[Incidence of Candidaemia Following Abdominal Surgery in German Hospitals]. / Inzidenz der Candidämie nach gastrointestinal-chirurgischen Eingriffen in deutschen Akutkrankenhäusern.

BACKGROUND: Invasive Candida infections following abdominal surgery represent a significant medical problem. This study initiates a benchmarking project to pinpoint the current role and epidemiology of candidemia in this patient group in German hospitals. MATERIAL AND METHODS: During the year 2010 data derived from 47 704 abdominal surgery cases in hospitals from Germany were analysed in order to determine benchmarking incidences for candidemia. RESULTS AND CONCLUSION: In 20.3 % of all recognised bloodstream infections Candida spp. were identified as the responsible organisms. If related to all abdominal surgery cases analysed in this study, a candidemia-benchmarking incidence of 0.15 % (95 % CI: 0.10-0.21 %) was determined. In patients who required intensive care after surgery the incidence of candidemia was found to be 0.89 % (95 % CI: 0.57-1.38 %). The incidence increased to 3.13 % (95 % CI: 2.09-4.66 %) in patients who received blood culture diagnosis. The German National Reference Centre of Systemic Mycosis provides hospital specific data for participants of this study to enable benchmarking and infection control (www.nrz-mykosen.de/gastrointestinalchirurgie).

Mucocutaneous candidiasis in a mandrill (Mandrillus sphinx).

An adult male mandrill (Mandrillus sphinx) suffered from chronic ulceration of the facial and gluteal skin and the oral and nasal mucosa. The ulcers were resistant to therapy and led to deterioration in the general condition of the animal. Microscopical examination revealed a severe, chronic, multifocal, granulomatous and eosinophilic dermatitis and panniculitis. There was also stomatitis and rhinitis with numerous intralesional fungal elements. These organisms were identified by immunohistochemistry, transmission electron microscopy, polymerase chain reaction and fungal culture as Candida albicans. Species identification was confirmed by MALDI-TOF mass spectrometry. A specific predisposing immunosuppressive factor for the deep chronic mucocutaneous candidiasis was not identified; however, social stress and/or a primary defect in cell-mediated immunity could not be excluded as possible causes for a predisposing immunodeficiency in the animal.

Improved clinical laboratory identification of human pathogenic yeasts by matrix-assisted laser desorption ionization time-of-flight mass spectrometry.

The key to therapeutic success with yeast infections is an early onset of antifungal treatment with an appropriate drug regimen. To do this, yeast species identification is necessary, but conventional biochemical and morphological approaches are time-consuming. The recent arrival of biophysical methods, such as matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS), in routine diagnostic laboratories holds the promise of significantly speeding up this process. In this study, two commercially available MALDI-TOF MS species identification systems were evaluated for application in clinical diagnostics, using a geographically diverse collection of 1192 clinical yeast and yeast-like isolates. The results were compared with those of the classical differentiation scheme based on microscopic and biochemical characteristics. For 95.1% of the isolates, all three procedures consistently gave the correct species identification, but the rate of misclassification was greatly reduced in both MALDI-TOF MS systems. Furthermore, several closely related species (e.g. Candida orthopsilosis/metapsilosis/parapsilosis or Candida glabrata/bracarensis) could be resolved by both MALDI-TOF MS systems, but not by the biochemical approach. A significant advantage of MALDI-TOF MS over biochemistry in the recognition of isolates novel to the system was observed. Although both MALDI-TOF MS systems employed different approaches in the database structure and showed different susceptibilities to errors in database entries, these were negligible in terms of clinical usefulness. The time-saving benefit of MALDI-TOF MS over biochemical identification will substantially improve fungal diagnostics and patient treatment.

Mid-cycle serum levels of endogenous LH are not associated with the likelihood of pregnancy in artificial frozen-thawed embryo transfer cycles without pituitary suppression.

BACKGROUND: The aim of the present study was to evaluate the association between clinical pregnancy and serum luteinizing hormone (LH) levels, assessed after 14 days of endometrial preparation with estradiol (E(2)) in the absence of pituitary suppression during a frozen-thawed embryo transfer (FRET) cycle. METHODS: A total of 513 patients undergoing their first FRET cycle (01/99 to 11/05) participated in this prospective study. Endometrium preparation for FRET was started on cycle day 1 and continued for a fixed period of 14 days with trans-dermal E(2) patches. On day 14, serum LH, progesterone and E(2) levels were assessed. On day 15, progesterone supplementation was initiated and patients underwent embryo transfer on day 17 or day 18. The association between clinical pregnancy and LH levels was evaluated in groups of patients defined according to Tukey's Hinges percentile analysis of LH levels on day 14. In addition, robust logistic regression was performed with the dependent variable clinical pregnancy and independent variables LH, progesterone, embryos score, cycle rank and gravidity. RESULTS: Age, BMI, parity, cycle rank, embryo number, embryo score, endometrial diameter, E(2) and progesterone were not significantly different in cycles with low (0.1-8.1 IU/l; n = 132), intermediate (8.2-19.4 IU/l; n = 238) and high (20.0-78.0 IU/l; n = 143) levels of LH, respectively. Clinical pregnancy rates were not significantly different in cycles with low [12.1%, 95% confidence intervel (CI) 7.6-18.8], intermediate (13.4%, 9.7-18.4) and high levels of LH (16.1%, 11.0-23.0). Robust logistic regression analysis indicated that embryo score [Odds ratios (OR) 1.04, 95% CI 1.02-1.06, P < 0.01] was statistically significantly associated with the likelihood of clinical pregnancy achievement, but not day 14 levels of LH or progesterone, gravidity or cycle rank. CONCLUSIONS: The likelihood of clinical pregnancy is not associated with serum LH levels on day 14 of an artificial FRET cycle. Hormonal monitoring of LH levels does not yield useful information with regard to cycle management and patient prognosis, and should therefore not be conducted.

Use of recombinant mitogillin for improved serodiagnosis of Aspergillus fumigatus-associated diseases.

During human infection, Aspergillus fumigatus secretes a 18-kDa protein that can be detected as an immunodominant antigen in the urine of infected patients. Recently, this protein was shown to be mitogillin, a ribotoxin that cleaves a single phosphodiester bond of the 29S rRNA of eukaryotic ribosomes. We proved the immunogenic capacity of mitogillin in a rabbit animal model, indicating its usefulness as an antigen for serological diagnosis of invasive aspergillosis. The mitogillin gene from A. fumigatus was transferred from plasmid pMIT+ to expression vector pQE30 and expressed in Escherichia coli as a fusion protein. Purified recombinant mitogillin was recognized by serum immunoglobulin G (IgG) of polyclonal rabbit sera that were obtained by immunization with purified native mitogillin. Consequently, we developed an enzyme-linked immunosorbent assay for detection of IgG, IgM, and IgA antibodies to recombinant mitogillin. In serum samples of patients suffering from aspergilloma (AO; n = 32), invasive pulmonary aspergillosis (IPA; n = 42), or invasive disseminated aspergillosis (IDA; n = 40), a good correlation of production of IgG antibody against mitogillin and clinical disease was observed (for patients with AO, 100% [32 of 32] were positive; for patients with IPA, 64% [31 of 42] were positive; for patients with IDA, 60% [24 of 40] were positive). In contrast, positive titers for serum IgG and IgM antibodies against mitogillin were found in only 1.3% of the serum samples of healthy volunteers and positive titers for IgA antibody were found in only 1.0% of the serum samples of healthy volunteers (n = 307; specificity = 95.4%). These results indicate that recombinant mitogillin expressed in E. coli can be used for improvement of the serodiagnosis of A. fumigatus-associated diseases.

Synergism of voriconazole and terbinafine against Candida albicans isolates from human immunodeficiency virus-infected patients with oropharyngeal candidiasis.

The synergism of voriconazole (VRC) and terbinafine was studied by using 39 genotypically defined clinical Candida albicans isolates that were cross-resistant to fluconazole and VRC and serial isolates that gradually developed azole resistance. Synergy was noticed in 100% (eight of eight) of the strains that were resistant to VRC. Antagonism was not observed.

Evaluation of the intestinal microflora in the rat model for esophageal adenocarcinoma.

Surgically induced duodenal reflux results in cancer development in the rat esophagus. One proposed mechanism of carcinogenesis relies on the production of carcinogens in the presence of bacterial overgrowth. Against this background, intestinal microflora in the rat jejunum was analyzed before and after reflux-inducing surgery. Total gastrectomy and esophagojejunostomy were performed on Sprague-Dawley rats to produce esophageal reflux of duodenal juice (n = 12). Three days before surgery they were randomized into three groups: animals which received tap water; animals which received acidified water at pH 1.8; and animals subjected to oral decontamination with triple antibiotics. During surgery and at autopsy after 2 weeks, intestinal juice was aspirated and analyzed immediately for bacterial content. The physiologic microflora of the rat jejunum contained Lactobacillus spp. and Bacteroides spp., both of which were resistant to the antibiotic regimen. Bacterial overgrowth with fecal bacteria was found following surgery. Acidified water did not alter the intestinal microflora. Triple antibiotics eliminated Escherichia coli and Proteus spp. and reduced the concentration of Enterococcus spp. Bacterial overgrowth by bacteria of the fecal flora occurs in the rat model of esophageal adenocarcinoma with the potential to catalyze the production of carcinogens.

Limited effect of refined carbohydrate dietary supplementation on colonization of the gastrointestinal tract of healthy subjects by Candida albicans.

BACKGROUND: Infections due to Candida albicans occur readily in situations in which ample glucose is available. In mice, dietary refined carbohydrate supplementation leads to higher rates of Candida growth in the gastrointestinal tract and favors mucosal invasion. OBJECTIVE: The modulating properties of dietary carbohydrate supplementation on colonization of the human gastrointestinal tract by C. albicans were evaluated. DESIGN: A 2-step study was conducted in 28 healthy volunteers. First, we determined the subjects' habitual uptake of refined carbohydrates and correlated these data with the C. albicans blastoconidia concentration in the mouth washes and feces of subjects with no intervention. Second, we compared C. albicans counts in the specimens before, during, and after a high-sugar diet. RESULTS: No correlation between C. albicans counts in the specimens and the habitual uptake of refined carbohydrates was observed. A high-sugar diet did not increase the frequency of C. albicans-positive samples, the number of subjects positive for C. albicans in the mouth washes, or the concentration of candidal blastoconidia in the samples of the 28 subjects. However, in selected subjects with elevated counts of oral C. albicans, we observed an increase in fecal C. albicans counts in response to the diet. CONCLUSIONS: The effect of adding a high amount of refined carbohydrates to the diet of healthy human subjects has a limited influence on Candida colonization. Follow-up studies should define whether selected patient groups might benefit from dietary restriction of refined carbohydrates.

Usefulness of PCR for diagnosis of Pneumocystis carinii pneumonia in different patient groups.

Pneumocystis carinii pneumonia (PCP) is one of the most predominant opportunistic infectious diseases in patients with AIDS. Nested PCR has been described as a sensitive and specific tool for detecting P. carinii DNA in clinical specimens. Little is known about the correlation of positive PCR results and clinical evidence of PCP in patients with different forms of immunosuppression. One hundred and thirty-six sputum samples, 26 tracheal-bronchial aspirate samples, 35 bronchoalveolar lavage samples, and 11 lung biopsy samples from (i) human immunodeficiency virus (HIV)-infected patients with AIDS, (ii) immunocompromised patients with leukemia or lymphoma, and (iii) immunocompetent control patients were investigated by a nested PCR amplifying DNA from the mitochondrial large subunit of P. carinii. All patients suffered from acute episodes of respiratory disease. The resulting data were correlated with clinical evidence of PCP. A high degree of association of positive P. carinii PCR results and clinical evidence of PCP in HIV-infected patients with AIDS was found. When calculated for bronchoalveolar lavage and lung biopsy samples, the positive and the negative predictive values of P. carinii PCR for PCP diagnosis in HIV-infected patients with AIDS were 1 and the specificity and the sensitivity were 100%. In contrast, in the group of patients with leukemia or lymphoma, the positive predictive value of the nested PCR for these materials was found to be as low as 0.09, the negative predictive value was 0.73, the specificity was 44.4%, and the sensitivity was 25.0%. No P. carinii DNA could be detected in specimens from immunocompetent patients. In summary, in contrast to patients with leukemia and lymphoma, nested PCR seems to be a sensitive and specific tool for PCP diagnosis in HIV-infected patients with AIDS.

Phylogeny and dating of some pathogenic keratinophilic fungi using small subunit ribosomal RNA.

The phylogenetic relationship of representative members of the genera Trichophyton, Microsporum and Epidermophyton was studied. 844 base pairs were compared after sequencing the nuclear 18S ribosomal RNA gene spanning the most variable area within the central 600 bases of this gene. The dermatophytes, which are monophyletic in origin, could be classified most effectively when placed as a subgroup in the Onygenales, Ascomycotina. The calculated radiation time was about 50 million years ago. The early cenozoic adaptive explosion of mammals, which can serve as a host for the keratinophilic fungi, provides corroboration for proximate co-evolution.

[Detection by molecular biology techniques of diphtheria toxin production in corynebacteria]. / Molekularbiologischer Nachweis der Diphtherie-Toxinproduktion bei Corynebakterien.

The ability to secrete a potent protein-toxin called diphtheria toxin (DT) is of outstanding importance for the outcome of diphtheria epidemics. Rapid molecular-biological screening methods are shown that can improve the differentiation between toxinogenic and non-toxinogenic Corynebacterium diphtheriae strains. The recently reported infection with an endemic, putative toxinogenic Corynebacterium diphtheriae strain in Lower Saxony is discussed.