .04) and IRI (0.04, 95% CI: 0.02-0.06, p = .0008). When patients were stratified by mPBS into low (scores 0-3), moderate (4-7) and high risk (≥8), there were significant differences among the survival curves (p < .0001, log-rank test), and 30-day mortality rates were 13.8% (40/290), 36.8% (28/76) and 69.4% (34/49), respectively. CONCLUSIONS mPBS can be a useful tool for predicting mortality in candidaemia patients.
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Affiliation(s)
| | - Taiga Miyazaki
- Department of Respiratory Medicine, Nagasaki University, Nagasaki, Japan.,Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Takashi Ueda
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Japan
| | - Koichi Yamada
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hideki Kawamura
- Division of Medical and Environmental Safety, Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - Hiroshi Kakeya
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University, Nagasaki, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Japan
| | - Yoshio Takesue
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shigeru Kohno
- Department of Respiratory Medicine, Nagasaki University, Nagasaki, Japan
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6
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1537] [Impact Index Per Article: 512.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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7
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Kotey FCN, Dayie NTKD, Tetteh-Uarcoo PB, Donkor ES. Candida Bloodstream Infections: Changes in Epidemiology and Increase in Drug Resistance. Infect Dis (Lond) 2021; 14:11786337211026927. [PMID: 34248358 PMCID: PMC8236779 DOI: 10.1177/11786337211026927] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/30/2021] [Indexed: 11/17/2022] Open
Abstract
The literature on bloodstream infections (BSIs) have predominantly been biased towards bacteria, given their superior clinical significance in comparison with the other types of microorganisms. Fungal pathogens have epidemiologically received relatively less attention, although they constitute an important proportion of BSI aetiologies. In this review, the authors discuss the clinical relevance of fungal BSIs in the context of Candida species, as well as treatment options for the infections, emphasizing the compelling need to develop newer antifungals and strengthen antimicrobial stewardship programmes in the wake of the rapid spread of antifungal resistance.
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Affiliation(s)
- Fleischer CN Kotey
- Department of Medical Microbiology, University of Ghana Medical School, Korle Bu, Accra, Ghana
- FleRhoLife Research Consult, Teshie, Accra, Ghana
| | - Nicholas TKD Dayie
- Department of Medical Microbiology, University of Ghana Medical School, Korle Bu, Accra, Ghana
| | | | - Eric S Donkor
- Department of Medical Microbiology, University of Ghana Medical School, Korle Bu, Accra, Ghana
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8
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Macauley P, Epelbaum O. Epidemiology and Mycology of Candidaemia in non-oncological medical intensive care unit patients in a tertiary center in the United States: Overall analysis and comparison between non-COVID-19 and COVID-19 cases. Mycoses 2021; 64:634-640. [PMID: 33608923 PMCID: PMC8013328 DOI: 10.1111/myc.13258] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 01/07/2023]
Abstract
The epidemiology and mycology of invasive candidiasis in the ICU is well‐described in certain types of critically ill patients but not in others. One population that has been scarcely studied is non‐neutropenic patients admitted specifically to medical ICUs. Even less is known about the broader category of medical ICU patients without active oncological disease. This group constitutes a very large share of the patients requiring critical care across the globe, especially in the era of the SARS‐CoV‐2 pandemic. We analysed medical ICU candidaemia episodes that occurred in non‐oncological patients in our tertiary academic centre in the United States from May 2014 to October 2020 to determine the incidence and species distribution of the associated isolates. We then separately considered non‐COVID‐19 and COVID‐19 cases and compared their characteristics. In the non‐COVID‐19 group, there were 38 cases for an incidence of 1.1% and rate of 11/1000 admissions. In the COVID‐19 group, there were 12 cases for an incidence of 5.1% and rate of 51/1000 admissions. In the entire sample, as well as separately in the non‐COVID‐19 and COVID‐19 groups,Candida albicans accounted for a minority of isolates. Compared to non‐COVID‐19 patients with candidaemia, COVID‐19 patients had lower ICU admission SOFA score but longer ICU length of stay and central venous catheter dwell time at candidaemia detection. This study provides valuable insight into the incidence and species distribution of candidaemia cases occurring in non‐oncological critically ill patients and identifies informative differences between non‐COVID‐19 and COVID‐19 patients.
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Affiliation(s)
- Precious Macauley
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Oleg Epelbaum
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
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9
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Keighley CL, Pope A, Marriott DJE, Chapman B, Bak N, Daveson K, Hajkowicz K, Halliday C, Kennedy K, Kidd S, Sorrell TC, Underwood N, van Hal S, Slavin MA, Chen SCA. Risk factors for candidaemia: A prospective multi-centre case-control study. Mycoses 2020; 64:257-263. [PMID: 33185290 DOI: 10.1111/myc.13211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 11/04/2020] [Accepted: 11/07/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Candidaemia carries a mortality of up to 40% and may be related to increasing complexity of medical care. Here, we determined risk factors for the development of candidaemia. METHODS We conducted a prospective, multi-centre, case-control study over 12 months. Cases were aged ≥18 years with at least one blood culture positive for Candida spp. Each case was matched with two controls, by age within 10 years, admission within 6 months, admitting unit, and admission duration at least as long as the time between admission and onset of candidaemia. RESULTS A total of 118 incident cases and 236 matched controls were compared. By multivariate analysis, risk factors for candidaemia included neutropenia, solid organ transplant, significant liver, respiratory or cardiovascular disease, recent gastrointestinal, biliary or urological surgery, central venous access device, intravenous drug use, urinary catheter and carbapenem receipt. CONCLUSIONS Risk factors for candidaemia derive from the infection source, carbapenem use, host immune function and organ-based co-morbidities. Preventive strategies should target iatrogenic disruption of mucocutaneous barriers and intravenous drug use.
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Affiliation(s)
- Caitlin Livia Keighley
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, New South Wales Health Pathology, Sydney, NSW, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, NSW, Australia.,The Department of Infectious Diseases, Westmead Hospital, Sydney, NSW, Australia
| | - Alun Pope
- Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Deborah J E Marriott
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Belinda Chapman
- Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Narin Bak
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases and Microbiology, Canberra Hospital, Australian National University Medical School, Canberra, ACT, Australia
| | - Krispin Hajkowicz
- Department of Infectious Diseases, School of Medicine, Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Catriona Halliday
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, New South Wales Health Pathology, Sydney, NSW, Australia
| | - Karina Kennedy
- Department of Infectious Diseases and Microbiology, Canberra Hospital, Australian National University Medical School, Canberra, ACT, Australia
| | - Sarah Kidd
- National Mycology Reference Centre, SA Pathology, Adelaide, SA, Australia
| | - Tania C Sorrell
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, NSW, Australia.,The Department of Infectious Diseases, Westmead Hospital, Sydney, NSW, Australia.,Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Neil Underwood
- Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Sebastiaan van Hal
- Department of Infectious Diseases and Microbiology, New South Wales Health Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, National Centre for Infections in Cancer, Melbourne, VIC, Australia
| | - Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, New South Wales Health Pathology, Sydney, NSW, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, NSW, Australia.,The Department of Infectious Diseases, Westmead Hospital, Sydney, NSW, Australia.,Westmead Institute for Medical Research, Westmead, NSW, Australia
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10
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Ohki S, Shime N, Kosaka T, Fujita N. Impact of host- and early treatment-related factors on mortality in ICU patients with candidemia: a bicentric retrospective observational study. J Intensive Care 2020; 8:30. [PMID: 32351697 PMCID: PMC7183603 DOI: 10.1186/s40560-020-00450-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/21/2020] [Indexed: 12/15/2022] Open
Abstract
Background Candidemia is one of the most life-threatening infections among critically ill patients in the intensive care unit. However, the number of studies on the impact of host- and early treatment-related factors on mortality in this cohort is limited. The aim of this study was to investigate the relationship between clinically relevant factors, including early treatment (appropriate antifungal therapy and/or central venous catheter removal) and mortality in intensive care unit patients with candidemia. Methods We performed a retrospective observational study in two Japanese University hospitals between January 2007 and December 2016. Adult intensive care unit patients with candidemia who met the following inclusion criteria: (1) ≥ 18 years old; (2) admitted in intensive care unit at the time of onset; and (3) central venous catheter in situ at the time of onset were included. We performed univariate and multivariate logistic regression analysis to identify factors associated with 30-day crude mortality. Results A total of 68 patients met the inclusion criteria, 47 (69%) of whom were males. The median age was 68.0 (interquartile range, 61.0-76.0) years. The most common causative Candida species was Candida albicans (40 [59%] patients). With respect to the source of infection, central venous catheter-related candidemia was the most frequent (30 [44%] patients). Thirty-day crude mortality was 54% (37 patients). In multivariate logistic regression analysis, Acute Physiology and Chronic Health Evaluation II score (1-point increments) was the only factor that was independently associated with higher 30-day crude mortality. Other variables, including appropriate antifungal therapy and/or central venous catheter removal ≤ 24 h and ≤ 48 h following onset, did not significantly influence mortality. Conclusions Candidemia in intensive care unit patients is still associated with high 30-day crude mortality rates. The only predictor of death was Acute Physiology and Chronic Health Evaluation II score ≤ 24 h following candidemia onset. Early empiric antifungal therapy and/or early CVC removal conferred no significant clinical benefit on survival in this patient population.
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Affiliation(s)
- Shingo Ohki
- 1Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Nobuaki Shime
- 1Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Tadashi Kosaka
- 2Department of Pharmacy, Kyoto Prefectural University of Medicine, Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan
| | - Naohisa Fujita
- 3Department of Infection Control and Laboratory Medicine, Kyoto Prefectural University of Medicine, Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan
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11
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Risk factors, clinical characteristics and mortality of candidemia in non-neutropenic, critically ill patients in a tertiary care hospital. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.686677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Synthesis of new pyrazolo[5,1-c][1,2,4]triazines with antifungal and antibiofilm activities. CHEMICAL PAPERS 2019. [DOI: 10.1007/s11696-019-00974-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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13
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Keighley C, Chen SCA, Marriott D, Pope A, Chapman B, Kennedy K, Bak N, Underwood N, Wilson HL, McDonald K, Darvall J, Halliday C, Kidd S, Nguyen Q, Hajkowicz K, Sorrell TC, Van Hal S, Slavin MA. Candidaemia and a risk predictive model for overall mortality: a prospective multicentre study. BMC Infect Dis 2019; 19:445. [PMID: 31113382 PMCID: PMC6528341 DOI: 10.1186/s12879-019-4065-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/02/2019] [Indexed: 01/21/2023] Open
Abstract
Background Candidaemia is associated with high mortality. Variables associated with mortality have been published previously, but not developed into a risk predictive model for mortality. We sought to describe the current epidemiology of candidaemia in Australia, analyse predictors of 30-day all-cause mortality, and develop and validate a mortality risk predictive model. Methods Adults with candidaemia were studied prospectively over 12 months at eight institutions. Clinical and laboratory variables at time of blood culture-positivity were subject to multivariate analysis for association with 30-day all-cause mortality. A predictive score for mortality was examined by area under receiver operator characteristic curves and a historical data set was used for validation. Results The median age of 133 patients with candidaemia was 62 years; 76 (57%) were male and 57 (43%) were female. Co-morbidities included underlying haematologic malignancy (n = 20; 15%), and solid organ malignancy in (n = 25; 19%); 55 (41%) were in an intensive care unit (ICU). Non-albicans Candida spp. accounted for 61% of cases (81/133). All-cause 30-day mortality was 31%. A gastrointestinal or unknown source was associated with higher overall mortality than an intravascular or urologic source (p < 0.01). A risk predictive score based on age > 65 years, ICU admission, chronic organ dysfunction, preceding surgery within 30 days, haematological malignancy, source of candidaemia and antibiotic therapy for ≥10 days stratified patients into < 20% or ≥ 20% predicted mortality. The model retained accuracy when validated against a historical dataset (n = 741). Conclusions Mortality in patients with candidaemia remains high. A simple mortality risk predictive score stratifying patients with candidaemia into < 20% and ≥ 20% 30-day mortality is presented. This model uses information available at time of candidaemia diagnosis is easy to incorporate into decision support systems. Further validation of this model is warranted. Electronic supplementary material The online version of this article (10.1186/s12879-019-4065-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Keighley
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, New South Wales Health Pathology, Westmead Hospital, Darcy Rd, 3rd Level, ICPMR Building, Westmead, Sydney, New South Wales, 2145, Australia. .,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, NSW, Australia. .,Department of Infectious Diseases, Westmead Hospital, Westmead, Sydney, NSW, Australia.
| | - S C-A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, New South Wales Health Pathology, Westmead Hospital, Darcy Rd, 3rd Level, ICPMR Building, Westmead, Sydney, New South Wales, 2145, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, NSW, Australia.,Department of Infectious Diseases, Westmead Hospital, Westmead, Sydney, NSW, Australia
| | - D Marriott
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - A Pope
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia.,School of Mathematics and Statistics, University of NSW, Sydney, NSW, Australia
| | - B Chapman
- Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - K Kennedy
- Department of Infectious Diseases and Microbiology, Canberra Hospital, Australian National University Medical School, Canberra, ACT, Australia
| | - N Bak
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - N Underwood
- Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - H L Wilson
- Department of Infectious Diseases and Microbiology, Canberra Hospital, Australian National University Medical School, Canberra, ACT, Australia
| | - K McDonald
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - J Darvall
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - C Halliday
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, New South Wales Health Pathology, Westmead Hospital, Darcy Rd, 3rd Level, ICPMR Building, Westmead, Sydney, New South Wales, 2145, Australia
| | - S Kidd
- National Mycology Reference Centre, SA Pathology, Adelaide, SA, Australia
| | - Q Nguyen
- National Centre for Clinical Excellence on Emerging Drugs of Concern (NCCRED), National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, Australia
| | - K Hajkowicz
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - T C Sorrell
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, NSW, Australia.,Department of Infectious Diseases, Westmead Hospital, Westmead, Sydney, NSW, Australia.,Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - S Van Hal
- Department of Infectious Diseases and Microbiology, New South Wales Health Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - M A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, National Centre for Infections in Cancer, Melbourne, VIC, Australia
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14
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The Evolution of Azole Resistance in Candida albicans Sterol 14α-Demethylase (CYP51) through Incremental Amino Acid Substitutions. Antimicrob Agents Chemother 2019; 63:AAC.02586-18. [PMID: 30783005 PMCID: PMC6496074 DOI: 10.1128/aac.02586-18] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/10/2019] [Indexed: 12/13/2022] Open
Abstract
Recombinant Candida albicans CYP51 (CaCYP51) proteins containing 23 single and 5 double amino acid substitutions found in clinical strains and the wild-type enzyme were expressed in Escherichia coli and purified by Ni2+-nitrilotriacetic acid agarose chromatography. Catalytic tolerance to azole antifungals was assessed by determination of the concentration causing 50% enzyme inhibition (IC50) using CYP51 reconstitution assays. The greatest increase in the IC50 compared to that of the wild-type enzyme was observed with the five double substitutions Y132F+K143R (15.3-fold), Y132H+K143R (22.1-fold), Y132F+F145L (10.1-fold), G307S+G450E (13-fold), and D278N+G464S (3.3-fold). The single substitutions K143R, D278N, S279F, S405F, G448E, and G450E conferred at least 2-fold increases in the fluconazole IC50, and the Y132F, F145L, Y257H, Y447H, V456I, G464S, R467K, and I471T substitutions conferred increased residual CYP51 activity at high fluconazole concentrations. In vitro testing of select CaCYP51 mutations in C. albicans showed that the Y132F, Y132H, K143R, F145L, S405F, G448E, G450E, G464S, Y132F+K143R, Y132F+F145L, and D278N+G464S substitutions conferred at least a 2-fold increase in the fluconazole MIC. The catalytic tolerance of the purified proteins to voriconazole, itraconazole, and posaconazole was far lower and limited to increased residual activities at high triazole concentrations for certain mutations rather than large increases in IC50 values. Itraconazole was the most effective at inhibiting CaCYP51. However, when tested against CaCYP51 mutant strains, posaconazole seemed to be the most resistant to changes in MIC as a result of CYP51 mutation compared to itraconazole, voriconazole, or fluconazole.
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15
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Trovato L, Astuto M, Castiglione G, Scalia G, Oliveri S. Diagnostic surveillance by Candida albicans germ tube antibody in intensive care unit patients. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 53:778-784. [PMID: 30902614 DOI: 10.1016/j.jmii.2019.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/23/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The diagnosis of Invasive Candidiasis (IC) presents serious problems, mainly associated with the absence of pathognomonic symptoms of the disease and the difficulty of isolating the fungus in blood culture. Candida albicans germ tube antibody (CAGTA) provides a rapid and simple test for diagnosis of IC. The aim of this study was to evaluate the diagnostic role of the CAGTA in the monitoring of critically-ill patients at risk of developing IC. METHODS During diagnostic surveillance in the intensive care units (ICU) CAGTA was performed twice a week if predetermined risk factors were present and a positive result was considered when a serum titer ≥1/160 was detected in at least one sample. RESULTS Seventy critically ill patients were included in the study. Twenty-three patients with proven/probable IC were identified. The sensitivity, specificity, PPV, and NPV of CAGTA for the diagnosis of proven/probable IC in all 70 patients were 91.3%, 68.1%, 58.3%, and 94.1%, respectively. Statistically significant highest titers were found in patients with proven/probable IC as well as increasing titers more than 1/160. CONCLUSIONS Our results suggest that detection of CAGTA could be a useful biomarker for the diagnosis of proven and probable IC in critical patients during prolonged ICU stay. During the monitoring it is opportune to evaluate the titers kinetics since the clinical diagnosis of proven/probable IC coincided with increase titer from negative (<1/160) to more than 1/160.
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Affiliation(s)
- Laura Trovato
- Department of Biomedical and Biotechnological Sciences, University of Catania, Laboratory Analysis Unit, A.O.U. "Policlinico -Vittorio Emanuele", Catania, Italy.
| | - Marinella Astuto
- Department of Anesthesia and Intensive Care, A.O.U. "Policlinico -Vittorio Emanuele", Catania, Italy
| | - Giacomo Castiglione
- Department of Anesthesia and Intensive Care, A.O.U. "Policlinico -Vittorio Emanuele", Catania, Italy
| | - Guido Scalia
- Department of Biomedical and Biotechnological Sciences, University of Catania, Laboratory Analysis Unit, A.O.U. "Policlinico -Vittorio Emanuele", Catania, Italy
| | - Salvatore Oliveri
- Department of Biomedical and Biotechnological Sciences, University of Catania, Laboratory Analysis Unit, A.O.U. "Policlinico -Vittorio Emanuele", Catania, Italy
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16
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Inflammatory Cell Recruitment in Candida glabrata Biofilm Cell-Infected Mice Receiving Antifungal Chemotherapy. J Clin Med 2019; 8:jcm8020142. [PMID: 30691087 PMCID: PMC6406391 DOI: 10.3390/jcm8020142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 01/12/2019] [Accepted: 01/20/2019] [Indexed: 12/14/2022] Open
Abstract
(1) Background: Due to a high rate of antifungal resistance, Candida glabrata is one of the most prevalent Candida spp. linked to systemic candidiasis, which is particularly critical in catheterized patients. The goal of this work was to simulate a systemic infection exclusively derived from C. glabrata biofilm cells and to evaluate the effectiveness of the treatment of two echinocandins—caspofungin (Csf) and micafungin (Mcf). (2) Methods: CD1 mice were infected with 48 h-biofilm cells of C. glabrata and then treated with Csf or Mcf. After 72 h, the efficacy of each drug was evaluated to assess the organ fungal burden through colony forming units (CFU) counting. The immune cell recruitment into target organs was evaluated by flow cytometry or histopathology analysis. (3) Results: Fungal burden was found to be higher in the liver than in the kidneys. However, none of the drugs was effective in completely eradicating C. glabrata biofilm cells. At the evaluated time point, flow cytometry analysis showed a predominant mononuclear response in the spleen, which was also evident in the liver and kidneys of the infected mice, as observed by histopathology analysis. (4) Conclusions: Echinocandins do not have a significant impact on liver and kidney fungal burden, or recruited inflammatory infiltrate, when mice are intravenously (i.v.) infected with C. glabrata biofilm-grown cells.
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Epidemiologic characteristics of adult candidemic patients in a secondary hospital in Kuwait: A retrospective study. J Mycol Med 2018; 29:35-38. [PMID: 30578148 DOI: 10.1016/j.mycmed.2018.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 11/11/2018] [Accepted: 12/10/2018] [Indexed: 01/05/2023]
Abstract
Candida blood steam infection is a life-threatening disease that seems to be under estimated. Understanding epidemiology of such disease is crucial for improved diagnosis, optimized treatment, and better outcome. Through this retrospective study, we aimed to determine the incidence of candidemia in a secondary care hospital, and to describe the epidemiology and outcome of candidemia among adult patients. The incidence of candidemia for all age groups was 0.24, 0.16 and 0.15 cases/1000 patient-days in 2014, 2015 and 2016 respectively. Among adult patients, 82 cases were identified. The patients had the following clinical characteristics with varying proportions: old age, diabetes, antibiotic exposure, use of vascular catheter, abdominal surgery, ICU hospitalization, haemodialysis, and total parenteral nutrition. All-cause 30-day mortality was 54% and ICU hospitalization was a recognized risk factor for death. The leading causative agents were Candida albicans (32%), and Candida parapsilosis (32%), followed by Candida tropicalis (20%), Candida glabrata (13%) and one each by Candida dubliniensis, Candida famata, and Candida auris. Almost all tested isolates were susceptible to caspofungin and amphotericin B. With regard to fluconazole, C. glabrata showed variable susceptibility. Other species were susceptible except one isolate, each of C. parapsilosis and C. auris. The study highlights the growing importance of non-C. albicans Candida species in the etiology of candidemia. Emergence of C. auris is a warning sign and needs to be closely monitored.
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18
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Naderi J, Giles C, Saboohi S, Griesser HJ, Coad BR. Surface coatings with covalently attached anidulafungin and micafungin preventCandida albicansbiofilm formation. J Antimicrob Chemother 2018; 74:360-364. [DOI: 10.1093/jac/dky437] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/28/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Javad Naderi
- Future Industries Institute, University of South Australia, Adelaide, Australia
| | - Carla Giles
- Future Industries Institute, University of South Australia, Adelaide, Australia
- Centre for Aquatic Animal Health & Vaccines, Tasmania Department of Primary Industries, Parks Water & Environment, 165 Westbury Road, Prospect, Tasmania, Australia
| | - Solmaz Saboohi
- Future Industries Institute, University of South Australia, Adelaide, Australia
| | - Hans J Griesser
- Future Industries Institute, University of South Australia, Adelaide, Australia
| | - Bryan R Coad
- Future Industries Institute, University of South Australia, Adelaide, Australia
- School of Agriculture, Food & Wine, University of Adelaide, Adelaide, Australia
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19
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Al-Dorzi HM, Sakkijha H, Khan R, Aldabbagh T, Toledo A, Ntinika P, Al Johani SM, Arabi YM. Invasive Candidiasis in Critically Ill Patients: A Prospective Cohort Study in Two Tertiary Care Centers. J Intensive Care Med 2018; 35:542-553. [PMID: 29628014 PMCID: PMC7222290 DOI: 10.1177/0885066618767835] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background: Invasive candidiasis is not uncommon in critically ill patients but has variable epidemiology and outcomes between intensive care units (ICUs). This study evaluated the epidemiology, characteristics, management, and outcomes of patients with invasive candidiasis at 6 ICUs of 2 tertiary care centers. Methods: This was a prospective observational study of all adults admitted to 6 ICUs in 2 different hospitals between August 2012 and May 2016 and diagnosed to have invasive candidiasis by 2 intensivists according to predefined criteria. The epidemiology of isolated Candida and the characteristics, management, and outcomes of affected patients were studied. Multivariable logistic regression analyses were performed to identify the predictors of non-albicans versus albicans infection and hospital mortality. Results: Invasive candidiasis was diagnosed in 162 (age 58.4 ± 18.9 years, 52.2% males, 82.1% medical admissions, and admission Acute Physiology and Chronic Health Evaluation II score 24.1 ± 8.4) patients at a rate of 2.6 cases per 100 ICU admissions. On the diagnosis day, the Candida score was 2.4 ± 0.9 in invasive candidiasis compared with 1.6 ± 0.9 in Candida colonization (P < .01). The most frequent species were albicans (38.3%), tropicalis (16.7%), glabrata (16%), and parapsilosis (13.6%). In patients with candidemia, antifungal therapy was started on average 1 hour before knowing the culture result (59.6% of therapy initiated after). Resistance to fluconazole, caspofungin, and amphotericin B occurred in 27.9%, 2.9%, and 3.1%, respectively. The hospital mortality was 58.6% with no difference between albicans and non-albicans infections (61.3% and 54.9%, respectively; P = .44). The independent predictors of mortality were renal replacement therapy after invasive candidiasis diagnosis (odds ratio: 5.42; 95% confidence interval: 2.16-13.56) and invasive candidiasis leading/contributing to ICU admission versus occurring during critical illness (odds ratio: 2.87; 95% confidence interval: 1.22-6.74). Conclusions: In critically ill patients with invasive candidiasis, non-albicans was responsible for most cases, and mortality was high (58.6%). Antifungal therapy was initiated after culture results in 60% suggesting low preclinical suspicion. Study registration: NCT01490684; registered in ClinicalTrials.gov on February 11, 2012.
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Affiliation(s)
- Hasan M Al-Dorzi
- Intensive Care Department, International Medical Research Center, College of Medicine, King Saud bin Abdulaziz, University for Health Sciences and King Abdullah Riyadh, Saudi Arabia
| | - Hussam Sakkijha
- Pulmonary and Critical Care Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Raymond Khan
- Intensive Care Department, International Medical Research Center, College of Medicine, King Saud bin Abdulaziz, University for Health Sciences and King Abdullah Riyadh, Saudi Arabia
| | - Tarek Aldabbagh
- Intensive Care Department, International Medical Research Center, College of Medicine, King Saud bin Abdulaziz, University for Health Sciences and King Abdullah Riyadh, Saudi Arabia
| | - Aron Toledo
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Pendo Ntinika
- Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Sameera M Al Johani
- Laboratory Medicine Department, College of Medicine, King Saud bin Abdulaziz, University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yaseen M Arabi
- Intensive Care Department, International Medical Research Center, College of Medicine, King Saud bin Abdulaziz, University for Health Sciences and King Abdullah Riyadh, Saudi Arabia
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Affiliation(s)
- John E Bennett
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, MD Clinical Monitoring Research Program, Leidos Biomedical Research, NCI Campus at Frederick, Frederick, MD
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Treviño-Rangel RDJ, Espinosa-Pérez JF, Villanueva-Lozano H, Montoya AM, Andrade A, Bonifaz A, González GM. First report of Candida bracarensis in Mexico: hydrolytic enzymes and antifungal susceptibility pattern. Folia Microbiol (Praha) 2018; 63:517-523. [PMID: 29488180 DOI: 10.1007/s12223-018-0592-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 02/13/2018] [Indexed: 12/11/2022]
Abstract
Candida bracarensis is an emerging cryptic species within the Candida glabrata clade. To date, little is known about its epidemiology, virulence, and antifungal susceptibility. This study documents the occurrence of C. bracarensis for the first time in Mexico and focuses on its in vitro production of hydrolytic enzymes, as well as antifungal susceptibility to echinocandins. This strain was isolated from a vaginal swab of a female with vulvovaginal candidosis; exhibited a very strong activity of aspartyl proteinase, phospholipase, and hemolysin; and was susceptible to caspofungin, anidulafungin, and micafungin (MIC = 0.031 μg/mL). Data obtained could contribute to the knowledge of the epidemiology and virulence attributes of this yeast as a fungal opportunistic human pathogen.
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Affiliation(s)
- Rogelio de J Treviño-Rangel
- Department of Microbiology, School of Medicine, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero and Dr. Eduardo A. Pequeño, s/n. Mitras Centro, 64460, Monterrey, NL, Mexico
| | - José F Espinosa-Pérez
- Department of Microbiology, School of Medicine, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero and Dr. Eduardo A. Pequeño, s/n. Mitras Centro, 64460, Monterrey, NL, Mexico
| | - Hiram Villanueva-Lozano
- Department of Microbiology, School of Medicine, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero and Dr. Eduardo A. Pequeño, s/n. Mitras Centro, 64460, Monterrey, NL, Mexico
| | - Alexandra M Montoya
- Department of Microbiology, School of Medicine, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero and Dr. Eduardo A. Pequeño, s/n. Mitras Centro, 64460, Monterrey, NL, Mexico
| | - Angel Andrade
- Department of Microbiology, School of Medicine, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero and Dr. Eduardo A. Pequeño, s/n. Mitras Centro, 64460, Monterrey, NL, Mexico
| | - Alexandro Bonifaz
- Dermatology Service and Mycology Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Gloria M González
- Department of Microbiology, School of Medicine, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero and Dr. Eduardo A. Pequeño, s/n. Mitras Centro, 64460, Monterrey, NL, Mexico.
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Russo A, Carriero G, Farcomeni A, Ceccarelli G, Tritapepe L, Venditti M. Role of oral nystatin prophylaxis in cardiac surgery with prolongedextracorporeal circulation. Mycoses 2017; 60:826-829. [PMID: 28877374 DOI: 10.1111/myc.12680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 08/05/2017] [Accepted: 08/07/2017] [Indexed: 11/25/2022]
Abstract
Duration >120 minutes of extracorporeal circulation (ECC) during cardiopulmonary bypass procedure was associated to an increased risk of candidemia in the intensive care unit (ICU). To evaluate oral nystatin prophylaxis in cardiac surgery considering its exclusive effect on Candida, in the absence of systemic effects and selection of resistant strains to polyene. We conducted an observational study in the postcardiac surgery ICU of Policlinico "Umberto I" of Rome. From January 2014, all patients with a prolonged ECC >120 minutes were systematically treated with oral nystatin (Prophylaxis group). This group was compared with all patients hospitalised in the same ICU, who have not received oral nystatin after ECC >120 minutes (No prophylaxis group). Overall, 672 consecutive patients were analyzed: 318 (47.3%) patients belonged to the no prophylaxis group, and 354 (52.7%) patients to the prophylaxis group. Diagnosis of candidemia was confirmed in 7 (2.2%) patients, all belonged to the no prophylaxis group. At multivariate analysis, oral nystatin prophylaxis showed a protective effect for development of candidemia after cardiac surgery. Oral nystatin prophylaxis, in patients who underwent a ECC >120 minutes, seems to reduce development of candidemia; however, the real efficacy of such prophylaxis approach requires further investigation.
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Affiliation(s)
- Alessandro Russo
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy
| | - Giovanni Carriero
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy
| | - Luigi Tritapepe
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy
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24
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Gómez-Sequeda N, Torres R, Ortiz C. Synthesis, characterization, and in vitro activity against Candida spp. of fluconazole encapsulated on cationic and conventional nanoparticles of poly(lactic-co-glycolic acid). Nanotechnol Sci Appl 2017; 10:95-104. [PMID: 28572725 PMCID: PMC5441665 DOI: 10.2147/nsa.s96018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
In this study, nanoparticles (NPs) of poly(lactic-co-glycolic acid) (PLGA) loaded with fluconazole (FLZ) and FLZ-NPs coated with the cationic polymer polyethylenimine (PEI) (FLZ-NP-PEI) were synthetized in order to improve antimycotic activity against four strains of Candida spp. of clinical relevance. FLZ-NPs and FLZ-NP-PEI were synthesized by double emulsion solvent-diffusion (DES-D) and characterized. Minimum inhibitory concentration (MIC50) and minimum fungicide concentration (MFC) were determined in vitro by culturing Candida strains in the presence of these nanocompounds. FLZ-NPs were spherical in shape with hydrodynamic sizes of ~222 nm and surface charge of -11.6 mV. The surface charges of these NPs were successfully modified using PEI (FLZ-NP-PEI) with mean hydrodynamic sizes of 281 nm and surface charge of 23.5 mV. The efficiency of encapsulation (~53%) and a quick release of FLZ (≥90% after 3 h) were obtained. Cytotoxicity assay showed a good cell viability for FLZ-NPs (≥86%), and PEI-modified NPs presented a decrease in cell viability (~38%). FLZ-NPs showed an increasing antifungal activity of FLZ for sensitive (Candida parapsilosis ATCC22019 and Candida albicans ATCC10231, MIC50 =0.5 and 0.1 µg/mL, respectively) and resistant strains (Candida glabrata EMLM14 and Candida krusei ATCC6258, MIC50 =0.1 and 0.5 µg/mL, respectively). FLZ-NP-PEI showed fungicidal activity even against C. glabrata and C. krusei (MFC =4 and 8 µg/mL, respectively). MIC50 values showed best results for FLZ-NPs and FLZ-NP-PEI. Nevertheless, only FLZ-NP-PEI displayed fungicidal activity against the studied strains.
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Affiliation(s)
| | | | - Claudia Ortiz
- School of Microbiology, Faculty of Health, Universidad Industrial de Santander, Bucaramanga, Santander, Colombia
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Impact of initial empirical antifungal agents on the outcome of critically ill patients with invasive candidiasis: analysis of the China-SCAN study. Int J Antimicrob Agents 2017; 50:74-80. [PMID: 28499959 DOI: 10.1016/j.ijantimicag.2017.02.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/16/2017] [Accepted: 02/22/2017] [Indexed: 01/05/2023]
Abstract
The effect of different empirical antifungal agents on the clinical outcome of critically ill patients with invasive candidiasis (IC) has not been fully elucidated. In this study, 136 patients with proven IC who received empirical therapy in the China-SCAN multicentre study were retrospectively analysed. Initial empirical antifungal monotherapy consisted of a triazole [fluconazole (n = 61), voriconazole (n = 20) or itraconazole (n = 12)] or an echinocandin (n = 43). Hospital mortality as the primary outcome and global responses (clinical and microbiological) were assessed. The results indicated that rates of hospital mortality (P = 0.006) and intensive care unit (ICU) mortality (P = 0.011) were significantly lower in patients treated with an echinocandin compared with those receiving fluconazole, voriconazole or itraconazole. Multivariate regression analysis indicated that the type of antifungal agent used in empirical therapy was an independent predictor of hospital mortality (P = 0.033). Initial empirical echinocandin treatment was associated with decreased hospital mortality compared with fluconazole [odds ratio (OR) = 0.22, 95% confidence interval (CI) 0.06-0.85; P = 0.028], voriconazole (OR = 0.11, 95% CI 0.02-0.56; P = 0.008) or itraconazole (OR = 0.12, 95% CI 0.02-0.72; P = 0.020). Similar findings were observed for the clinical success endpoint. This study demonstrated that the initial empirical antifungal agent was an independent predictor of hospital mortality in critically ill patients with IC. Empirical therapy with an echinocandin was associated with decreased hospital mortality and greater clinical success than empirical therapy with fluconazole, voriconazole or itraconazole.
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Pang YK, Ip M, You JHS. Potential clinical and economic outcomes of active beta-D-glucan surveillance with preemptive therapy for invasive candidiasis at intensive care units: a decision model analysis. Eur J Clin Microbiol Infect Dis 2016; 36:187-194. [DOI: 10.1007/s10096-016-2796-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 09/16/2016] [Indexed: 11/29/2022]
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Razzaghi R, Momen-Heravi M, Erami M, Nazeri M. Candidemia in patients with prolonged fever in Kashan, Iran. Curr Med Mycol 2016; 2:20-26. [PMID: 28681025 PMCID: PMC5490286 DOI: 10.18869/acadpub.cmm.2.3.20] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background and Purpose: Candida species are considered a common cause of fungal blood stream infections, which are associated with considerable mortality and morbidity rates, especially in the admitted and immunocompromised patients. Despite the increase in new and available antifungal agents, the emergence of resistant strains is growing. Regarding this, the aim of the present study was to assess the fungal epidemiology of candidemia and the antifungal susceptibility patterns against five current antifungal agents among the patients with prolonged fever, who were admitted to Beheshti Educational Hospital, Kashan, Iran. Materials and Methods: This cross-sectional study was conducted on 253 hospitalized patients with prolonged fever despite receiving broad-spectrum antibiotic therapy. Blood samples were collected aseptically, and then cultured using an automated blood culture system and conventional broth culture bottle. Candida isolates were identified at species level using morphological and physiological properties and produced color on the CHROMagar Candida. Furthermore, the antifungal susceptibility testing was performed using (CLSI M27-A3 and CLSI M27-S4) broth microdilution methods. Results: The most positive cultures were detected by the automated blood culture system. C.albicans (%50) was the most prevalent species, followed by C. glabrata (%40), and C. parapsilosis, (%10) respectively .The mortality rate was high (%60) and most patients with candidemia were admitted to the Intensive Care Unit and Neonatal Intensive Care Unit. All isolates were susceptible to amphotericin B, while the highest resistance belonged to caspofungin. Conclusion: In this study, high resistance was reported, especially for caspofungin, which can be regarded as the emergence of caspofungin-resistant strains. Regarding this, the establishment of a surveillance and prevention program for the reduction of the emergence of resistant species is necessary.
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Affiliation(s)
- R Razzaghi
- Department of Infectious Diseases, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - M Momen-Heravi
- Department of Infectious Diseases, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - M Erami
- Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - M Nazeri
- Department of Medical Parasitology and Mycology, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
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Abstract
BACKGROUND Candida bloodstream infections most often affect those already suffering serious, potentially life-threatening conditions and often cause significant morbidity and mortality. Most affected persons have a central venous catheter (CVC) in place. The best CVC management in these cases has been widely debated in recent years, while the incidence of candidaemia has markedly increased. OBJECTIVES The main purpose of this review is to examine the impact of removing versus retaining a CVC on mortality in adults and children with candidaemia who have a CVC in place. SEARCH METHODS We searched the following databases from inception to 3 December 2015: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid SP), EMBASE (Ovid SP), the Commonwealth Agricultural Bureau (CAB), Web of Science and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We searched for missed, unreported and ongoing trials in trial registries and in reference lists of excluded articles. SELECTION CRITERIA We searched for randomized controlled trials (RCTs) and quasi-RCTs involving adults and children with candidaemia and in which participants were randomized for removal of a CVC (the intervention under study), irrespective of publication status, date of publication, blinding status, outcomes published or language.However, two major factors make the conduct of RCTs in this population a difficult task: the large sample size required to document the impact of catheter removal in terms of overall mortality; and lack of economic interest from the industry in conducting such a trial. DATA COLLECTION AND ANALYSIS Our primary outcome measure was mortality. Several secondary outcome measures such as required time for clearance of blood cultures for Candida species, frequency of persistent candidaemia, complications, duration of mechanical ventilation and length of stay in the intensive care unit (ICU) and in the hospital were planned, as were various subgroup and sensitivity analyses, according to our protocol. We assessed papers and abstracts for eligibility and resolved disagreements by discussion. However, we were not able to include any RCTs or quasi-RCTS in this review and, as a result, have carried out no meta-analyses. However, we have chosen to provide a brief overview of excluded observational studies. MAIN RESULTS We found no RCT and thus no available data for evaluation of the primary outcome (mortality) nor secondary outcomes or adverse effects. Therefore, we conducted no statistical analysis.A total of 73 observational studies reported on various clinically relevant outcomes following catheter removal or catheter retention. Most of these excluded, observational studies reported a beneficial effect of catheter removal in patients with candidaemia. None of the observational studies reported results in favour of retaining a catheter. However, the observational studies were very heterogeneous with regards to population, pathogens and interventions. Furthermore, they suffered from confounding by indication and an overall high risk of bias. As a consequence, we are not able to provide recommendations or to draw firm conclusions because of the difficulties involved in interpreting the results of these observational studies (very low quality of evidence, GRADE - Grades of Recommendation, Assessment, Development and Evaluation Working Group). AUTHORS' CONCLUSIONS Despite indications from observational studies in favour of early catheter removal, we found no eligible RCTs or quasi-RCTs to support these practices and therefore could draw no firm conclusions. At this stage, RCTs have provided no evidence to support the benefit of early or late catheter removal for survival or other important outcomes among patients with candidaemia; no evidence with regards to assessment of harm or benefit with prompt central venous catheter removal and subsequent re-insertion of new catheters to continue treatment; and no evidence on optimal timing of insertion of a new central venous catheter.
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Affiliation(s)
- Susanne Janum
- Rigshospitalet, Copenhagen University HospitalDepartment of Neuroanesthesiology and Neurointensive Care 2093Blegdamsvej 9CopenhagenDenmark2100
| | - Arash Afshari
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
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Wang TY, Hung CY, Shie SS, Chou PC, Kuo CH, Chung FT, Lo YL, Lin SM. The clinical outcomes and predictive factors for in-hospital mortality in non-neutropenic patients with candidemia. Medicine (Baltimore) 2016; 95:e3834. [PMID: 27281087 PMCID: PMC4907665 DOI: 10.1097/md.0000000000003834] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Recent epidemiologic studies have showed that candidemia is an important nosocomial infection in hospitalized patients. The majority of candidemia patients were non-neutropenic rather than neutropenic status. The aim of this study was to determine the clinical outcome of non-neutropenic patients with candidemia and to measure the contributing factors for mortality. A total of 163 non-neutropenic patients with candidemia during January 2010 to December 2013 were retrospectively enrolled. The patients' risk factors for mortality, clinical outcomes, treatment regimens, and Candida species were analyzed. The overall mortality was 54.6%. Candida albicans was the most frequent Candida species (n = 83; 50.9% of patients). Under multivariate analyses, hemodialysis (OR, 4.554; 95% CI, 1.464-14.164) and the use of amphotericin B deoxycholate (OR, 8.709; 95% CI, 1.587-47.805) were independent factors associated with mortality. In contrast, abdominal surgery (OR, 0.360; 95% CI, 0.158-0.816) was associated with a better outcome. The overall mortality is still high in non-neutropenic patients with candidemia. Hemodialysis and use of amphotericin B deoxycholate were independent factors associated with mortality, whereas prior abdominal surgery was associated with a better outcome.
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Affiliation(s)
| | | | - Shian-Sen Shie
- Division of Infectious Diseases, Department of Medicine, Chang Gung Memorial Hospital, Chang Gung University, School of Medicine, Taipei, Taiwan
| | | | | | | | | | - Shu-Min Lin
- Department of Thoracic Medicine
- ∗Correspondence: Shu-Min Lin, Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan (e-mail: )
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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.
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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.
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Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, Reboli AC, Schuster MG, Vazquez JA, Walsh TJ, Zaoutis TE, Sobel JD. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1-50. [PMID: 26679628 PMCID: PMC4725385 DOI: 10.1093/cid/civ933] [Citation(s) in RCA: 1888] [Impact Index Per Article: 236.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/02/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
| | - Carol A Kauffman
- Veterans Affairs Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor
| | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | - Thomas J Walsh
- Weill Cornell Medical Center and Cornell University, New York, New York
| | | | - Jack D Sobel
- Harper University Hospital and Wayne State University, Detroit, Michigan
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Antifungal coatings by caspofungin immobilization onto biomaterials surfaces via a plasma polymer interlayer. Biointerphases 2015; 10:04A307. [PMID: 26467660 DOI: 10.1116/1.4933108] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Not only bacteria but also fungal pathogens, particularly Candida species, can lead to biofilm infections on biomedical devices. By covalent grafting of the antifungal drug caspofungin, which targets the fungal cell wall, onto solid biomaterials, a surface layer can be created that might be able to provide long-term protection against fungal biofilm formation. Plasma polymerization of propionaldehyde (propanal) was used to deposit a thin (∼20 nm) interfacial bonding layer bearing aldehyde surface groups that can react with amine groups of caspofungin to form covalent interfacial bonds for immobilization. Surface analyses by x-ray photoelectron spectroscopy and time-of-flight secondary ion mass spectrometry confirmed the intended grafting and uniformity of the coatings, and durability upon extended washing. Testing for fungal cell attachment and ensuing biofilm formation showed that caspofungin retained activity when covalently bound onto surfaces, disrupting colonizing Candida cells. Mammalian cytotoxicity studies using human primary fibroblasts indicated that the caspofungin-grafted surfaces were selective in eliminating fungal cells while allowing attachment and spreading of mammalian cells. These in vitro data suggest promise for use as antifungal coatings, for example, on catheters, and the use of a plasma polymer interlayer enables facile transfer of the coating method onto a wide variety of biomaterials and biomedical devices.
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Ko ER, Yang WE, McClain MT, Woods CW, Ginsburg GS, Tsalik EL. What was old is new again: using the host response to diagnose infectious disease. Expert Rev Mol Diagn 2015; 15:1143-58. [PMID: 26145249 DOI: 10.1586/14737159.2015.1059278] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A century of advances in infectious disease diagnosis and treatment changed the face of medicine. However, challenges continue to develop including multi-drug resistance, globalization that increases pandemic risks and high mortality from severe infections. These challenges can be mitigated through improved diagnostics, focusing on both pathogen discovery and the host response. Here, we review how 'omics' technologies improve sepsis diagnosis, early pathogen identification and personalize therapy. Such host response diagnostics are possible due to the confluence of advanced laboratory techniques (e.g., transcriptomics, metabolomics, proteomics) along with advanced mathematical modeling such as machine learning techniques. The road ahead is promising, but obstacles remain before the impact of such advanced diagnostic modalities is felt at the bedside.
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Affiliation(s)
- Emily R Ko
- a 1 Department of Medicine Center for Applied Genomics & Precision Medicine, Duke University, Durham, NC 27708, USA
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Gupta A, Gupta A, Varma A. Candida glabrata candidemia: An emerging threat in critically ill patients. Indian J Crit Care Med 2015; 19:151-4. [PMID: 25810610 PMCID: PMC4366913 DOI: 10.4103/0972-5229.152757] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Candidemia is an important nosocomial blood stream infection in critically ill patients. Although several studies have addressed candidemia, very few have reviewed the impact of Candida glabrata candidemia in Intensive Care Unit (ICU) patients. Materials and Methods: The medical records of ICU patients between 2006 and 2010 were reviewed retrospectively. The epidemiology, clinical features and mortality related risk factors among our adult ICU patients were seen. Results: Among 144 episodes of candidemia, C. glabrata (n = 26; 18.05%) was the third most common species isolated. The incidence of C. glabrata candidemia was 0.21/1000 ICU admissions. The most common risk factors were prior exposure to broad spectrum antibiotics (100%), central venous catheter (100%), mechanical ventilation (76.9%), diabetes mellitus (50%), age >65 years (46.15%). Urine (23%) was the most common source of C. glabrata candidemia. Overall in hospital 30 days mortality rate due to C. glabrata fungemia was 53.8%. Patients who were treated with fluconazole showed better outcome than patients treated with amphotericin B. Renal failure requiring hemodialysis was the significantly associated with mortality in our study. Conclusion: Candida glabrata was the 3rd most common Candida causing candidemia in our ICUs with a incidence of 0.21/1000 ICU admissions. The outcome of ICU acquired C. glabrata candidemia was poor with 30 days mortality rate of 53.8%. Renal failure requiring hemodialysis was the only risk factor associated with mortality. Further studies are required to identify the other risk factors associated with mortality in C. glabrata candidemia.
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Affiliation(s)
- Ashish Gupta
- Department of Critical Care Medicine, Fortis Escorts Heart Institute, New Delhi, India
| | - Anu Gupta
- Department of Microbiology, Fortis Escorts Heart Institute, New Delhi, India
| | - Amit Varma
- Department of Critical Care Medicine, Fortis Escorts Heart Institute, New Delhi, India
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Synergistic activity of chloroquine with fluconazole against fluconazole-resistant isolates of Candida species. Antimicrob Agents Chemother 2014; 59:1365-9. [PMID: 25512426 DOI: 10.1128/aac.04417-14] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The in vitro activity of chloroquine and the interactions of chloroquine combined with fluconazole against 37 Candida isolates were tested using the broth microdilution, disk diffusion, and Etest susceptibility tests. Synergistic effect was detected with 6 of 9 fluconazole-resistant Candida albicans isolates, with Candida krusei ATCC 6258, and with all 12 fluconazole-resistant Candida tropicalis isolates.
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Invasive Candida infections in patients of a medical intensive care unit. Wien Klin Wochenschr 2014; 127:132-42. [DOI: 10.1007/s00508-014-0644-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 10/13/2014] [Indexed: 10/24/2022]
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Tang HJ, Liu WL, Lin HL, Lai CC. Clinical manifestations and prognostic factors of central line-associated candidemia. Am J Infect Control 2014; 42:1238-40. [PMID: 25238665 DOI: 10.1016/j.ajic.2014.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 07/16/2014] [Accepted: 07/17/2014] [Indexed: 01/01/2023]
Abstract
From 2009-2012, a total of 281 episodes of central line-associated candidemia were identified, and the overall incidence was 2.05 episodes per 1,000 hospital admissions. More than half of the patients were classified as older adults, with an age ≥65 years. Cancer was the most common underlying disease (n = 231, 82.2%). Twenty patients had polycandidal candidemia, and 94 had concomitant bacteremia. The overall in-hospital mortality rate was 50.9%, and a multivariable analysis showed that this rate was only significantly associated with a Charlson comorbidity index score >5, jaundice, no antifungal agent use, and use of mechanical ventilators.
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Parker JE, Warrilow AGS, Price CL, Mullins JGL, Kelly DE, Kelly SL. Resistance to antifungals that target CYP51. J Chem Biol 2014; 7:143-61. [PMID: 25320648 DOI: 10.1007/s12154-014-0121-1] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 08/06/2014] [Indexed: 12/23/2022] Open
Abstract
Fungal diseases are an increasing global burden. Fungi are now recognised to kill more people annually than malaria, whilst in agriculture, fungi threaten crop yields and food security. Azole resistance, mediated by several mechanisms including point mutations in the target enzyme (CYP51), is increasing through selection pressure as a result of widespread use of triazole fungicides in agriculture and triazole antifungal drugs in the clinic. Mutations similar to those seen in clinical isolates as long ago as the 1990s in Candida albicans and later in Aspergillus fumigatus have been identified in agriculturally important fungal species and also wider combinations of point mutations. Recently, evidence that mutations originate in the field and now appear in clinical infections has been suggested. This situation is likely to increase in prevalence as triazole fungicide use continues to rise. Here, we review the progress made in understanding azole resistance found amongst clinically and agriculturally important fungal species focussing on resistance mechanisms associated with CYP51. Biochemical characterisation of wild-type and mutant CYP51 enzymes through ligand binding studies and azole IC50 determinations is an important tool for understanding azole susceptibility and can be used in conjunction with microbiological methods (MIC50 values), molecular biological studies (site-directed mutagenesis) and protein modelling studies to inform future antifungal development with increased specificity for the target enzyme over the host homologue.
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Affiliation(s)
- Josie E Parker
- Centre for Cytochrome P450 Biodiversity, Institute of Life Science, College of Medicine, Swansea University, Swansea, Wales SA2 8PP UK
| | - Andrew G S Warrilow
- Centre for Cytochrome P450 Biodiversity, Institute of Life Science, College of Medicine, Swansea University, Swansea, Wales SA2 8PP UK
| | - Claire L Price
- Centre for Cytochrome P450 Biodiversity, Institute of Life Science, College of Medicine, Swansea University, Swansea, Wales SA2 8PP UK
| | - Jonathan G L Mullins
- Centre for Cytochrome P450 Biodiversity, Institute of Life Science, College of Medicine, Swansea University, Swansea, Wales SA2 8PP UK
| | - Diane E Kelly
- Centre for Cytochrome P450 Biodiversity, Institute of Life Science, College of Medicine, Swansea University, Swansea, Wales SA2 8PP UK
| | - Steven L Kelly
- Centre for Cytochrome P450 Biodiversity, Institute of Life Science, College of Medicine, Swansea University, Swansea, Wales SA2 8PP UK
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Colombo AL, Guimarães T, Sukienik T, Pasqualotto AC, Andreotti R, Queiroz-Telles F, Nouér SA, Nucci M. Prognostic factors and historical trends in the epidemiology of candidemia in critically ill patients: an analysis of five multicenter studies sequentially conducted over a 9-year period. Intensive Care Med 2014; 40:1489-98. [PMID: 25082359 PMCID: PMC4176831 DOI: 10.1007/s00134-014-3400-y] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/06/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe temporal trends in the epidemiology, clinical management and outcome of candidemia in intensive care unit (ICU) patients. METHODS This study was a retrospective analysis of 1,392 episodes of candidemia in 647 adult ICU patients from 22 Brazilian hospitals. The characteristics of candidemia in these ICU patients were compared in two periods (2003-2007, period 1; 2008-2012, period 2), and the predictors of 30-day mortality were assessed. RESULTS The proportion of patients who developed candidemia while in the ICU increased from 44 % in period 1 to 50.9 % in period 2 (p = 0.01). Prior exposure to fluconazole before candidemia (22.3 vs. 11.6 %, p < 0.001) and fungemia due to Candida glabrata (13.1 vs. 7.8 %, p = 0.03) were more frequent in period 2, as was the proportion of patients receiving an echinocandin as primary therapy (18.0 vs. 5.9 %, p < 0.001). The 30-day mortality rate decreased from 76.4 % in period 1 to 60.8 % in period 2 (p < 0.001). Predictors of 30-day mortality by multivariate analysis were older age, period 1, treatment with corticosteroids and higher APACHE II score, while treatment with an echinocandin were associated with a higher probability of survival. CONCLUSIONS We found a clear change in the epidemiology and clinical management of candidemia in ICU patients over the 9-year period of the study. The use of echinocandins as primary therapy for candidemia appears to be associated with better outcomes.
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Affiliation(s)
- Arnaldo L Colombo
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil,
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Abstract
OBJECTIVES To determine the epidemiology of Candida bloodstream infections, variables influencing mortality, and antifungal resistance rates in ICUs in Spain. DESIGN Prospective, observational, multicenter population-based study. SETTING Medical and surgical ICUs in 29 hospitals distributed throughout five metropolitan areas of Spain. PATIENTS Adult patients (≥ 18 yr) with an episode of Candida bloodstream infection during admission to any surveillance area ICU from May 2010 to April 2011. INTERVENTIONS Candida isolates were sent to a reference laboratory for species identification by DNA sequencing and susceptibility testing using the methods and breakpoint criteria promulgated by the European Committee on Antimicrobial Susceptibility Testing. Prognostic factors associated with early (0-7 d) and late (8-30 d) mortality were analyzed using logistic regression modeling. MEASUREMENTS AND MAIN RESULTS We detected 773 cases of candidemia, 752 of which were included in the overall cohort. Among these, 168 (22.3%) occurred in adult ICU patients. The rank order of Candida isolates was as follows: Candida albicans (52%), Candida parapsilosis (23.7%), Candida glabrata (12.7%), Candida tropicalis (5.8%), Candida krusei (4%), and others (1.8%). Overall susceptibility to fluconazole was 79.2%. Cumulative mortality at 7 and 30 days after the first episode of candidemia was 16.5% and 47%, respectively. Multivariate analysis showed that early appropriate antifungal treatment and catheter removal (odds ratio, 0.27; 95% CI, 0.08-0.91), Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.11; 95% CI, 1.04-1.19), and abdominal source (odds ratio, 8.15; 95% CI, 1.75-37.93) were independently associated with early mortality. Determinants of late mortality were age (odds ratio, 1.04; 95% CI, 1.01-1.07), intubation (odds ratio, 7.24; 95% CI, 2.24-23.40), renal replacement therapy (odds ratio, 6.12; 95% CI, 2.24-16.73), and primary source (odds ratio, 2.51; 95% CI, 1.06-5.95). CONCLUSIONS Candidemia in ICU patients is caused by non-albicans species in 48% of cases, C. parapsilosis being the most common among these. Overall mortality remains high and mainly related with host factors. Prompt adequate antifungal treatment and catheter removal could be critical to decrease early mortality.
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Moreno Camacho A, Ruiz Camps I. [Nosocomial infection in patients receiving a solid organ transplant or haematopoietic stem cell transplant]. Enferm Infecc Microbiol Clin 2014; 32:386-95. [PMID: 24950613 PMCID: PMC7103322 DOI: 10.1016/j.eimc.2014.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 05/27/2014] [Indexed: 12/25/2022]
Abstract
Bacterial infections are the most common infections in solid organ transplant recipients. These infections occur mainly in the first month after transplantation and are hospital-acquired. Nosocomial infections cause significant morbidity and are the most common cause of mortality in this early period of transplantation. These infections are caused by multi-drug resistant (MDR) microorganisms, mainly Gram-negative enterobacteria, non-fermentative Gram-negative bacilli, enterococci, and staphylococci. The patients at risk of developing nosocomial bacterial infections are those previously colonized with MDR bacteria while on the transplant waiting list. Intravascular catheters, the urinary tract, the lungs, and surgical wounds are the most frequent sources of infection. Preventive measures are the same as those applied in non-immunocompromised, hospitalized patients except in patients at high risk for developing fungal infection. These patients need antifungal therapy during their hospitalization, and for preventing some bacterial infections in the early transplant period, patients need vaccinations on the waiting list according to the current recommendations. Although morbidity and mortality related to infectious diseases have decreased during the last few years in haematopoietic stem cell transplant recipients, they are still one of the most important complications in this population. Furthermore, as occurs in the general population, the incidence of nosocomial infections has increased during the different phases of transplantation. It is difficult to establish general preventive measures in these patients, as there are many risk factors conditioning these infections. Firstly, they undergo multiple antibiotic treatments and interventions; secondly, there is a wide variability in the degree of neutropenia and immunosuppression among patients, and finally they combine hospital and home stay during the transplant process. However, some simple measures could be implemented to improve the current situation.
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Affiliation(s)
- Asunción Moreno Camacho
- Servicio de Enfermedades Infecciosas, Hospital Clínic-IDIBAPS, Universidad de Barcelona, Barcelona, España.
| | - Isabel Ruiz Camps
- Servicio de Enfermedades Infecciosas, Hospital Universitari Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
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An Observational Study on Early Empiric versus Culture-Directed Antifungal Therapy in Critically Ill with Intra-Abdominal Sepsis. Crit Care Res Pract 2014; 2014:479413. [PMID: 24959349 PMCID: PMC4052101 DOI: 10.1155/2014/479413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/17/2014] [Indexed: 11/30/2022] Open
Abstract
Objective. To compare early empiric antifungal treatment with culture-directed treatment in critically ill patients with intra-abdominal sepsis. Methods. A prospective observational cohort study was conducted between August 2010 and July 2011, on SICU patients admitted after surgery for gastrointestinal perforation, bowel obstruction or ischemia, malignancy and anastomotic leakages. Patients who received antifungal treatment within two days of sepsis onset were compared to patients who received culture-directed antifungal treatment in terms of mortality rate and clinical improvement. Patients' demographics, comorbidities, severity-of-illness scores, and laboratory results were systematically collected and analysed. Results. Thirty-three patients received early empiric and 19 received culture-directed therapy. Of these, 30 from the early empiric group and 18 from culture-directed group were evaluable and analysed. Both groups had similar baseline characteristics and illness severity. Patients on empiric antifungal use had significantly lower 30-day mortality (P = 0.03) as well as shorter median time to clinical improvement (P = 0.025). Early empiric antifungal therapy was independently associated with survival beyond 30 days (OR 0.131, 95% CI: 0.018 to 0.966; P = 0.046). Conclusion. Early empiric antifungal therapy in surgical patients with intra-abdominal sepsis was associated with reduced mortality and warrants further evaluation in randomised controlled trials.
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Candidemia in the critically ill: initial therapy and outcome in mechanically ventilated patients. BMC Anesthesiol 2013; 13:37. [PMID: 24172136 PMCID: PMC3827504 DOI: 10.1186/1471-2253-13-37] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 10/23/2013] [Indexed: 11/20/2022] Open
Abstract
Background Mortality among critically ill patients with candidemia is very high. We sought to determine whether the choice of initial antifungal therapy is associated with survival among these patients, using need for mechanical ventilatory support as a marker of critical illness. Methods Cohort analysis of outcomes among mechanically ventilated patients with candidemia from the 24 North American academic medical centers contributing to the Prospective Antifungal Therapy (PATH) Alliance registry. Patients were included if they received either fluconazole or an echinocandin as initial monotherapy. Results Of 5272 patients in the PATH registry at the time of data abstraction, 1014 were ventilated and concomitantly had candidemia, with 689 eligible for analysis. 28-day survival was higher among the 374 patients treated initially with fluconazole than among the 315 treated with an echinocandin (66% versus 51%, P < .001). Initial fluconazole therapy remained associated with improved survival after adjusting for non-treatment factors in the overall population (hazard ratio .75, 95% CI .59–.96), and also among patients with albicans infection (hazard ratio .62, 95% CI .44–.88). While not statistically significant, fluconazole appeared to be associated with higher mortality among patients infected with glabrata (HR 1.13, 95% CI .70–1.84). Conclusions Among ventilated patients with candidemia, those receiving fluconazole as initial monotherapy were significantly more likely to survive than those treated with an echinocandin. This difference persisted after adjustment for non-treatment factors.
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Deshpande A, Gaur S, Bal A. Candidaemia in the non-neutropenic patient: A critique of the guidelines. Int J Antimicrob Agents 2013; 42:294-300. [DOI: 10.1016/j.ijantimicag.2013.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 06/11/2013] [Indexed: 10/26/2022]
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ÉPICO project. Development of educational recommendations using the DELPHI technique on invasive candidiasis in non-neutropenic critically ill adult patients. ACTA ACUST UNITED AC 2013; 60:e1-e18. [PMID: 23911095 DOI: 10.1016/j.redar.2013.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 05/14/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although there has been an improved management of invasive candidiasis in the last decade, controversial issues still remain, especially in the diagnostic and therapeutic approaches. AIMS We sought to identify the core clinical knowledge and to achieve high level agreement recommendations required to care for critically ill adult patients with invasive candidiasis. METHODS A prospective Spanish survey reaching consensus by the DELPHI technique was made. It was anonymously conducted by electronic mail in a first term to 25 national multidisciplinary experts in invasive fungal infections from five national scientific societies, including intensivists, anesthesiologists, microbiologists, pharmacologists and infectious diseases specialists, who answered to 47 questions prepared by a coordination group after a strict review of the literature in the last five years. The educational objectives spanned five categories, including epidemiology, diagnostic tools, prediction rules, and treatment and de-escalation approaches. The level of agreement achieved among the panel experts in each item should exceed 75% to be selected. In a second term, after extracting recommendations from the selected items, a face to face meeting was performed where more than 80 specialists in a second round were invited to validate the preselected recommendations. RESULTS In the first term, 20 recommendations were preselected (Epidemiology 4, Scores 3, Diagnostic tools 4, Treatment 6 and De-escalation approaches 3). After the second round, the following 12 were validated: (1) Epidemiology (2 recommendations): think about candidiasis in your Intensive Care Unit (ICU) and do not forget that non-Candida albicans-Candida species also exist. (2) Diagnostic tools (4 recommendations): blood cultures should be performed under suspicion every 2-3 days and, if positive, every 3 days until obtaining the first negative result. Obtain sterile fluid and tissue, if possible (direct examination of the sample is important). Use non-culture based methods as microbiological tools, whenever possible. Determination of antifungal susceptibility is mandatory. (3) Scores (1 recommendation): as screening tool, use the Candida Score and determine multicolonization in high risk patients. (4) Treatment (4 recommendations): start early. Choose echinocandins. Withdraw any central venous catheter. Fundoscopy is needed. (5) De-escalation (1 recommendation): only applied when knowing susceptibility determinations and after 3 days of clinical stability. The higher rate of agreement was achieved in the optimization of microbiological tools and the withdrawal of the catheter, whereas the lower rate corresponded to de-escalation therapy and the use of scores. CONCLUSIONS The management of invasive candidiasis in ICU patients requires the application of a broad range of knowledge and skills that we summarize in our recommendations. These recommendations may help to identify the potential patients, standardize their global management and improve their outcomes, based on the DELPHI methodology.
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[Épico project: Development of educational recommendations using the DELPHI technique on invasive candidiasis in non-neutropenic critically ill adult patients. Grupo Proyecto Épico]. Rev Iberoam Micol 2013; 30:135-49. [PMID: 23764554 DOI: 10.1016/j.riam.2013.05.005] [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: 04/25/2013] [Accepted: 05/15/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Although there has been an improved management of invasive candidiasis in the last decade, controversial issues still remain, especially in the diagnostic and therapeutic approaches. AIMS We sought to identify the core clinical knowledge and to achieve high level agreement recommendations required to care for critically ill adult patients with invasive candidiasis. METHODS A prospective Spanish survey reaching consensus by the DELPHI technique was made. It was anonymously conducted by electronic mail in a first term to 25 national multidisciplinary experts in invasive fungal infections from five national scientific societies, including intensivists, anesthesiologists, microbiologists, pharmacologists and infectious diseases specialists, who answered to 47 questions prepared by a coordination group after a strict review of the literature in the last five years. The educational objectives spanned five categories, including epidemiology, diagnostic tools, prediction rules, and treatment and de-escalation approaches. The level of agreement achieved among the panel experts in each item should exceed 75% to be selected. In a second term, after extracting recommendations from the selected items, a face to face meeting was performed where more than 80 specialists in a second round were invited to validate the preselected recommendations. RESULTS In the first term, 20 recommendations were preselected (Epidemiology 4, Scores 3, Diagnostic tools 4, Treatment 6 and De-escalation approaches 3). After the second round, the following 12 were validated: (1) Epidemiology (2 recommendations): think about candidiasis in your Intensive Care Unit (ICU) and do not forget that non-Candida albicans-Candida species also exist. (2) Diagnostic tools (4 recommendations): blood cultures should be performed under suspicion every 2-3 days and, if positive, every 3 days until obtaining the first negative result. Obtain sterile fluid and tissue, if possible (direct examination of the sample is important). Use non-culture based methods as microbiological tools, whenever possible. Determination of antifungal susceptibility is mandatory. (3) Scores (1 recommendation): as screening tool, use the Candida Score and determine multicolonization in high risk patients. (4) Treatment (4 recommendations): start early. Choose echinocandins. Withdraw any central venous catheter. Fundoscopy is needed. (5) De-escalation (1 recommendation): only applied when knowing susceptibility determinations and after 3 days of clinical stability. The higher rate of agreement was achieved in the optimization of microbiological tools and the withdrawal of the catheter, whereas the lower rate corresponded to de-escalation therapy and the use of scores. CONCLUSIONS The management of invasive candidiasis in ICU patients requires the application of a broad range of knowledge and skills that we summarize in our recommendations. These recommendations may help to identify the potential patients, standardize their global management and improve their outcomes, based on the DELPHI methodology.
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Neoh CF, Liew D, Slavin MA, Marriott D, Chen SCA, Morrissey O, Stewart K, Kong DCM. Economic evaluation of micafungin versus caspofungin for the treatment of candidaemia and invasive candidiasis. Intern Med J 2013; 43:668-77. [DOI: 10.1111/imj.12110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 02/20/2013] [Indexed: 11/30/2022]
Affiliation(s)
| | - D. Liew
- Melbourne EpiCentre; Department of Medicine; University of Melbourne, Royal Melbourne Hospital; Australia
| | - M. A Slavin
- Department of Infectious Diseases; Peter MacCallum Cancer Centre; Australia
| | - D. Marriott
- Department of Clinical Microbiology and Infectious Diseases; St Vincent's Hospital; Sydney; Australia
| | - S. C.-A. Chen
- Centre for Infectious Diseases and Microbiology; Westmead Hospital; Sydney; New South Wales; Australia
| | - O. Morrissey
- Infectious Diseases Unit; Department of Medicine; Alfred Health and Monash University; Melbourne; Victoria; Australia
| | - K. Stewart
- Centre for Medicine Use and Safety; Faculty of Pharmacy and Pharmaceutical Sciences; Monash University (Parkville campus); Australia
| | - D. C. M. Kong
- Centre for Medicine Use and Safety; Faculty of Pharmacy and Pharmaceutical Sciences; Monash University (Parkville campus); Australia
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Zaragoza R, Llinares P, Maseda E, Ferrer R, Rodríguez A. Épico Project. Development of educational recommendations using the DELPHI technique on invasive candidiasis in non-neutropenic critically ill adult patients. Rev Iberoam Micol 2013; 30:135-49. [PMID: 23727234 DOI: 10.1016/j.riam.2013.05.006] [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: 04/25/2013] [Accepted: 05/15/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Although there has been an improved management of invasive candidiasis in the last decade, controversial issues still remain, especially in the diagnostic and therapeutic approaches. AIMS We sought to identify the core clinical knowledge and to achieve high level agreement recommendations required to care for critically ill adult patients with invasive candidiasis. METHODS A prospective Spanish survey reaching consensus by the DELPHI technique was made. It was anonymously conducted by electronic mail in a first term to 25 national multidisciplinary experts in invasive fungal infections from five national scientific societies, including intensivists, anesthesiologists, microbiologists, pharmacologists and infectious diseases specialists, who answered to 47 questions prepared by a coordination group after a strict review of the literature in the last five years. The educational objectives spanned five categories, including epidemiology, diagnostic tools, prediction rules, and treatment and de-escalation approaches. The level of agreement achieved among the panel experts in each item should exceed 75% to be selected. In a second term, after extracting recommendations from the selected items, a face to face meeting was performed where more than 80 specialists in a second round were invited to validate the preselected recommendations. RESULTS In the first term, 20 recommendations were preselected (Epidemiology 4, Scores 3, Diagnostic tools 4, Treatment 6 and De-escalation approaches 3). After the second round, the following 12 were validated: (1) Epidemiology (2 recommendations): think about candidiasis in your Intensive Care Unit (ICU) and do not forget that non-Candida albicans-Candida species also exist. (2) Diagnostic tools (4 recommendations): blood cultures should be performed under suspicion every 2-3 days and, if positive, every 3 days until obtaining the first negative result. Obtain sterile fluid and tissue, if possible (direct examination of the sample is important). Use non-culture based methods as microbiological tools, whenever possible. Determination of antifungal susceptibility is mandatory. (3) Scores (1 recommendation): as screening tool, use the Candida Score and determine multicolonization in high risk patients. (4) Treatment (4 recommendations): start early. Choose echinocandins. Withdraw any central venous catheter. Fundoscopy is needed. (5) De-escalation (1 recommendation): only applied when knowing susceptibility determinations and after 3 days of clinical stability. The higher rate of agreement was achieved in the optimization of microbiological tools and the withdrawal of the catheter, whereas the lower rate corresponded to de-escalation therapy and the use of scores. CONCLUSIONS The management of invasive candidiasis in ICU patients requires the application of a broad range of knowledge and skills that we summarize in our recommendations. These recommendations may help to identify the potential patients, standardize their global management and improve their outcomes, based on the DELPHI methodology.
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Affiliation(s)
- Rafael Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain.
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Mikulska M, Del Bono V, Ratto S, Viscoli C. Occurrence, presentation and treatment of candidemia. Expert Rev Clin Immunol 2013; 8:755-65. [PMID: 23167687 DOI: 10.1586/eci.12.52] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Candida is one of the most common causes of nosocomial bloodstream infections. Candidemia is not confined to hematological patients, intensive care units or abdominal surgery wards, but it is remarkably frequent in the internal medicine setting. High mortality associated with candidemia can be reduced by prompt, appropriate antifungal therapy. The epidemiology of species has been shifting toward non-albicans strains. Significant improvements in nonculture-based diagnostic methods, such as serological markers, have been made in recent years, and novel diagnostic techniques should be further studied to enable early pre-emptive therapy. Treatment guidelines indicate that echinocandins are at present the best choice for patients who are severely ill or possibly infected with fluconazole-resistant strains.
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Affiliation(s)
- Małgorzata Mikulska
- Division of Infectious Diseases, Department of Health Science, University of Genoa, Genoa, Italy
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Guo F, Yang Y, Kang Y, Zang B, Cui W, Qin B, Qin Y, Fang Q, Qin T, Jiang D, Li W, Gu Q, Zhao H, Liu D, Guan X, Li J, Ma X, Yu K, Chan D, Yan J, Tang Y, Liu W, Li R, Qiu H. Invasive candidiasis in intensive care units in China: a multicentre prospective observational study. J Antimicrob Chemother 2013; 68:1660-8. [PMID: 23543609 DOI: 10.1093/jac/dkt083] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To describe the epidemiology, microbiology and management of invasive Candida infection (ICI) in intensive care units (ICUs) in China. METHODS A multicentre, prospective, observational study in 67 hospital ICUs across China. Patients were ≥18 years old with clinical signs of infection and at least one of the following diagnostic criteria: (i) histopathological, cytopathological or microscopic confirmation of yeast cells from a normally sterile site; (ii) at least one peripheral blood culture positive for Candida; and (iii) positive Candida culture from a normally sterile site. The China-SCAN study is registered with ClinicalTrials.gov (NCT T01253954). RESULTS ICI incidence was 0.32% (306 patients/96,060 ICU admissions) and median time between ICU admission and diagnosis was 10.0 days. Candida albicans was the most prevalent single isolate (41.8% of patients), although non-albicans species accounted for the majority of infections. Diagnostic confirmation was based solely on at least one positive blood culture in 290 (94.8%) cases. Treatment was initiated after diagnostic confirmation in 166/268 (61.9%) patients. Triazoles (62.7%) and echinocandins (34.2%) were the most commonly used antifungal agents; first-line therapy was typically fluconazole (37.7%). The median duration of antifungal therapy was 14 days. The mortality rate was 36.6% (112/306); the median time between diagnosis and death was 14.5 days. Mortality was higher in older individuals, those with solid tumours, those with recent invasive mechanical ventilation and those with a higher sequential organ failure assessment score at diagnostic confirmation. Susceptibility to first-line antifungals was associated with lower mortality than dose-dependent susceptibility or complete resistance (P=0.008). CONCLUSIONS More infections were caused by non-albicans than Candida albicans strains. The majority of patients were treated only after diagnostic confirmation, rather than empirically. First-line antifungal susceptibility was associated with lower mortality.
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Affiliation(s)
- Fengmei Guo
- Nanjing Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
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