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Pawar RD, Balaji L, Grossestreuer AV, Thompson G, Holmberg MJ, Issa MS, Patel PV, Kronen R, Berg KM, Moskowitz A, Donnino MW. Thiamine Supplementation in Patients With Alcohol Use Disorder Presenting With Acute Critical Illness : A Nationwide Retrospective Observational Study. Ann Intern Med 2022; 175:191-197. [PMID: 34871057 PMCID: PMC9169677 DOI: 10.7326/m21-2103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Thiamine supplementation is recommended for patients with alcohol use disorder (AUD). The authors hypothesize that critically ill patients with AUD are commonly not given thiamine supplementation. OBJECTIVE To describe thiamine supplementation incidence in patients with AUD and various critical illnesses (alcohol withdrawal, septic shock, traumatic brain injury [TBI], and diabetic ketoacidosis [DKA]) in the United States. DESIGN Retrospective observational study. SETTING Cerner Health Facts database. PATIENTS Adult patients with a diagnosis of AUD who were admitted to the intensive care unit with alcohol withdrawal, septic shock, TBI, or DKA between 2010 and 2017. MEASUREMENTS Incidence and predicted probability of thiamine supplementation in alcohol withdrawal and other critical illnesses. RESULTS The study included 14 998 patients with AUD. Mean age was 52.2 years, 77% of participants were male, and in-hospital mortality was 9%. Overall, 7689 patients (51%) received thiamine supplementation. The incidence of thiamine supplementation was 59% for alcohol withdrawal, 26% for septic shock, 41% for TBI, and 24% for DKA. Most of those receiving thiamine (n = 3957 [52%]) received it within 12 hours of presentation in the emergency department. The predominant route of thiamine administration was enteral (n = 3119 [41%]). LIMITATION Specific dosing and duration were not completely captured. CONCLUSION Thiamine supplementation was not provided to almost half of all patients with AUD, raising a quality-of-care issue for this cohort. Supplementation was numerically less frequent in patients with septic shock, DKA, or TBI than in those with alcohol withdrawal. These data will be important for the design of quality improvement studies in critically ill patients with AUD. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Rahul D Pawar
- Division of Hospital Medicine, Department of Medicine, and Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.D.P.)
| | - Lakshman Balaji
- Center for Resuscitation Science and Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (L.B., A.V.G., G.T., P.V.P.)
| | - Anne V Grossestreuer
- Center for Resuscitation Science and Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (L.B., A.V.G., G.T., P.V.P.)
| | - Garrett Thompson
- Center for Resuscitation Science and Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (L.B., A.V.G., G.T., P.V.P.)
| | - Mathias J Holmberg
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, and Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, and Department of Anesthesiology and Intensive Care, Randers Regional Hospital, Randers, Denmark (M.J.H.)
| | - Mahmoud S Issa
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts (M.S.I.)
| | - Parth V Patel
- Center for Resuscitation Science and Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (L.B., A.V.G., G.T., P.V.P.)
| | - Ryan Kronen
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.K.)
| | - Katherine M Berg
- Center for Resuscitation Science and Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (K.M.B.)
| | - Ari Moskowitz
- Center for Resuscitation Science and Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, and Division of Critical Care Medicine, Montefiore Medical Center, Bronx, New York (A.M.)
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, and Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (M.W.D.)
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Kronen R, Ziehr DR, Kane AE, VanderLaan PA, Kholdani CA, Hallowell RW. Pulmonary amyloidosis as the presenting finding in a patient with multiple myeloma. Respir Med Case Rep 2022; 37:101626. [PMID: 35342704 PMCID: PMC8943293 DOI: 10.1016/j.rmcr.2022.101626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/19/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ryan Kronen
- Department of Medicine, University of Washington, Seattle, WA, USA
- Corresponding author. Department of Medicine University of Washington, 1959 NE Pacific Street Seattle, WA, 98195, USA.
| | - David R. Ziehr
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ashley E.D. Kane
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Paul A. VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Cyrus A. Kholdani
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert W. Hallowell
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Foong KS, Sung A, Burnham JP, Kronen R, Lian Q, Salazar Zetina A, Hsueh K, Lin C, Powderly WG, Spec A. Risk factors predicting Candida infective endocarditis in patients with candidemia. Med Mycol 2021; 58:593-599. [PMID: 31613365 DOI: 10.1093/mmy/myz104] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 09/19/2019] [Accepted: 10/01/2019] [Indexed: 12/15/2022] Open
Abstract
Candida infective endocarditis (CIE) is a rare but serious complication of candidemia. Incidence and risk factors associated with CIE among candidemic patients are poorly defined from small cohorts. Identification of clinical predictors associated with this entity may guide more judicious use of cardiac imaging. We conducted a retrospective analysis of all inpatients aged ≥18 years diagnosed with candidemia at our institution. CIE was diagnosed by fulfilling two of the major Duke criteria: specifically a vegetation(s) on echocardiogram and positive blood cultures for Candida spp. We used univariable and multivariable regression analyses to identify risk factors associated with CIE. Of 1,873 patients with candidemia, 47 (2.5%) were identified to have CIE. In our multivariable logistic model, existing valvular heart disease was associated with a higher risk for CIE (adjusted odds ratio [aOR], 7.66; 95% confidence interval [CI], 2.95-19.84). Predictors that demonstrated a decreased risk of CIE included infection with C. glabrata (aOR, 0.17; 95% CI, 0.04-0.69), hematologic malignancy (aOR, 0.09; 95% CI, 0.01-0.68), and receipt of total parenteral nutrition (aOR, 0.38; 95% CI, 0.16-0.91). The 90-day crude mortality for CIE was 48.9%, similar to the overall non-CIE mortality of 41.9% (P = .338). We identified a set of clinical factors that can predict the presence of CIE among patient with candidemia. These findings may reduce the need for unnecessary expensive and invasive imaging studies in a subset of patients with a lower risk profile for endocarditis and alternative infection source.
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Affiliation(s)
- Kap Sum Foong
- Section of Infectious Diseases, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Abby Sung
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ryan Kronen
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Qinghua Lian
- Washington University School of Medicine, St Louis, Missouri, USA
| | - Ana Salazar Zetina
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Kevin Hsueh
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
| | - Charlotte Lin
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - William G Powderly
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
| | - Andrej Spec
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
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Mejia-Chew C, O'Halloran JA, Olsen MA, Stwalley D, Kronen R, Lin C, Salazar AS, Larson L, Hsueh K, Powderly WG, Spec A. Effect of infectious disease consultation on mortality and treatment of patients with candida bloodstream infections: a retrospective, cohort study. Lancet Infect Dis 2019; 19:1336-1344. [PMID: 31562024 DOI: 10.1016/s1473-3099(19)30405-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/30/2019] [Accepted: 06/24/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Candida bloodstream infection is associated with high mortality. Infectious disease consultation improves outcomes in several infections, including Staphylococcus aureus and cryptococcosis, as well as multidrug-resistant organisms. We aimed to examine the association between infectious disease consultation and differences in management with mortality in candida bloodstream infections. METHODS In this retrospective, single-centre cohort study, we reviewed the medical charts of all patients admitted to Barnes-Jewish Hospital (St Louis, MO, USA), a tertiary referral centre, aged 18 years or older with candida bloodstream infection from 2002 to 2015. We collected data for demographics, comorbidities, predisposing factors, all-cause mortality, antifungal use, central-line removal, and ophthalmological and echocardiographic evaluation to assess 90-day all-cause mortality between individuals with and without an infectious disease consultation. For the survival analysis we used Cox proportional hazards model with inverse weighting by propensity score to assess the effects of infectious disease consultation on mortality and differences in management. FINDINGS Between Jan 1, 2002, and Dec 31, 2015, of 1794 patients assessed for eligibility, we analysed 1691 patients with candida bloodstream infection; 776 (45·9%) who had an infectious disease consultation and 915 (54·1%) who did not have an infectious disease consultation. All 1691 patients were included in the analysis. None were missing data. Most underlying comorbidities were evenly distributed between groups. 90-day mortality was lower in the infectious disease consultation group than in patients who did not receive an infectious disease consultation (29% [222/776] vs 51% [468/915]; p<0·0001). In the model with inverse weighting by the propensity score, infectious disease consultation was associated with a hazard ratio of 0·81 (95% CI 0·73-0·91; p<0·0001) for mortality. In the consultation group, median duration of antifungal therapy was longer (18 [IQR 14-35] vs 14 [6-20] days; p<0·0001) and central-line removal (587 [76%] of 776 vs 538 [59%] of 915; p<0·0001), echocardiography use (442 [57%] of 776 vs 305 [33%] of 915; p<0·0001), and ophthalmological examination (412 [53%] of 776 vs 160 [17%] of 915; p<0·0001) were more frequently done. Fewer patients in the infectious disease consultation group were not treated (13 [2%] of 776 vs 128 [14%] of 915; p<0·0001). INTERPRETATION Patients with candida bloodstream infection receiving an infectious disease consultation have lower mortality. This finding might be attributable to these individuals receiving a higher number of non-pharmacological, evidence-based interventions and lower amounts of non-treatment. These data suggest that an infectious disease consultation should be an integral part of clinical care of patients with candida bloodstream infection. FUNDING Astellas Global Development Pharma, Washington University Institute of Clinical and Translational Sciences, and the Agency for Healthcare Research and Quality.
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Affiliation(s)
- Carlos Mejia-Chew
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Jane A O'Halloran
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Margaret A Olsen
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Dustin Stwalley
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Ryan Kronen
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Charlotte Lin
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Ana S Salazar
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Lindsey Larson
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Kevin Hsueh
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - William G Powderly
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Andrej Spec
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA.
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Wang K, Hsueh K, Kronen R, Lin C, Salazar AS, Powderly WG, Spec A. Creation and assessment of a clinical predictive model for candidaemia in patients with candiduria. Mycoses 2019; 62:554-561. [PMID: 31025417 DOI: 10.1111/myc.12917] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/19/2019] [Accepted: 04/20/2019] [Indexed: 12/28/2022]
Abstract
Candidaemia is the most common clinical presentation of invasive candidiasis and is a major cause of morbidity and mortality. Candiduria is a predictor for candidaemia; however, patient characteristics that are associated with concurrent candidaemia in the setting of candiduria are unclear. Identifying these characteristics could aid in the early detection of systemic disease. We performed a retrospective cohort analysis of hospitalised patients with candiduria at our institution over a 13-year period. Our evaluation of patient characteristics included demographics, comorbidities, medications, procedures, devices, vital signs and laboratory values. We developed a multivariable logistic model to identify factors associated with candidaemia in patients with candiduria. We identified 4240 patients with candiduria, 263 (6.2%) of whom had candidaemia. Predictors for increased risk of candidaemia with candiduria included hospitalisations > 12 days, central venous catheter, parenteral nutrition, haematological and gynaecological malignancy, and receipt of β-lactam/β-lactamase inhibitors. Vital signs and laboratory values associated with candidaemia included elevated heart rate, temperature and creatinine, along with neutropenia and neutrophilia. Factors that demonstrated a decreased risk of candidaemia included diabetes mellitus, gastrostomy and urinary catheter with antibiotic use. The c-statistic was 0.741 (95% CI, 0.710-0.772). We identified a set of clinical characteristics that can predict the presence of candidaemia with candiduria.
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Affiliation(s)
- Katie Wang
- Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Kevin Hsueh
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Ryan Kronen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Charlotte Lin
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Ana S Salazar
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - William G Powderly
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
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Aljorayid A, Kronen R, Salazar AS, Hsueh K, Lin C, Powderly W, Spec A. 376. Predictive Model for Fluconazole Resistance in Patient With Candida Bloodstream Infection. Open Forum Infect Dis 2018. [PMCID: PMC6253675 DOI: 10.1093/ofid/ofy210.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Methods Results Conclusion Disclosures
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Affiliation(s)
- Abdullah Aljorayid
- Infectious Disease, Barns Jewish Hospital/Washington University in St.Louis, St. Louis, Missouri
| | - Ryan Kronen
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ana S Salazar
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Kevin Hsueh
- Infectious Disease, Barns Jewish Hospital/Washington University in St.Louis, St. Louis, Missouri
| | - Charlotte Lin
- Internal Medicine, Washington University in St.Louis, St. Louis, Missouri
| | - William Powderly
- Infectious Disease, Barns Jewish Hospital/Washington University in St.Louis, St. Louis, Missouri
| | - Andrej Spec
- Infectious Disease, Barns Jewish Hospital/Washington University in St.Louis, St. Louis, Missouri
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Foong KS, Kronen R, Salazar AS, Hsueh K, Lin C, Powderly W, Spec A. 1030. Risk Predictive Model for Candida Endocarditis in Patients with Candidemia: A 12-year Experience in a Single Tertiary Care Hospital. Open Forum Infect Dis 2018. [PMCID: PMC6253236 DOI: 10.1093/ofid/ofy210.867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Methods Results Conclusion Disclosures
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Affiliation(s)
- Kap Sum Foong
- Infectious Diseases, Washington University in St. Louis, St. Louis, Missouri
| | - Ryan Kronen
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ana S Salazar
- Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - Kevin Hsueh
- Infectious Disease, Barns Jewish Hospital/Washington University in St.Louis, St. Louis, Missouri
| | - Charlotte Lin
- Internal Medicine, Washington University in St.Louis, St. Louis, Missouri
| | - William Powderly
- Infectious Diseases, Barns Jewish Hospital/Washington University in St.Louis, St. Louis, Missouri
| | - Andrej Spec
- Infectious Diseases, Barns Jewish Hospital/Washington University in St.Louis, St. Louis, Missouri
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Kronen R, Hsueh K, Lin C, Powderly WG, Spec A. Creation and Assessment of a Clinical Predictive Calculator and Mortality Associated With Candida krusei Bloodstream Infections. Open Forum Infect Dis 2018; 5:ofx253. [PMID: 29450209 PMCID: PMC5808796 DOI: 10.1093/ofid/ofx253] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 02/05/2018] [Indexed: 11/23/2022] Open
Abstract
Background Candida krusei bloodstream infection (CK BSI) is associated with high mortality, but whether this is due to underlying comorbidities in affected patients or the organism itself is unknown. Identifying patient characteristics that are associated with CK BSI is crucial for clinical decision-making and prognosis. Methods We conducted a retrospective analysis of hospitalized patients with Candida BSI at our institution between 2002 and 2015. Data were collected on demographics, comorbidities, medications, procedures, central lines, vital signs, and laboratory values. Multivariable logistic and Cox regression were used to identify risk factors associated with CK and mortality, respectively. Results We identified 1873 individual patients who developed Candida BSI within the study period, 59 of whom had CK BSI. CK BSI was predicted by hematologic malignancy, gastric malignancy, neutropenia, and the use of prophylactic azole antifungals, monoclonal antibodies, and β-lactam/β-lactamase inhibitor combinations. The C-statistic was 0.86 (95% confidence interval, 0.81–0.91). The crude mortality rates were 64.4% for CK BSI and 41.4% for non-CK BSI. Although CK was associated with higher mortality in univariable Cox regression, this relationship was no longer significant with the addition of the following confounders: lymphoma, neutropenia, glucocorticoid use, chronic liver disease, and elevated creatinine. Conclusions Six patient comorbidities predicted the development of CK BSI with high accuracy. Although patients with CK BSI have higher crude mortality rates than patients with non-CK BSI, this difference is not significant when accounting for other patient characteristics.
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Affiliation(s)
- Ryan Kronen
- Washington University School of Medicine, St Louis, Missouri
| | - Kevin Hsueh
- Division of Infectious Diseases, St Louis, Missouri
| | - Charlotte Lin
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | | | - Andrej Spec
- Division of Infectious Diseases, St Louis, Missouri
- Correspondence: A. Spec, MD, MSCI, Infectious Disease Clinical Research Unit, 4523 Clayton Ave., Campus Box 8051 St Louis, MO, 63110-0193 ()
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Abstract
Background Candida krusei (CK) candidemia is associated with high mortality, but whether this is due to underlying comorbidities in affected patients or the organism itself is unknown. We analyzed factors associated with C. krusei candidemia and its outcomes. Methods A retrospective analysis of hospitalized patients with candidemia was conducted at our institution between 2002 and 2015. Data were collected on demographics, comorbidities, medications, procedures, central lines, vital signs, and labs. Univariable logistic and Cox regression were used to identify potential risk factors associated with CK and mortality, respectively. Multivariable analyses were then constructed parsimoniously from these variables. Results Of 1,873 candidemia events, 59 were due to CK. In multivariable analysis, CK candidemia was predicted by hematologic malignancy (OR 8.9, 95% CI [4.1, 19.7]), stomach cancer (OR 14.6, 95% CI [2.9, 72.5]), absolute neutrophil count (OR 2.4, 95% CI [1.2, 4.8]), and the use of prophylactic azole antifungals (OR 2.2, 95% CI [1.1, 4.3]), monoclonal antibodies (OR 5.7, 95% CI [2.0, 15.8]), and penicillin β-lactamase inhibitors (OR 2.5, 95% CI [1.3, 4.8]). The C-statistic was 0.86 (95% CI [0.81, 0.91]). The crude mortality rates were 86.4% for CK candidemia and 63.6% for non-CK candidemia. Although CK was associated with higher mortality in univariable Cox regression (Figure 1, HR 1.8, 95% CI [1.3, 2.4]), this relationship was no longer significant (HR 1.2, 95% CI [0.8, 1.7]) with the addition of the following confounders: hematologic malignancy (HR 0.9, 95% CI [0.7, 1.1]), absolute neutrophil count (HR 1.7, 95% CI [1.4, 2.2]), stomach cancer (HR 1.0, 95% CI [0.5, 1.9]), coagulopathy (HR 1.0, 95% CI [0.9, 1.2], and prophylactic corticosteroids (HR 1.4, 95% CI [1.2, 1.7] (Figure 2). Conclusion A similar set of patient characteristics is associated with both CK infection and increased mortality, suggesting that patients with CK candidemia are at higher risk of mortality due to underlying illness rather than organism-specific mechanisms. Disclosures W. Powderly, Merck: Grant Investigator and Scientific Advisor, Consulting fee and Research grant Gilead: Scientific Advisor, Consulting fee Astellas: Grant Investigator, Research grant A. Spec, Astellas Pharma US, Inc.: Grant Investigator, Research grant
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Affiliation(s)
- Ryan Kronen
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Charlotte Lin
- Infectious Disease, Washington University School of Medicine, St. Louis, Missouri
| | - Kevin Hsueh
- Infectious Disease, Washington University in St Louis, St Louis, Missouri
| | - William Powderly
- Division of Infectious Disease, Washington University in St. Louis, St. Louis, Missouri
| | - Andrej Spec
- Infectious Disease, Washington University, St. Louis, Missouri
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O’Halloran J, Kronen R, Lin C, Hsueh K, Powderly W, Spec A. Risk Factors Predicting Candida glabrata Bloodstream Infection. Open Forum Infect Dis 2017. [PMCID: PMC5632078 DOI: 10.1093/ofid/ofx163.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Increased incidence of Candida glabrata (CG) infection is a growing concern in recent years due to the higher rates of fluconazole resistance associated with C. glabrata . This study aimed to create a risk predictive model for C. glabrata in patients with culture-positive candidemia. Methods Demographic data, risk factors, laboratory parameters, and outcomes were retrospectively collected on all cases of candidemia occurring at a large tertiary referral hospital between January 2002 and January 2015. Between-group differences were compared using 2 square tests. A risk predictive model was built using multivariate logistic regression. Results Of 1,913 subjects with candidemia, 398 (21%) had C. glabrata isolated. Those with C. glabrata were older (mean [SD] 61 [23] vs. 58 [23] years; P < 0.001) and more often female (231 (58%) vs. 681 (45%); P < 0.001). On univariate analysis, age (OR 1.01 [95% CI 1.01,1.02]), gender (0.6 [0.5, 0.7]), history of rectal cancer (2.00 [1.2, 3.5]), other GI malignancy (3.0 [1.5, 6.2]), breast cancer (1.8 [1.1, 3.0]), enteral and parenteral feeding (1.9 [1.2, 3.2]), bowel resection (3.0 [1.4, 6.2]), temperature (0.9 [0.8, 1.0], recent fluconazole use (2.0 [1.4, 2.9]), and The presence of urinary catheter (2.3 [1.4, 3.6]), central line (1.4 [1.1, 1.7) or ventilator (2.2 [1.3, 3.8]) were all associated with C. glabrata infection (P < 0.05) and included in the multivariate modeling. Age, gender, history of rectal malignancy, other GI malignancies, use of enteral or parenteral feeding and recent fluconazole use remained significant (effect size 1.2 [95% CI 1.1, 1.3]; 1.8 [1.4, 2.3]; 2.0 [1.1, 3.6]; 3.0 [1.3, 6.9]; 1.9 [1.0, 3.3]; 2.0 [1.3, 3.0], respectively). The final model had a c-statistic of 0.66 [95% CI 0.63–0.69]). Ninety-day mortality in the C. glabrata group was not significantly different from the non-C. glabrata group (40% (158/398) vs. 42.5% (644/1515). Conclusion Underlying bowel pathology was more commonly associated with C. glabrata candidemia than with other candida species. Further exploration of the direct association between C. glabrata and GI malignancy and indirect effects of prior surgery or antifungal use on risk of C. glabrata candidemia are required. Interestingly, mortality did not differ between groups with glabrata and non-glabrata candida blood stream infections. This may reflect increasing empiric use of echinocandin therapy. Disclosures A. Spec, Astellas Pharma US, Inc.: Grant Investigator, Research grant
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Affiliation(s)
- Jane O’Halloran
- Infectious Diseases, Washington University in St Louis, Saint Louis, Missouri
| | - Ryan Kronen
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Charlotte Lin
- Infectious Disease, Washington University School of Medicine, St. Louis, Missouri
| | - Kevin Hsueh
- Infectious Disease, Washington University in St louis, St Louis, Missouri
| | - William Powderly
- Division of Infectious Diseases, Washington University, St. Louis, Missouri
| | - Andrej Spec
- Infectious Disease, Washington University, St Louis, Missouri
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Abstract
Background An infectious diseases (ID) consultation is often, but not always, obtained to help guide treatment of patients with candidemia. We examined if ID consultation affected patient outcome in patients with culture positive candidemia. Methods We assembled a retrospective cohort of 1,873 cases of candidemia in patients hospitalized in our academic tertiary care hospital from 2002 to 2015. We collected data on comorbidities, predisposing factors; antifungal therapy, survival and ID consult. Patients who died within 24 hours of diagnosis were excluded, under the presumption that they did not have an opportunity to receive an ID consult. Survival analysis was performed via univariate and multivariate Cox Regression with censoring at 90 days, as subsequent mortality was less likely to be related to candidemia. Results 913 (49%) of the candidemic patients received an ID consult; 960 (51%) did not. Underlying comorbidities were evenly distributed between patients with and without an ID consult, except that patients with an ID consult more frequently had a central line (39% vs. 26%, p < 0.001), were on mechanical ventilation (4% vs. 2%, P = 0.003) or were receiving extracorporeal membrane oxygenation (2.2% vs. 0.5%, p = 0.002). The ID consult group had lower 90-day mortality compared with patients without an ID consult (34% vs. 49%, P < 0.001), with an adjusted hazard ratio of mortality for those patients receiving an ID consult of 0.55 (95% CI: 0.48, 0.64, P < 0.001) (Fig 1). Patient management differed significantly: the ID consult group was more likely to receive an echinocandin (29% vs. 21%, P < 0.001) or amphotericin B (AmB) (3.4% vs. 1.4%, P = 0.006). Conclusion Candidemic patients who received an ID consult were significantly less likely to die, and were more likely to receive therapy with amphotericin or an echinocandin. These data suggest that an ID consult should be an integral part of clinical care of patients with candidemia. Disclosures W. Powderly, Merck: Grant Investigator and Scientific Advisor, Consulting fee and Research grant; Gilead: Scientific Advisor, Consulting fee; Astellas: Grant Investigator, Research grant; A. Spec, Astellas Pharma US, Inc.: Grant Investigator, Research grant
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Affiliation(s)
- Carlos Mejia
- Infectious Disease, Washington University, Saint Louis, Missouri
| | - Ryan Kronen
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Charlotte Lin
- Infectious Disease, Washington University School of Medicine, St. Louis, Missouri
| | - Kevin Hsueh
- Infectious Disease, Washington University in St louis, St Louis, Missouri
| | - William Powderly
- Division of Infectious Disease, Washington University in St. Louis, St. Louis, Missouri
| | - Andrej Spec
- Infectious Disease, Washington University, St Louis, Missouri
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Kronen R, Liang SY, Bochicchio G, Bochicchio K, Powderly WG, Spec A. Invasive Fungal Infections Secondary to Traumatic Injury. Int J Infect Dis 2017; 62:102-111. [PMID: 28705753 DOI: 10.1016/j.ijid.2017.07.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 06/30/2017] [Accepted: 07/05/2017] [Indexed: 12/20/2022] Open
Abstract
Invasive fungal infection (IFI) is a rare but serious complication of traumatic injury. The purpose of this article is to review the epidemiology, natural history, mycology, risk factors, diagnosis, treatment, and outcomes associated with post-traumatic IFI in military and civilian populations. The epidemiology of post-traumatic IFI is poorly characterized, but incidence appears to be rising. Patients often suffer from severe injuries and require extensive medical interventions. Fungi belonging to the order Mucorales are responsible for most post-traumatic IFI in both civilian and military populations. Risk factors differ between these cohorts but include specific injury patterns and comorbidities. Diagnosis of post-traumatic IFI typically follows positive laboratory results in the appropriate clinical context. The gold standard of treatment is surgical debridement in addition to systemic antifungal therapy. Patients with post-traumatic IFI may be at greater risk of amputation, delays in wound healing, hospital complications, and death as compared to trauma patients who do not develop IFI. More research is needed to understand the factors surrounding the development and management of post-traumatic IFI to reduce the significant morbidity and mortality associated with this disease.
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Affiliation(s)
- Ryan Kronen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA.
| | - Stephen Y Liang
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA; Division of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA
| | - Grant Bochicchio
- Section of Acute and Critical Care Surgery, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA
| | - Kelly Bochicchio
- Section of Acute and Critical Care Surgery, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA
| | - William G Powderly
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA.
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