The Diagnostic Value of Procalcitonin Versus Other Biomarkers in Prediction of Bloodstream Infection

BACKGROUND

We compared the diagnostic utility of procalcitonin (PCT), C-reactive protein (CRP), and hematological markers, including white blood cell count (WBC), neutrophils (NEU), percentage of neutrophils (NEU%), lymphocytes (LYM), neutrophil-lymphocyte count ratio (NLCR), and platelet count (PLT) for predicting bloodstream infection (BSI), which was confirmed by blood culture (BC).

METHODS

A retrospective analysis was conducted for 1807 inpatients. The level of PCT, CRP, blood cells, and blood culture results were compared between the positive blood culture group and negative blood culture group; each indicator was analyzed in the performance of bacterial BSI diagnosis by drawing ROC curves.

RESULTS

Blood cultures were positive in 230 patients; hence, the prevalence of bacteremia was 12.7%. There were significant differences in the median value for each marker between positive group BCs and negative group BCs (p < 0.05). The areas under the receiver operating characteristic curves (ROC-AUCs) of PCT, CRP, WBC, NEU, NUE%, LYM, NLCR, and PLT for discriminating positive BCs from negative BCs were 0.811, 0.654, 0.612, 0.634, 0.684, 0.595, 0.682, and 0.633 respectively. PCT concentrations of gram-negative (14.94 ng/mL, IQR 2.93  48.76) were significantly higher than gram-positive (4.74 ng/mL, IQR 1.22  17.5) and fungal (1.47 ng/mL, IQR 0.66  35.34).

CONCLUSIONS

PCT proved to be the most reliable predictor of BSI, second were NEU% and NLCR. A higher PCT level was found in patients with a gram-negative BSI compared to gram-positive BSI and fungal BSI.

Microbiological Diagnosis of Sepsis: Polymerase Chain Reaction System Versus Blood Cultures

OBJECTIVE

To compare the utility of a multiplex polymerase chain reaction system (SeptiFast) and blood cultures for detecting bacteria and fungi in blood samples from patients with severe sepsis or septic shock.

METHODS

In a prospective observational study, whole blood samples for SeptiFast testing and for culture were collected on admission from all patients with severe sepsis or septic shock admitted to the intensive care unit between July 2011 and September 2012. SeptiFast results were compared with blood and other culture results.

RESULTS

The probability of at least 1 microorganism being isolated at 6 hours was 13-fold higher with the SeptiFast test than with blood cultures (relative risk, 13.5; 95% CI, 5.05-36.06). Unlike culture results, SeptiFast test results were not associated with previous antibiotic consumption. The median time to the first positive blood culture result was 17 hours; SeptiFast results were available in 6 hours. SeptiFast detected genetic material from potentially multiresistant microorganisms in patients whose blood cultures showed no growth at all.

CONCLUSIONS

The SeptiFast test provided quicker microbiological diagnosis and identified significantly more microorganisms than blood cultures did, particularly when samples were collected after antibiotic therapy had started or infections were due to resistant bacteria and yeast.

[Molecular markers: an important tool in the diagnosis, treatment and epidemiology of invasive aspergillosis]

Increase in the incidence of invasive aspergillosis has represented a difficult problem for management of patients with this infection due to its high rate of mortality, limited knowledge concerning its diagnosis, and therapeutic practice. The difficulty in management of patients with aspergillosis initiates with detection of the fungus in the specimens of immunosuppressed patients infected with Aspergillus fumigatus; in addition, difficulty exists in terms of the development of resistance to antifungals as a consequence of their indiscriminate use in prophylactic and therapeutic practice and to ignorance concerning the epidemiological data of aspergillosis. With the aim of resolving these problems, molecular markers is employed at present with specific and accurate results. However, in Mexico, the use of molecular markers has not yet been implemented in the routine of intrahospital laboratories; despite the fact that these molecular markers has been widely referred in the literature, it is necessary for it to validated and standardized to ensure that the results obtained in any laboratory would be reliable and comparable. In the present review, we present an update on the usefulness of molecular markers in accurate identification of A. fumigatus, detection of resistance to antifugal triazoles, and epidemiological studies for establishing the necessary measures for prevention and control of aspergillosis.

Subacute fungal endocarditis due to Acremonium spp: a case study and review of the literature

A 52 years old patient is hospitalized in June 2007 in the Cardiology Clinic of Cardiovascular Diseases Medical Institute in Iasi with suspected subacute infectious endocarditis. Echocardiography shows mobile vegetation on the pulmonary valve. Acremonium spp is isolated from blood cultures after 2 weeks of incubation. The patient was treated with fluconazole, but died after 3 months due to renal failure.

Early ultrasonographic finding of septic thrombophlebitis is the main indicator of central venous catheter removal to reduce infection-related mortality in neutropenic patients with bloodstream infection

BACKGROUND

Septic thrombophlebitis increases patient morbidity and mortality following metastatic infections, pulmonary emboli, and/or septic shock. Central venous catheter (CVC) removal for occult septic thrombophlebitis challenges current strategy in neutropenic patients.

PATIENTS AND METHODS

We prospectively evaluated infection-related mortality in 100 acute leukemia patients, with CVC-related bloodstream infection (CRBSI) after chemotherapy, who systematically underwent ultrasonography to identify the need for catheter removal. Their infection-related mortality was compared with that of a historical cohort of 100 acute leukemia patients, with CRBSI after chemotherapy, managed with a clinically driven strategy. Appropriate antimicrobial therapy was administered in all patients analyzed.

RESULTS

In the prospective series, 30/100 patients required catheter removal for ultrasonography-detected septic thrombophlebitis after 1 median day from BSI onset; 70/100 patients without septic thrombophlebitis retained their CVC. In the historical cohort, 60/100 patients removed the catheter (persistent fever, 40 patients; persistent BSI, 10 patients; or clinically manifest septic thrombophlebitis, 10 patients) after 8 median days from BSI onset; 40/100 patients retained the CVC because they had not clinical findings of complicated infection. At 30 days median follow-up, one patient died for infection in the ultrasonography-assisted group versus 17 patients in the historical cohort (P<0.01). With the ultrasonography-driven strategy, early septic thrombophlebitis detection and prompt CVC removal decrease infection-related mortality, whereas clinically driven strategy leads to inappropriate number, reasons, and timeliness of CVC removal.

CONCLUSION

Ultrasonography is an easy imaging diagnostic tool enabling effective and safe management of patients with acute leukemia and CRBSI.

Early diagnostic value of plasma PCT and BG assay for CRBSI after OLT

AIM

The aim was to evaluate the role of procalcitonin (PCT) and (1-3)-β-D-glucan (BG) tests for early detection or exclusion of central venous catheter-related bloodstream infections (CRBSI) in patients after orthotopic liver transplantation (OLT).

METHODS

Fifty-five patients with clinically suspected CRBSI were assessed after OLT in this prospective study. On the day of clinical suspicion of CRBSI, blood samples were obtained from central venous catheters and a peripheral vein for blood cultures and from a peripheral vein for PCT and BG tests. Plasma PCT and BG values were measured by using an immunoluminometric assay and Fungitell BG assay, respectively. No prisoners or organs from prisoners were used in this study.

RESULTS

Twenty-five patients (45%) were diagnosed with CRBIS. Among them, 13 (52%) displayed gram-positive bacteriemia, 11 (44%) gram-negative bacteriemia, and 1 (4%) fungemia. The PCT values were higher in CRBSI than in non-CRBSI patients (P = .003). CRBSI patients did not show significant increases in plasma BG values compared with non-CRBSI subjects (P = .051). PCT and BG area under receiver operating characteristic curves were 0.840 and 0.486, respectively. Sensitivity, specificity, and positive and negative predictive values of a PCT of ≥ 3.1 ng/mL for the diagnosis of CRBSI were 0.72, 0.87, 0.82, and 0.79, respectively. The figures for a BG of ≥ 83 pg/mL were 0.32, 0.90, 0.73, and 0.61, respectively. Among the 24 patients with bacteria infections, PCT was higher in patients with gram-negative than those with gram-positive bacterial infections (P = .022).

CONCLUSION

We concluded that the PCT assay may be a useful rapid diagnostic adjunct for the diagnosis of suspected CRBSI in OLT patients.

Comparative evaluation of (1, 3)-beta-D-glucan, mannan and anti-mannan antibodies, and Candida species-specific snPCR in patients with candidemia

BACKGROUND

Candidemia is a major infectious complication of seriously immunocompromised patients. In the absence of specific signs and symptoms, there is a need to evolve an appropriate diagnostic approach. A number of methods based on the detection of Candida mannan, nucleic acid and (1,3)-beta- D- glucan (BDG) have been used with varying specificities and sensitivities. In this retrospective study, attention has been focused to evaluate the usefulness of two or more disease markers in the diagnosis of candidemia.

METHODS

Diagnostic usefulness of Platelia Candida Ag for the detection of mannan, Platelia Candida Ab for the detection of anti-mannan antibodies, Fungitell for the detection of BDG, and of a semi-nested PCR (snPCR) for the detection Candida species-specific DNA have been retrospectively evaluated using 32 sera from 27 patients with culture-proven candidemia, 51 sera from 39 patients with clinically suspected candidemia, sera of 10 women with C. albicans vaginitis, and sera of 16 healthy controls.

RESULTS

Using cut-off values recommended by the manufacturers, the sensitivity of the assays for candidemia patients were as follows: Candida snPCR 88%, BDG 47%, mannan 41%, anti-mannan antibodies 47%, respectively. snPCR detected 5 patients who had candidemia due to more than one Candida species. The sensitivities of the combined tests were as follows: Candida mannan and anti-mannan antibodies 75%, and Candida mannan and BDG 56%. Addition of snPCR data improved the sensitivity further to 88%, thus adding 10 sera that were negative by BDG and/or mannan. In clinically suspected, blood culture negative patients; the positivities of the tests were as follows: Candida DNA was positive in 53%, BDG in 29%, mannan in 16%, and anti-mannan antibodies in 29%. The combined detection of mannan and BDG, and mannan, BDG and Candida DNA enhanced the positivity to 36% and 54%, respectively. None of the sera from Candida vaginitis patients and healthy subjects were positive for Candida DNA and mannan.

CONCLUSION

The observations made in this study reinforce the diagnostic value of snPCR in the sensitive and specific diagnosis of candidemia and detection of more than one Candida species in a given patient. Additionally, in the absence of a positive blood culture, snPCR detected Candida DNA in sera of more than half of the clinically suspected patients. While detection of BDG, mannan and anti-mannan antibodies singly or in combination could help enhancing sensitivity and eliminating false positive tests, a more extensive evaluation of these assays in sequentially collected serum samples is required to assess their value in the early diagnosis of candidemia.

Avances y limitaciones del diagnóstico precoz de las infecciones invasoras causadas por levaduras

In the last years, the main advances in the serological diagnosis of mycoses caused by yeasts have occurred in the area of antibody and (1-3)-beta-D-glucan detection. Commercialization of the Candida albicans IFA IgG test and detection of antibodies against recombinant antigens Hwp1 and enolase are the most important contributions to the first area. Detection of (1-3)-beta-D-glucan confirms its usefulness as a good marker for the diagnosis of invasive candidiasis. The most recent studies suggest that combination of two tests to detect antígen, antibodies, (1-3)-beta-D-glucan and DNA will be needed to optimize the diagnosis of systemic yeast infections.

False positive galactomannan results in adult hematological patients treated with piperacillin-tazobactam

In this prospective study including 78 adult patients with haematological malignancy (90 episodes) we performed galactomannan (GM) (Platelia Aspergillus) screening twice weekly for the diagnosis of invasive aspergillosis. There were five proven and four probable invasive aspergillosis cases. The sensitivity, specificity and positive and negative predictive values were 100, 88, 47 and 100%, respectively. There were eight patients with false positive GM (10.2%). In six patients the false GM reactivity was due to the administration of piperacillin-tazobactam (P-T). A significant association was found between false positive GM (= or > 0.5) and the administration of P-T (p < 0.01). Two other patients with no invasive aspergillosis (2.5%) and false GM reactivity had graft versus host disease (GVHD) and one of them had also mucositis grade IV. The kinetic patterns of false positive GM due to P-T is discussed.

Real-time PCR assay to detect DNA in sera for the diagnosis of deep-seated trichosporonosis

Deep-seated trichosporonosis due to Trichosporon asahii is life-threatening and has high mortality. A real-time PCR assay to detect T. asahii DNA in sera for diagnosis of this fungal infection was developed. The assay showed a higher sensitivity than polysaccharide antigen detection method. Our new real-time PCR assay may be used for diagnosing deep-seated trichosporonosis due to T. asahii.

Endocarditis por Aspergillus fumigatus en válvula nativa con hemocultivo positivo y galactomanano negativo. Descripción de un caso y revisión de la literatura

Native valve endocarditis caused by Aspergillus spp. is an uncommon disease with a high mortality rate. Generally, Aspergillus is isolated from affected valve in post-mortem or biopsy specimens. However, its isolation from blood cultures is exceedingly rare. We report a case of fungal endocarditis in a native mitral valve with the isolation of Aspergillus fumigatus both in valve vegetation and in blood culture bottles. The patient underwent valve replacement and antifungal treatment with voriconazole and caspofungin, but he died on post-operative day 45 with disseminated aspergillosis confirmed by necropsy. Paradoxically, galactomannan antigen detection in serum was negative. This is the third case of Aspergillus endocarditis with positive blood culture reported in the literature.

[Candidemia original diagnosis]

We reported here a case of fungemia, which was diagnosed by a globular numeration: peripheral blood smears showed yeast cells, especially in the cytoplasm of neutrophils, with characteristic images of fungal phagocytosis. This test induced a prompt diagnosis of fungal septicaemia and the prescription of adapted treatment, which probably permitted to rescue the patient from a high mortality pathology.

Serum and intraperitoneal levels of amphotericin B and flucytosine during intravenous treatment of critically ill patients with Candida peritonitis

OBJECTIVES

To study the relation between serum and peritoneal levels of amphotericin B and flucytosine during intravenous treatment in patients with abdominal sepsis due to a perforated gut.

PATIENTS AND METHODS

Included were consecutive patients with abdominal sepsis due to a perforated gut, who were treated intravenously with amphotericin B and/or flucytosine after surgery if an abdominal drain was present. Amphotericin B and flucytosine were measured from simultaneously collected serum and abdominal fluid samples.

RESULTS

Twenty-one consecutive patients were included. Five repeated samples were taken from three patients. The time interval between the start of the medication and the first sampling was median 4.0 days (range 2-7 days). The correlation coefficient (r(2)) between serum and peritoneal levels of amphotericin B was 0.79. In nine patients (43%) with a maximum serum level of 0.28 mg/L, amphotericin B in the peritoneal fluid was undetectable. The lowest serum level that was present with a detectable peritoneal level was 0.16 mg/L. A short duration of treatment (2 days) was associated with low serum and undetectable peritoneal levels. In seven patients, flucytosine levels were measured. Peritoneal flucytosine levels did not differ significantly from serum levels. Serum and peritoneal flucytosine levels correlated well with r(2)=0.88. Peritoneal amphotericin B level was inversely correlated with C-reactive protein level on the same day (r(2)=0.30).

CONCLUSIONS

It is shown, during continuous infusion, that peritoneal levels of amphotericin B are lower than serum levels. The amphotericin B serum levels should exceed 0.5 mg/L to obtain peritoneal levels above MIC values. Flucytosine levels in the abdominal fluid are comparable to serum levels and within MIC ranges.

[Bloodstream Candida infections]

Nosocomial Candida infection is an everincreasing cause of morbidity, mortality and prolonged hospitalization of the patients in intensive care units. The increase of the candidiasis cases is due to growing population of immunocompromised patients and the use of new, aggressive, and invasive therapeutic strategies. Some manifestations of Candida albicans infections are associated with formation of biofilms on the surface of biomaterials. The incidence, epidemiology, clinical characteristics and treatment of Candida bloodstream infections are surveyed.

Unexplained increase in Paecilomyces variotii blood culture isolates in the UK

Since July 2006, a marked increase has been seen in the number of Paecilomyces variotii isolates identified by hospital laboratories across the UK.

[Cryptococcus neoformans in the gastric contents of an AIDS patient]

The microscopic observation and isolation of Cryptococcus neoformans from the gastric contents of an AIDS patient, obtained by aspiration with a nasogastric catheter and parasitologically studied, is communicated. Because of the limited number of round yeasts visualized by wet mount of the sample concentrate, India ink was added: the typical capsules of C. neoformans were then observed. Dark brown colonies of C. neoformans were isolated from the clinical sample cultured on sunflower-seed-extract agar, incubated at 37 degrees C for 7 days. Bloodcultures for fungi were negative; it was impossible to obtain CSF due to the patient's refusal, then the capsular polysaccharide antigen of C. neoformans in blood was determined and proved positive to the 1:100 dilution. The patient, who had supposedly been suffering from Cryptosporidium sp. diarrhea, after the finding of C. neoformans in the gastric sample and the positive result of the antigenemia for this fungus, was treated with oral fluconazol, (800 mg/day), because he did not accept intravenous treatment. This communication emphasizes the finding of C. neoformans in a clinical sample where its presence is infrequent and its usefulness for the diagnosis of cryptococcosis is significant.

Measurement of serum D-arabinitol/creatinine ratios for initial diagnosis and for predicting outcome in an unselected, population-based sample of patients with Candida fungemia

D-Arabinitol (DA) is a useful diagnostic marker for candidiasis in patients with neutropenia and other high-risk groups, but its use in unselected patients with a broad range of underlying diseases and conditions has not been studied. We used an automated enzymatic fluorometric assay to measure serum DA/creatinine ratios (DA/cr's) in 30 healthy adults, 100 hospitalized controls without Candida fungemia, and 83 patients from a study of all Candida fungemias in Connecticut between October 1998 and September 1999. Sixty-three of 83 (76%) fungemic patients and 11 of 100 (11%) nonfungemic controls had serum DA/cr's >or=3.9 microM/mg/dl (mean + 3 standard deviations for 30 healthy adults). High serum DA/cr's were less frequent in patients with cancer or fungemia caused by the DA nonproducer Candida glabrata than in patients with cancer or fungemia caused by a DA producer, C. albicans, C. tropicalis, or C. parapsilosis. The serum DA/cr was first >or=3.9 microM/mg/dl before, on the same day as, or after the first positive blood culture was drawn for 30 (36%), 22 (27%), and 11 (13%) fungemia patients, respectively. Mortality did not differ significantly among the patients with high or normal initial or peak serum DA/cr's, but mortality was higher if any serum DA/cr value was >or=3.9 microM/mg/dl 3 or more days after the onset of fungemia (18/27 versus 4/24 patients, respectively; P < 0.001). We conclude that serum DA/cr's are useful both for the initial diagnosis of Candida fungemia and for prognostic purposes for unselected patients with a broad range of underlying diseases and conditions.

Epidemiological study of Candida infections in blood: susceptibilities of Candida spp. to antifungal agents, and clinical features associated with the candidemia

The purpose of this study was to evaluate the susceptibility to antifungal agents of Candida spp. isolated from blood samples from patients in our hospital, located in Osaka, Japan. We also examined the clinical background of these patients. We analyzed fungi isolated from clinical blood samples obtained in our hospital over a period of 10 years (1993 to 2002). Antifungal susceptibility testing was carried out for six agents, using the National Committee of Clinical Laboratory Standards (NCCLS) M-27-A2 method. The clinical backgrounds were reviewed using the medical records of 125 patients who were diagnosed as having candidemia. The major fungi isolated were Candida parapsilosis (39.2%) and C. albicans (30.1%), and both were sensitive to fluconazole. One strain of C. glabrata and six strains of C. krusei were resistant to fluconazole, and they constituted 4.4% of all Candida spp. isolated. With the exception of C. parapsilosis, most fungi were susceptible to micafungin, although there is no universally agreed breakpoint for this drug. Analysis of the patients' clinical backgrounds revealed that the major underlying disease was cancer (46.4% excluding hematological malignancies). C. krusei was detected almost exclusively in patients with hematological malignancies. Indwelling venous catheters had been responsible for infection in 93.6% of the infected patients. The clinical outcomes of the 125 patients were favorable in 52% and poor in 48%, and subsequent removal of the indwelling catheters was effective in about half of the patients in whom this was done, with good prognosis. To prevent mycosis and its complications, indwelling catheters should be avoided as much as possible. Attention must be paid to the possibility that resistant isolates of Candida spp. can be selected as a result of the use of antifungal agents.

Systemic and cerebrospinal fluid T-helper cytokine responses in organ transplant recipients with Cryptococcus neoformans infection

BACKGROUND

The role of Th1 and Th2 mediated cytokine responses in the pathogenesis of Cryptococcus neoformans infection in organ transplant recipients has not been defined.

METHODS

We assessed cytokine levels in the sera and CSF collected prospectively at the time of diagnosis of infection in 25 transplant recipients with cryptococcosis. Serum levels were compared with those in healthy individuals and transplant recipients without cryptococcosis. IFN-gamma or IL-12 (Th1)/IL-10 (Th2) ratio < 1.0 was considered a dominant Th2 response.

RESULTS

Cases had lower ratios of IFN-gamma/IL-10 (p = 0.03) and IL-12/IL-10 (p = 0.03) compared to healthy individuals. Cytokine responses, however, did not differ significantly for cases vs. transplant controls. Cases with fungemia compared to those without fungemia tended to have higher serum IL-10 levels (p = 0.07) and lower IL-12/IL-10 ratios (p = 0.06). CSF ratios of IFN-gamma/IL-10 (p = 0.04) and IL-12/IL-10 (p = 0.04) were lower in cases with cryptococcal meningitis compared to those without meningitis; 80% (8/10) of the cases with cryptococcal meningitis vs. 0% (4/4) of those without meningitis had CSF IFN-gamma/IL-10 ratio of < 1.0 (p = 0.015). The levels of IL-10 (p = 0.04) and IFN-gamma (p = 0.04) in the CSF in cases with cryptococcal meningitis were significantly higher than those in their serum, respectively.

CONCLUSIONS

High expression of Th2 phenotype in cryptococcal meningitis and in fungemia suggests that Th dysregulation may contribute to the pathogenesis of cryptococcosis in organ transplant recipients.

A study of the role of multiple site blood cultures in the evaluation of neonatal sepsis

BACKGROUND

The optimal number of blood cultures needed to document sepsis in an ill neonate has undergone little critical evaluation. Multiple site cultures may improve pathogen detection if intermittent bacteremia occurs, or if a low density of bacteria is present in the blood. We hypothesized, however, that bacterial clearance is slower and bacteremia more continuous in septic neonates, so that a single site blood culture should be sufficient to accurately document true septicemia.

OBJECTIVE

To determine the need for multiple site blood cultures in the evaluation of neonates for sepsis.

DESIGN/METHODS

Clinical data were prospectively collected for 216 neonates who had 269 pairs of blood cultures taken from two different peripheral sites for the evaluation of possible sepsis. A minimum of 1 ml of blood was obtained from the two peripheral sites within 15-30 min of each other. Based on prior retrospective data, we determined that 203 infants would need to have two site blood cultures to demonstrate a significant improvement in pathogen detection at an alpha of 0.05 and a beta of 0.20 (80%) power.

RESULTS

A total of 186 culture pairs were taken for evaluation of early-onset sepsis in 186 neonates, while 83 pairs were drawn for evaluation of late-onset sepsis in 43 neonates. In all, 21 neonates from the late-onset group were evaluated more than once, and 12 neonates were evaluated for both early- and late-onset sepsis. In all, 20 (9.2%) of 216 neonates had 22 episodes of culture-proven sepsis at a median age of 18 days. All neonates with positive cultures had the same organism with a similar sensitivity pattern obtained from the two different peripheral sites. The other 196 study neonates had negative blood cultures from both sites. The single episode of early-onset sepsis was caused by Listeria monocytogenes, while all remaining episodes were late-onset with the following organisms: Staphylococcus epidermidis (7), methicillin-resistant Staphylococcus aureus (MRSA) (3), combined MRSA and Candida albicans (2), Candida albicans alone (2), late-onset Group B beta-hemolytic Streptococcus (GBS) (2), Klebsiella pneumoniae (2), Enterococcus fecalis (1), Escherichia coli (1), and Serratia marcescens (1). Since no infant grew organisms from only one of the two sites, the data indicate that the diagnosis of sepsis would have been made correctly in all infants with a single site culture.

CONCLUSIONS

Two site blood cultures for the initial evaluation of neonatal sepsis do not have a better yield in pathogen detection. Sepsis in neonates can be detected with no loss of accuracy with a single site blood culture with blood volume of>or=1 ml.

Delaying the empiric treatment of candida bloodstream infection until positive blood culture results are obtained: a potential risk factor for hospital mortality

Fungal bloodstream infections are associated with significant patient mortality and health care costs. Nevertheless, the relationship between a delay of the initial empiric antifungal treatment until blood culture results are known and the clinical outcome is not well established. A retrospective cohort analysis with automated patient medical records and the pharmacy database at Barnes-Jewish Hospital was conducted. One hundred fifty-seven patients with a Candida bloodstream infection were identified over a 4-year period (January 2001 through December 2004). Fifty (31.8%) patients died during hospitalization. One hundred thirty-four patients had empiric antifungal treatment begun after the results of fungal cultures were known. From the time that the first blood sample for culture that was positive was drawn, 9 (5.7%) patients received antifungal treatment within 12 h, 10 (6.4%) patients received antifungal treatment between 12 and 24 h, 86 (54.8%) patients received antifungal treatment between 24 and 48 h, and 52 (33.1%) patients received antifungal treatment after 48 h. Multiple logistic regression analysis identified Acute Physiology and Chronic Health Evaluation II scores (one-point increments) (adjusted odds ratio [AOR], 1.24; 95% confidence interval [CI], 1.18 to 1.31; P < 0.001), prior antibiotic treatment (AOR, 4.05; 95% CI, 2.14 to 7.65; P = 0.028), and administration of antifungal treatment 12 h after having the first positive blood sample for culture (AOR, 2.09; 95% CI, 1.53 to 2.84; P = 0.018) as independent determinants of hospital mortality. Administration of empiric antifungal treatment 12 h after a positive blood sample for culture is drawn is common among patients with Candida bloodstream infections and is associated with greater hospital mortality. Delayed treatment of Candida bloodstream infections could be minimized by the development of more rapid diagnostic techniques for the identification of Candida bloodstream infections. Alternatively, increased use of empiric antifungal treatment in selected patients at high risk for fungal bloodstream infection could also reduce delays in treatment.

[Direct fluorescent and indirect immunofluorescent assay in buffy coat for candidemia diagnosis in pediatric patients: a comparative study]

The diagnosis of candidemia by blood culture has poor sensitivity; therefore, immunossupresed patients and those with risk factors may receive empirical antifungal therapy, wich is potentially toxic. Fluorescent tests have been developed to obtain an early and more sensitive diagnosis than blood culture. The aim of this study was to compare indirect immunofluorescence vs direct calcofluor white fluorescence in buffy coat for candidemia diagnosis. Sensitivity, specificity, predictive values, of positive and negative samples were 60%, 86%, 33%, 95% and 90%, 80%, 35%, 99%, for indirect immunofluorescence and calcofluor white, respectively.

Candida parapsilosis bloodstream infection in pediatric oncology patients: results of an epidemiologic investigation

OBJECTIVE

To investigate an outbreak of Candida parapsilosis bloodstream infections (BSIs) involving three patients admitted to a pediatric oncology unit between April and June 2002.

METHODS

After the third case was documented, cultures were performed of the hands of all medical and paramedical staff members in the pediatric oncology unit and of environmental surfaces in the rooms occupied by the three patients. Electrophoretic karyotyping with pulsed-field gel electrophoresis and arbitrarily primed polymerase chain reaction were used to assess the genetic relatedness among C. parapsilosis isolates.

RESULTS

The three cases of C. parapsilosis BSI were diagnosed based on blood cultures performed during a 38-day period. Evidence of prior C parapsilosis colonization of the gastrointestinal tract was present in only the first case. Each patient had an indwelling central venous catheter (CVC), which was promptly removed, and semiquantitative catheter tip cultures also revealed C. parapsilosis. None of the 30 environmental cultures performed was positive for C. parapsilosis, but the fungus was isolated from the hands of 6 of the 20 nurses tested. Both molecular typing methods revealed identical DNA fingerprinting patterns for all 13 patient isolates (7 from blood, 3 from CVC tips, and 3 from the gastrointestinal tract) and for 5 of the 6 recovered from the nurses' hands.

CONCLUSIONS

These findings suggest the possibility of cross-infection with a single C. parapsilosis strain that was transmitted (probably during CVC dressing changes) by nurses whose hands were colonized with it. The role of previous gastrointestinal colonization in the first case cannot be excluded.

Beta-D-glucan as a diagnostic adjunct for invasive fungal infections: validation, cutoff development, and performance in patients with acute myelogenous leukemia and myelodysplastic syndrome

The Glucatell (1-->3)- beta-D-glucan (BG) detection assay (Associates of Cape Cod) was studied as a diagnostic adjunct for invasive fungal infections (IFIs). On the basis of findings from a preliminary study of 30 candidemic subjects and 30 healthy adults, a serum BG level of >or=60 pg/mL was chosen as the cutoff. Testing was performed with serial serum samples obtained from 283 subjects with acute myeloid leukemia or myelodysplastic syndrome who were receiving antifungal prophylaxis. At least 1 serum sample was positive for BG at a median of 10 days before the clinical diagnosis in 100% of subjects with a proven or probable IFI. IFIs included candidiasis, fusariosis, trichosporonosis, and aspergillosis. Absence of a positive BG finding had a 100% negative predictive value, and the specificity of the test was 90% for a single positive test result and >or=96% for >or=2 sequential positive results. The Glucatell serum BG detection assay is highly sensitive and specific as a diagnostic adjunct for IFI.

The prognostic virtue of inflammatory markers during late-onset sepsis in preterm infants

AIM

Late-onset sepsis (occurring after the first three days of life) is a serious complication in preterm infants. In order to assess the possible prognostic virtues of the acute phase inflammatory response in the disease, we compared the inflammatory response of preterm infants who died within 72 hours (h) (fulminant sepsis) to infants who recovered from the disease (non-fulminant sepsis).

METHODS

Of 42 preterm infants that were evaluated: 10 had fulminant sepsis and 32 non-fulminant sepsis. Acute phase inflammatory response markers-C-reactive protein (CRP), serum amyloid A (SAA), interleukin (IL)-6 levels and white blood cell (WBC) counts were measured at the first suspicion of LOS and after 8, 24 and 48 h.

RESULTS

Small for gestational age (SGA) infants who were treated with fewer days of antibiotics characterized the fulminant sepsis group. The initial high levels of inflammatory markers were similar in both groups, but as early as 8 h after onset significantly lower levels of SAA, CRP and WBC counts were documented in the fulminant sepsis group. The inflammatory response remained low at 24 and 48 h in the fulminant sepsis group, while in the survivors, significantly increased inflammatory markers were measured. Decreases in the levels of the inflammatory markers preceded episodes of metabolic acidosis and arterial hypotension that were more common in the fulminant sepsis group. Infant mortality correlated inversely with SAA levels at 8 h and with CRP and WBC counts at 24 h after onset.

CONCLUSION

SAA, CRP and WBC counts can be used as prognostic markers in LOS in preterm infants, with SAA being the earliest prognostic marker.

Procalcitonin serum levels in perinatal bacterial and fungal infection of preterm infants

AIM

To determine reference values for procalcitonin (PCT) and C-reactive protein (CRP) for gestational age and to use these parameters as diagnostic markers of perinatal bacterial and fungal infection.

METHODS

PCT and CRP serum levels were measured in a case-control study in a group of 35 low birthweight infants (< 34 wk of gestation). 27 babies (77%) had clinical signs of infection confirmed by positive blood cultures and were compared to 8 (23%) uninfected matched patients. Seventeen (63%) of them had bacterial infection and 10 (37%) had fungal infection (Candida). Serum PCT (Brahms Diagnostika) and CRP (Immunoassay Vitros 950) were measured serially at 3, 7 and 10d of life.

RESULTS

At any time, PCT and CRP levels were significantly higher in neonates with perinatal infection (p < 0.05) (> 0.7 ng ml(-1) and > 1 mg dl(-1) respectively). PCT showed a more rapid response to infection (9.3 +/- 1.5 ng ml(-1)). especially to bacterial infection (10.8 +/- 1.4 ng ml(-1)), than CRP (1.5 +/- 0.5 mg dl(-1)) (sensitivity 99% vs 88%). Lower sensitivity was noted for both parameters. PCT and CRP, to follow babies with fungal infection (6.7 +/- 0.8 ng ml(-1) and 0.9 +/- 0.7 mg dl(-1), respectively) (sensitivity 77% vs 58%).

CONCLUSION

This study gives PCT reference values in preterm babies with perinatal infection. In these babies, PCT seems to be more sensitive than CRP as a diagnostic marker of infection. Both parameters can be used alone or in combination for a better identification and follow-up of bacterial and fungal infection during the perinatal period.

[An unusual type of the chromatography profile of blood serum carbohydrates in the diagnosis of deep mycosis by gas and liquid chromatography]

The paper contains a description of a diagnosis method (now under elaboration) applicable to human mycosis, which is based on a high-sensitivity gas-liquid chromatography. According to the study results, despite its promising nature, the method in question is not accurate enough in terms of a precise diagnosis of invasive candidosis in oncology patients. The authors point out that the chromatography-diagnosis results need now a histological confirmation.

Rapid Identification of Yeasts Commonly Found in Positive Blood Cultures by Amplification of the Internal Transcribed Spacer Regions 1 and 2

A multiplex PCR method using one universal and eight species-specific primers was developed to rapidly identify eight yeast species found in positive blood cultures. The species-specific primers were designed from the internal transcribed spacer regions 1 and 2 of the rRNA gene, whereas the universal primer was located at the 26S rRNA gene. The eight species were Candida albicans, Candida glabrata, Candida guilliermondii, Candida krusei, Candida lusitaniae, Candida parapsilosis, Candida tropicalis, and Cryptococcus neoformans. The PCR products (116 to 630 bp) were different in length and could be effectively separated and recognized by polyacrylamide gel electrophoresis. By testing 234 positive blood cultures (237 isolates), 234 (98.7%) isolates of the above eight species were correctly identified by the multiplex PCR. The present method is simple to perform and can be completed within 6 h.

The European Confederation of Medical Mycology (ECMM) survey of candidaemia in Italy: antifungal susceptibility patterns of 261 non-albicans Candida isolates from blood

OBJECTIVES

To analyse the in vitro antifungal susceptibility of 261 non-albicans Candida bloodstream strains isolated during the European Confederation of Medical Mycology survey of candidaemia performed in Lombardia, Italy (September 1997-December 1999).

METHODS

In vitro susceptibility to flucytosine, fluconazole, itraconazole, posaconazole and voriconazole was determined using the broth microdilution method described in the NCCLS M27-A guidelines. Etest strips were used to assess susceptibility to amphotericin B. In vitro findings were correlated with the patient's underlying condition and previous antifungal treatment.

RESULTS

MICs (mg/L) at which 90% of the strains were inhibited were, respectively, 2 for flucytosine, 8 for fluconazole, 0.5 for itraconazole, 0.25 for voriconazole and 0.25 for posaconazole. Amphotericin B MIC endpoints were <0.50 mg/L in all the isolates tested. Flucytosine resistance was detected in 19 isolates (7%), mainly among Candida tropicalis strains (30%). Innate or secondary fluconazole resistance was detected in 13 strains (5%). Among the 13 patients with fluconazole-resistant Candida bloodstream infection, three were HIV positive, including one treated with fluconazole for oral candidosis; the four who were HIV negative had received the azole during the 2 weeks preceding the candidaemia. Cross-resistance among fluconazole and other azoles was a rare event.

CONCLUSIONS

Resistance is still uncommon in non-albicans Candida species recovered from blood cultures. However, in fungaemias caused by C. tropicalis, Candida glabrata and Candida krusei, there is a high prevalence of resistance to fluconazole and flucytosine. Fluconazole resistance should be suspected in patients treated previously with azoles, mainly those with advanced HIV infection.

[Laboratory diagnosis of invasive aspergillosis]

Invasive aspergillosis is major cause of morbility and mortality in immunosuppressed patients, in part due to the inability to identify infected patients at an early stage of the disease. Diagnosis is based on a combination of imaging (high-resolution computed tomography) and a number of laboratory techniques including direct examination, culture and circulating markers (galactomannan and Aspergillus DNA) which can be detected at early stages of the infection.

[Invasive aspergillosis]

Invasive aspergillosis is one of the most frequent fungal infections in neutropenic patients, in whom it is associated with a high mortality. Its diagnosis is difficult by the traditionally used laboratory tests. In the last years, an ELISA (Platelia Aspergillus, Bio-Rad, France) to detect galactomannan in neutropenic and cancer patients with high risk of suffering invasive aspergillosis has been developed. The experience accumulated in Spain in the diagnosis of invasive aspergillosis by Platelia Aspergillus is presented in this monograph.

[Early diagnosis of invasive aspergillosis in neutropenic patients with bi-weekly serial screening of circulating galactomannan by Platelia Aspergillus]

The diagnosis of invasive aspergillosis in neutropenic individuals is difficult and lengthy since non-invasive diagnostic tests lack sensitivity and specificity. The diagnosis of invasive aspergillosis in 154 prolonged neutropenic patients was prospectively bi-weekly validated by screening circulating galactomannan. The global sensitivity was 73% and specificity was 96%. The positive and negative predictive values were 73% and 98% respectively. False positive reactions occurred at a rate of 2%. Antigenemia was detected before clinical suspicion of invasive aspergillosis (median, 6 days before) in 30% of patients and anticipated the onset of radiologic signs 9 days in 60% of patients.

CONCLUSION

the prospective screening of galactomannan is a sensitive and non-invasive tool for early diagnosis of invasive aspergillosis in high-risk adult hematology patients.

[Aspergillus galactomannan detection in allogenic hematopoietic cell transplantation]

Invasive aspergillosis has become the leading cause of death after allogeneic hematopoietic stem cell transplantation. This is partially due to the lack of a prompt diagnosis. Recently the detection of Aspergillus galactomannan antigen by means an ELISA technique in serum has been described. The objective of this study was to validate its usefulness in the allogeneic hematopoietic stem cell transplantation setting.

Empirical therapy for neonatal candidemia in very low birth weight infants

OBJECTIVE

Neonatal candidemia is often fatal. Empirical antifungal therapy is associated with improved survival in neonates and patients with fever and neutropenia. Although guidelines for empirical therapy exist for patients with fever and neutropenia, these do not exist for neonates.

METHODS

A multicenter, retrospective, cohort study was conducted of neonatal intensive care unit patients (N = 6172) who had a blood culture (N = 21,233) after day of life 3 and whose birth weight was <or=1250 g. We performed multivariable conditional logistic regression of risk factors for candidemia. From the regression modeling coefficients, we developed a candidemia score.

RESULTS

In multivariable modeling, thrombocytopenia (odds ratio [OR]: 3.56; 95% confidence interval [CI]: 2.68-4.74) and cephalosporin or carbapenem use in the 7 days before obtaining the blood culture (OR: 1.77; 95% CI: 1.33-2.29) were risk factors for subsequent candidemia. Children who were 25 to 27 weeks' estimated gestational age (OR: 2.02; 95% CI: 1.52-3.05) and children who were born at <25 weeks (OR: 4.15; 95% CI: 3.12-6.29) were at higher risk of developing candidemia than were children who were born at >or=28 weeks. We developed a candidemia score on the basis of the ORs from the multivariable model. Children with a candidemia score >or=2 points were classified as having a "positive" score, and a score of >or=2 points had a sensitivity of 85% and a specificity of 47%.

CONCLUSIONS

We developed a clinical predictive model for neonatal candidemia with high sensitivity and moderate specificity for candidemia. On the basis of our model, when a physician obtains a blood culture, the physician should consider providing antifungal therapy to neonates who are <25 weeks' estimated gestational age and to neonates who have thrombocytopenia at the time of blood culture. In addition, if a physician obtains a blood culture from a child who is 25 to 27 weeks' estimated gestational age and is not thrombocytopenic but has a history of third-generation cephalosporin or carbapenem exposure in the 7 days before the blood culture, then the physician should consider administration of empirical antifungal therapy.

Trends in frequency and in vitro susceptibilities to antifungal agents, including voriconazole and anidulafungin, of Candida bloodstream isolates. Results from a six-year study (1996-2001)

The frequency of isolation and antifungal susceptibility patterns to established and two new antifungal agents were determined for 218 Candida spp isolates causing bloodstream infection from 1996 to 2001. Overall, 41.7% of the candidemias were due to C. albicans, followed by C. parapsilosis (22%), C. tropicalis (16.1%), C. glabrata (11.9%), C. krusei (6%) and miscellaneous Candida spp (2.3%). Isolates of C. albicans C. parapsilosis and C. tropicalis (80% of isolates) were highly susceptible to fluconazole (94 to 100% at </= 8 microg/ml) and voriconazole (97 to 100% at </= 1 microg/ml). By comparison with the newer agents itraconazole was less active (77 to 97% at </=0.12 microg/ml). Only 77% and 15% of C. glabrata isolates were inhibited by fluconazole at </= 8 microg/ml and itraconazole at </=0.12 microg/ml, respectively. Voriconazole showed a remarkable in vitro potency against C. glabrata as well as C. krusei isolates (100% at </= 1 microg/ml). Anidulafungin was very active against Candida spp isolates (MIC90: </= 0.5 microg/ml), except C. parapsilosis (MIC90: 4 microg/ml) and two C. guilliermondii isolates (MIC: >/= 32 microg/ml).

Circulating inflammatory mediators predict shock and mortality in febrile patients with microbial infection

The host response to microbial infection is associated with the release of inflammatory mediators. We hypothesized that the type and degree of the systemic response as reflected by levels of circulating mediators predict morbidity and mortality, according to the invasiveness of microbial infection. We prospectively studied 133 medical patients with fever and culture-proven microbial infection. For 3 days after inclusion, the circulating levels of activated complement C3a, interleukin (IL)-6, and secretory phospholipase A(2) (sPLA(2)) were determined daily. Based on results of microbiological studies performed for up to 7 days, patients were classified as having local infections (Group 1, n = 80 positive local cultures or specific stains for fungal or tuberculous infections) or bacteremia (Group 2, n = 52 plus 1 patient with malaria parasitemia). Outcome was assessed as the development of septic shock and as mortality up to 28 days after inclusion. Fifteen patients (11%) developed septic shock and overall mortality was 18% (n = 24). Bacteremia was associated with shock and shock predisposed to death. Circulating mediator levels were generally higher in Group 2 than in Group 1. Circulating levels of IL-6 and sPLA(2) were higher in patients developing septic shock and in nonsurvivors, particularly in Group 1. High C3a was particularly associated with nonsurvival in Group 2. In Group 1, the area under the curve (AUC) of the receiver operating characteristic (ROC) curve for the peak sPLA(2) for shock development was 0.79 (P < 0.05). The AUC of the ROC curve of the peak IL-6 and sPLA(2) for mortality was 0.69 and 0.68 (P < 0.05), respectively. In Group 2, the AUC of the ROC for peak C3a predicting mortality was 0.73 (P < 0.05). In conclusion, in medical patients with fever and microbial infection, the systemic inflammatory host response predicts shock and death, at an early stage, dependent on the invasiveness of microbial infection. The results suggest a differential pathogenetic role of complement activation on the one hand and release of cytokine and lipid mediators on the other in bacteremic and local microbial infections, respectively. They may partly explain the failure of strategies blocking proinflammatory cytokines or sPLA(2) in human sepsis and may extend the basis for attempts to inhibit complement activation at an early stage in patients at risk of dying from invasive microbial infections.

[Bacterial and fungal bloodstream infections in patients at the University Hospital of Cracow]

In presented material evaluation of changes in sepsis and types of bloodstream infections of hospitalized patients in Wards of the University Hospital in Cracow were examined. Results of 9,138 blood cultures studied in years 1989-1999 were analysed. All of the blood samples were recovered from 4,656 infected adults at Clinics of the University Hospital in Cracow. Microbiological blood examinations were held in system of constant monitoring of isolated cultures applying BacT/Alert--colorimetric system (Organon Teknika). Cultured micro--organisms were identified using commercial biochemical tests (bio-Merieux). During period of research changes of profile of isolated microorganisms was observed. Percentage of blood infections of Enterococcus spp. etiology increased from 2.2% in 1989 to 9.8% in 1997-98 (p = 0.014). Dynamic growth of non-fermentative S. maltophilia bacilli to 5.5% (p = 0.036) and Serratia marcescens to 13.8% (p = 0.042) in 1999 was revealed. Designed according to our research review of fungal flora in years 1989-1999 revealed tendency of systematic growth of invasive candidemia frequency, from 1.1% to 10.4%. Diagnostic and therapeutic profile of Departments was in a strict connection with increase of the number and meaning of the politiological bacteremias (p = 0.036) in total number of systemic infections cases.

[Yeast-like fungi as etiologic agents of blood infections in patients hospitalized in 1998-1999]

The aim of the study was the analysis of frequency of yeast-like fungi as etiological agents of fungemias in patients hospitalized in operative and conservative wards of Medical Academy Central Clinical Hospital in Warsaw in 1998-1999. Peripheral blood samples and collected from vascular catheters were incubated in BacT/Alert system(Organon Teknika, USA). Positive blood samples were inoculated on Sabouraud medium with chloramphenicol (bioMerieux, France) (the time of cultivation from 48 h to 7 days at 30 C) and on chromogenic medium BBL CHROMagar Candida (Becton Dickinson, USA). Fungal strains were identified by standard mycological procedures using ID 32 C strips (ATB system, bioMerieux, France) and tests of Sanofi Diagnostics Pasteur (France). The total number of positive blood cultures was 1724. Fifty eight fungal strains were isolated from blood samples (3.36%). Strains belonged to 4 genera: Candida (55), Trichosporon (1), Saccharomyces (1) and Pichia (1). Thirty eight fungal strains were isolated from peripheral blood samples. Forty seven fungal strains were cultured from patients hospitalized in operative wards. Among fungi isolated from peripheral blood samples C. albicans (10), C. glabrata (9) and C. parapsilosis (5) strains dominated. From blood samples collected from vascular catheters most often C. albicans (7), C. glabrata (4) and C. parapsilosis (3) were isolated.

Candidemia in French hospitals: incidence rates and characteristics

OBJECTIVE

To determine the incidence of candidemia in French hospitals.

MATERIALS AND METHODS

A representative sample of 25 French hospitals [nine teaching hospitals (TH), ten general hospitals (GH) and six cancer referral centers (CRC)] was randomly selected. The incidence rates of candidemia per number of admissions and per patient-days of hospitalization were determined and extrapolated to the national level.

RESULTS

From January 1, 1995 to December 31, 1995, the overall incidence rate per 1000 admissions was 0.29, ranging from 0.71/1000 in CRC, to 0.17/1000 in GH. The overall incidence for 1000 patient-days was 0.035 and the highest incidence was also observed in CRC (0.116/1000), followed by TH (0.052/1000). Candida albicans (53%) was the most common species isolated, a central venous catheter (26%) was the most common portal of entry and 50% of the candidaemic patients had a neoplasm.

CONCLUSION

This study should enable us to optimize surveillance, prevention and treatment of these potentially life-threatening infections.

Nosocomial fungemia due to Trichosporon asteroides: firstly described bloodstream infection

Trichosporon spp. are oppurtunistic yeasts that cause deep-seated, mucosa-associated, and superficial infections in immunocompromised patients. It is well known that Trichosporon asteroides is mainly responsible of superficial infections and does not cause systemic infections in humans so far. In this study, we present the first case of disseminated infection due to Trichosporon asteroides in an intensive care patient. Yeast colonies were isolated from the specimens of blood, urine, aspiration fluid of the endotracheal tube and catheter tip swabs of the patient. Conventional mycological studies were not adequate for the identification of the isolate to the species level. The genetic identification of the yeast isolate was performed and the DNA sequence of the isolate exactly matched the corresponding sequence of the Trichosporon asteroides rRNA gene from the GenBank DNA database (accession numbers: AB018017, AF075513). Therefore, our isolate was identified as Trichosporon asteroides as a causative agent of deep-seated fungemia.

Laboratory diagnosis of bacteremia and fungemia

Many of the variables that affect the laboratory diagnosis of bacteremia and fungemia have been addressed in this article. Whereas the scientific basis and principles for blood cultures are well-established, and the methodology has improved, the diagnosis of bacteremia and fungemia still depends greatly on the care that is taken in obtaining the specimens of blood and the skill of the clinician in interpreting positive results.

Galactomannan enzyme immunoassay for monitoring systemic infection with Aspergillus fumigatus in mice

Intravenous (i.v.) infection of immunocompetent mice with Aspergillus fumigatus was used to investigate the ability of a commercial galactomannan enzyme-linked immunosorbent assay (ELISA) to monitor the course of organ infection after dissemination. The test detected 100% of the fungemias which occurred for up to 5 days after infection. When blood-cultures became negative but there was a high load of fungi in the parenchymal organs and a positive culture from the brain, the ELISA was again positive in all animals. However, when blood cultures as well as brain cultures were negative and lower amounts of fungi demarcated by immune cells were present in the liver and kidneys which was the case between day 5 and 30 of infection, the test was negative in most of the animals. Therefore, the test was excellent for detection of early i.v. infection with Aspergillus fumigatus but not suited for detection of limited organ infection in immunocompetent mice.

Fungemia in HIV-infected patients: a 12-year study in a tertiary care hospital

Opportunistic infections caused by fungi are common in human immunodeficiency virus (HIV)-infected patients. We focused on severe infections as indicated by detectable fungemia. Medical charts available for patients having positive blood cultures with fungi at the University of Geneva Hospital were retrospectively (1989 to 2000) reviewed. Of 328 patients with fungemia during the study period, 315 (96%) medical charts were accessible. Of these 315 patients, 37 (12.2%) were HIV-positive, and 13 (35.1%) died within 6 months from their episode of fungemia. This was a lower mortality rate than for the HIV seronegative patients (45.8%). The median and average age of the 34 HIV-positive patients was 37.2 years, and 24 (64.9%) were males. Cryptococcus neoformans (n = 14) and Candida albicans (n = 12) were the most frequently identified species, followed by Candida glabrata (n = 3), of which 3 were mixed C. albicans + C. glabrata, Histoplasma capsulatum (n = 2), and Penicillium marneffei (n = 2). The frequency decreased significantly (p < 0.007) from the time period 1993 to 1996 (n = 21) to the period 1997 to 2000 (n = 6). Fungemias in HIV-infected patients have declined significantly since 1996. This coincides with the introduction of highly active antiretroviral therapy (HAART).

Risk factors for candidal bloodstream infections in surgical intensive care unit patients: the NEMIS prospective multicenter study. The National Epidemiology of Mycosis Survey

To assess risk factors for development of candidal blood stream infections (CBSIs), a prospective cohort study was performed at 6 sites that involved all patients admitted to the surgical intensive care unit (SICU) for >48 h over a 2-year period. Among 4276 such patients, 42 CBSIs occurred (9.82 CBSIs per 1000 admissions). The overall incidence was 0.98 CBSIs per 1000 patient days and 1.42 per 1000 SICU days with a central venous catheter in place. In multivariate analysis, factors independently associated with increased risk of CBSI included prior surgery (relative risk [RR], 7.3), acute renal failure (RR, 4.2), receipt of parenteral nutrition (RR, 3.6), and, for patients who had undergone surgery, presence of a triple lumen catheter (RR, 5.4). Receipt of an antifungal agent was associated with decreased risk (RR, 0.3). Prospective clinical studies are needed to identify which antifungal agents are most protective and which high-risk patients will benefit from antifungal prophylaxis.

Ophthalmologic, visceral, and cardiac involvement in neonates with candidemia

A retrospective review of 86 neonates with candidemia hospitalized from January 1989 through June 1999 was conducted to determine the frequency of ophthalmologic, visceral, or cardiac involvement. Retinal abnormalities were observed in 4 (6%) of the 67 infants in whom indirect ophthalmoscopy examination was performed. Abdominal ultrasound abnormalities were detected in 5 (7.7%) of 65 infants. Echocardiogram revealed thrombi or vegetations in 11 (15.2%) of 72 infants. Age at onset, presence of central venous catheters, and species of Candida were not predictors for involvement at these sites. Infants with candidemia that lasted > or =5 days were more likely to demonstrate ophthalmologic, renal, or cardiac abnormalities than those with a shorter duration. Infants with involvement of these organs received larger cumulative doses of amphotericin B than those without detectable abnormalities. Because complication of disseminated candidiasis by eye, renal, or cardiac involvement has therapeutic implications, and because risk factors for candidemia inadequately predict these complications, evaluations are indicated for all neonates with candidemia.

Candida parapsilosis fungemia in cancer patients--incidence, risk factors and outcome

The paper presents an analysis of fungemia cases which were caused by C. parapsilosis in a cancer center within 10 years, with the aim to compare risk factors and the outcome with fungemias caused by C. albicans and other non-albicans Candida spp. fungemias. Before 1990 (1988-1989) in our institutes C. parapsilosis fungemias were not observed at all. During 1990-1997, the proportion of C. parapsilosis among fungemias increased, in 1990-1993 from 0% to 7.1% in 1996-1997 to 14.2-15%. It represents 25% out of non-albicans Candida spp. fungemias and 7.9% out of all fungemias and is the third commonest pathogen after C. albicans (50.5%) and C. krusei (9.9%). Two from eight (25%) C. parapsilosis fungemias were breakthroughs, one appeared during prophylaxis with ketoconazol and one with fluconazol. Considering the proportion of C. parapsilosis among blood cultures, 13 of 170 blood cultures contained C. parapsilosis (6.6% among all yeasts from blood cultures). C. parapsilosis was the second commonest fungal organism isolated from blood cultures (after C. albicans) in our cancer center. Infected vascular catheters were surprisingly not the major risk factor: central venous catheters were documented as a source in two cases only. The commonest risk factors were similar to those occurring with other fungemias--such as preceding antimicrobial therapy (62.5%), neutropenia (50%) and prior prophylaxis with azoles.

Resistance pattern of 2816 isolates isolated from 17631 blood cultures and etiology of bacteremia and fungemia in a single cancer institution

The resistance pattern of 2816 isolates from 17631 blood cultures and the etiology of isolates causing bacteremia and fungemia among 14591 admissions were investigated in an 80-bed single cancer institute during seven years (1990-1996) under the same empiric therapeutic antibiotic policy but with different prophylactic strategies. No change was found in the proportion of Gram-positive versus Gram-negative bacteria isolated from bacteremias (70% vs. 30%) during the past seven years. Furthermore, the proportion of coagulase-negative staphylococci and enterococci was about the same before and after the introduction of ofloxacin in prophylaxis. However, the proportion of Pseudomonas aeruginosa and Stenotrophomonas maltophilia causing bacteremia increased. There was no increase in Candida krusei and Candida glabrata after the introduction of fluconazole into our prophylactic regimen in 1992. Penicillin-resistance in viridans streptococci increased after penicillin was introduced into prophylaxis in acute leukemia in 1993. Until 1995 no quinolone-resistant Enterobacteriaceae were observed. Susceptibility to quinolones did not significantly change within the past seven years in Enterobacteriaceae after their introduction to prophylaxis in 1991, but Pseudomonas aeruginosa decreased from 90 to 58.2%. Glycopeptide resistance in enterococci and staphylococci was minimal in the observed period (0.9-4.3%).