Serum potassium, albumin and vitamin B12 as potential oxidative stress markers of fungal peritonitis.

BACKGROUND: Biomarkers of oxidative stress (OS) have been poorly explored in fungal peritonitis (FP). Potassium is a regulator of pro-oxidants and antioxidants. Albumin and vitamin B12 (B12) are vital antioxidant agents in the circulatory system. This study aimed to investigate the antioxidative role of serum potassium, albumin and B12 in FP. METHODS: Serum levels of potassium, albumin and B12 were retrospectively analyzed in 21 patients with a confirmed diagnosis of FP, 105 bacterial peritonitis (BP) patients and 210 patients receiving peritoneal dialysis without peritonitis. RESULTS: Serum levels of potassium, albumin and B12 were lower in FP patients than in BP patients. Serum potassium concentration was statistically related to albumin concentration in peritonitis patients. Univariate and multivariate binary logistic regression analysis suggested that serum level of potassium and albumin were independent risk factors of FP when compared with BP. Lower potassium and B12 levels were independently associated with higher rates of technique failure in peritonitis. CONCLUSION: These findings suggest lower serum potassium, albumin and B12 as potential oxidative stress markers of FP and raise the hypothesis that an increased level of OS could contribute to FP.KEY MESSAGESFP remains a serious complication of peritoneal dialysis (PD), with higher morbidity (1-23.8%) and mortality (2-25%), and oxidative stress plays a role in it.Our study suggested serum potassium, albumin and vitamin B12 as potential oxidative stress markers of fungal peritonitis.

A Novel Single Cell RNA-seq Analysis of Non-Myeloid Circulating Cells in Late Sepsis.

Background: With the successful implementation of the Surviving Sepsis Campaign guidelines, post-sepsis in-hospital mortality to sepsis continues to decrease. Those who acutely survive surgical sepsis will either rapidly recover or develop a chronic critical illness (CCI). CCI is associated with adverse long-term outcomes and 1-year mortality. Although the pathobiology of CCI remains undefined, emerging evidence suggests a post-sepsis state of pathologic myeloid activation, inducing suboptimal lymphopoiesis and erythropoiesis, as well as downstream leukocyte dysfunction. Our goal was to use single-cell RNA sequencing (scRNA-seq) to perform a detailed transcriptomic analysis of lymphoid-derived leukocytes to better understand the pathology of late sepsis. Methods: A mixture of whole blood myeloid-enriched and Ficoll-enriched peripheral blood mononuclear cells from four late septic patients (post-sepsis day 14-21) and five healthy subjects underwent Cellular Indexing of Transcriptomes and Epitopes by Sequencing (CITE-seq). Results: We identified unique transcriptomic patterns for multiple circulating immune cell subtypes, including B- and CD4+, CD8+, activated CD4+ and activated CD8+ T-lymphocytes, as well as natural killer (NK), NKT, and plasmacytoid dendritic cells in late sepsis patients. Analysis demonstrated that the circulating lymphoid cells maintained a transcriptome reflecting immunosuppression and low-grade inflammation. We also identified transcriptomic differences between patients with bacterial versus fungal sepsis, such as greater expression of cytotoxic genes among CD8+ T-lymphocytes in late bacterial sepsis. Conclusion: Circulating non-myeloid cells display a unique transcriptomic pattern late after sepsis. Non-myeloid leukocytes in particular reveal a host endotype of inflammation, immunosuppression, and dysfunction, suggesting a role for precision medicine-guided immunomodulatory therapy.

Fungal Infections in COVID-19 Intensive Care Patients.

Opportunistic fungal infections increase morbidity and mortality in COVID-19 patients monitored in intensive care units (ICU). As patients' hospitalization days in the ICU and intubation period increase, opportunistic infections also increase, which prolongs hospital stay days and elevates costs. The study aimed to describe the profile of fungal infections and identify the risk factors associated with mortality in COVID-19 intensive care patients. The records of 627 patients hospitalized in ICU with the diagnosis of COVID-19 were investigated from electronic health records and hospitalization files. The demographic characteristics (age, gender), the number of ICU hospitalization days and mortality rates, APACHE II scores, accompanying diseases, antibiotic-steroid treatments taken during hospitalization, and microbiological results (blood, urine, tracheal aspirate samples) of the patients were recorded. Opportunistic fungal infection was detected in 32 patients (5.10%) of 627 patients monitored in ICU with a COVID-19 diagnosis. The average APACHE II score of the patients was 28 ± 6. While 25 of the patients (78.12%) died, seven (21.87%) were discharged from the ICU. Candida parapsilosis (43.7%) was the opportunistic fungal agent isolated from most blood samples taken from COVID-19 positive patients. The mortality rate of COVID-19 positive patients with candidemia was 80%. While two out of the three patients (66.6%) for whom fungi were grown from their tracheal aspirate died, one patient (33.3%) was transferred to the ward. Opportunistic fungal infections increase the mortality rate of COVID-19-positive patients. In addition to the risk factors that we cannot change, invasive procedures should be avoided, constant blood sugar regulation should be applied, and unnecessary antibiotics use should be avoided.

Establishment of heparin-binding protein time-resolved immunoassay and some potential clinical applications.

AIM: To establish a highly sensitive time-resolved fluorescence immunoassay of heparin-binding protein (HBP-TRFIA) and evaluate its application value for bacterial or fungal infections in tumor patients. METHODS: Two types of HBP monoclonal specific antibodies against different epitopes of the antigen molecule were used as coating antibodies and Eu3+-labeled antibodies, respectively. The double-antibody sandwich method was used in establishing HBP-TRFIA, and the methodology was evaluated. The established HBP-TRFIA was used in detecting HBP concentration in the plasma samples of healthy individuals, patients with bacterial or fungal infections, and infected or uninfected patients with various types of tumors. RESULTS: The linear range of HBP-TRFIA was (0.11-530 ng/mL). Plasma HBP concentrations detected through HBP-TRFIA were consistent with the results of fluorescence quantitative immunochromatography (ρ = 0.964). The plasma HBP concentrations of infected tumor patients were significantly higher than those of uninfected tumor patients (P < 0.01). CONCLUSION: This study successfully established a highly sensitive HBP-TRFIA, which was highly comparable to commercially available fluorescent quantitative immunochromatographic kits and was able to facilitate the timely diagnosis of bacterial or fungal infections in patients with tumor.

Serum biomarkers to differentiate Gram-negative, Gram-positive and fungal infection in febrile patients.

Introduction. Contamination of specimens and overuse of broad spectrum antibiotics contribute to false positives and false negatives, respectively. Therefore, useful and applicable biomarkers of bacteremia are still required.Hypothesis/Gap Statement. IL-6 can be used as a serum biomarker to discriminate among bacterial infections and fungal infections in febrile patients with a bloodstream infection.Aim. We aimed to evaluate the diagnostic efficiency of neutrophil/lymphocyte ratio (NLR), procalcitonin (PCT) and interleukin-6 (IL-6) in discriminating Gram-negative (G-) bacteria from Gram-positive (G+) bacteria and fungi in febrile patients.Methodology. A total of 567 patients with fever were evaluated. Serum levels of IL-6, PCT, NLR and CRP were compared among a G- group (n=188), a G+ group (n=168), a fungal group (n=38) and a culture negative group (n=173). Sensitivity, specificity, Yuden's index and area under the Receiver operating characteristic (ROC) curve (AUC) were obtained to analyse the diagnostic abilities of these biomarkers in discriminating bloodstream infection caused by different pathogens.Results. Serum IL-6 and PCT in the G- group increased significantly when compared with both the G+ group and fungal group (P <0.05). AUC of IL-6 (0.767, 95 % CI:0.725-0.805) is higher than AUC of PCT (0.751, 95 % CI:0.708-0.796) in discriminating the G- group from G+ group. When discriminating the G- group from fungal group, the AUC of IL-6 (0.695, 95 % CI:0.651-0.747) with a cut-off value of 464.3 pg ml-1 was also higher than the AUC of PCT (0.630, 95 % CI:0.585-0.688) with a cut-off value of 0.68 ng ml-1. Additionally, AUC of NLR (0.685, 95 % CI:0.646-0.727) in discriminating the fungal group from G+ group at the cut-off value of 9.03, was higher than AUC of IL-6, PCT and CRP.Conclusion. This study suggests that IL-6 could be used as a serum biomarker to discriminate among bacterial infections and fungal infections in febrile patients with a bloodstream infection. In addition, NLR is valuable to discriminate fungal infections from Gram-positive infections in febrile patients with a bloodstream infection.

Diagnostic value of serum human Galactomannan aspergillus antigen and 1,3-beta-D-glucan in immunocompromised patient suspected fungal infection.

BACKGROUND: The prevalence of fungal infection (FI) in developing countries is high, but the diagnosis of FI is still challenging to determine, so it is needed evaluation of biomarkers other than microbiological culture, because the culture has low sensitivity, high cost, not available in every laboratory and needs a long time. The detection of human galactomannan Aspergillus antigen (GAL) and 1,3-beta-D-glucan (BDG) on the fungal cell wall could be the promising biomarkers for fungal infection. Neutropenia, lymphopenia and CD4T cells in the immunocompromised patients are essential factors, but these cell associations with BDG and GAL levels have not been evaluated yet. The study aimed to evaluate GAL and BDG for detecting fungal infection and their association with total leucocyte count, neutrophil, monocyte, lymphocyte and CD4T cells. METHOD: A cross-sectional study was conducted among 86 patient with suspected FI. Fungal infection established using EORTC/MSG criteria. Serology test performed using ELISA. Leucocyte cells were measured using a haematology autoanalyser, and CD4T cells were analysed using BD FACSPresto. Statistical analysis obtained using Spearman's correlation coefficient, ROC curve analysis and 2 × 2 contingency table. RESULTS: Serum Galactomannan and BDG had a significant correlation with CD4T cells and total lymphocyte count (p < 0.05). The cut-off OD GAL >0.3 had sensitivity 54.6%, specificity 87.5% and AUC 0.71; meanwhile, the BDG cut-off >115.78 pg/ mL had sensitivity 71.2%, specificity 52.4% and AUC 0.63 for detecting fungal infection. CONCLUSIONS: The immunocompromised patients can undergo GAL for determining the diagnose of FI. The lower the CD4T cells and total lymphocyte count, the higher the GAL and BDG serum levels.

NET formation - mechanisms and how they relate to other cell death pathways.

Cell death is an integral part of both infectious and sterile inflammatory reactions. Many cell death pathways cause the dying cell to lyse, thereby amplifying inflammation. A special form of lytic cell death is the formation of neutrophil extracellular traps (NETs), large structures of chromatin and antimicrobial proteins, which are released by dying neutrophils to capture extracellular pathogens and limit the spread of infections. The molecular mechanisms of NET formation remain incompletely understood. Recent research demonstrated substantial crosstalk between different cell death pathways, most notably between apoptosis, pyroptosis and necroptosis. Here, we review suicidal and vital NET formation and discuss potential crosstalk of their mechanisms of release with other forms of cell death.

A novel enzyme immunoassay for the measurement of plasma (1 → 3)-ß-D-glucan levels.

The presence of (1 â†’ 3)-ß-D-glucan in human plasma is a marker for fungal infections. Currently, the Limulus amebocyte lysate (LAL)-based assay is widely used for the quantification of plasma (1 â†’ 3)-ß-D-glucan. However, it has limitations in clinical use, such as an unstable supply of natural resources, complicated manufacturing process, and low-throughput of the reagents. Alternative assays exploiting specific antibodies against (1 â†’ 3)-ß-D-glucan have been developed to overcome these challenges. However, these methods are associated with low sensitivity and poorly correlate with the data obtained by the LAL-based assay. The aim of this study is to develop a novel enzyme immunoassay that is as sensitive and accurate in determining plasma (1 â†’ 3)-ß-D-glucan levels as compared to that obtained with the LAL-based assay. We generated specific monoclonal antibodies against (1 â†’ 3)-ß-D-glucan that recognizes four-unit glucose oligomers with (1 â†’ 3)-ß-D-linkages, and constructed a sandwich enzyme-linked immunosorbent assay (ELISA) using these antibodies. The newly developed ELISA showed proportional increase in absorbance with the volume of (1 â†’ 3)-ß-D-glucan added. The limit of detection of the assay was 4 pg/ml of plasma (1 â†’ 3)-ß-D-glucan that was equivalent to the LAL-based assay and the working range was 4-500 pg/ml. The intra-assay coefficient of variation was 2.2-5.4% using three different concentrations of plasma samples. We observed strong correlation (R = 0.941, slope = 0.986) between the measurements obtained by our ELISA and Fungitec G test ES Nissui, a commonly used LAL-based assay, using 26 types of plasma samples. This could be attributed to the epitopes of the antibodies. Both antibodies could inhibit the LAL-based assay, suggesting that the antibodies recognize the identical regions in ß-D-glucan, thereby inactivating factor G, an initiation zymogen for coagulation cascade, in the LAL-based assay. Thus, the ELISA developed in this study can detect fungal infections in clinical settings with similar efficiency as the LAL-based assay. This assay is characterized by good performance, stable supply of materials, and simple manufacturing process and is more suitable for the high-throughput diagnosis of fungal infections.

Immune Functions of Erythrocytes in Osteichthyes.

Red blood cells (RBCs)-erythrocytes-of Osteichthyes are primarily known for their involvement in the process of gas exchange and respiration. Currently, physiological properties of RCBs in fish should also include their ability to participate in defense processes as part of the innate and adaptive immune mechanisms. In response to viruses, bacteria, and fungi or recombinant nanoparticles, they can modulate expression of genes responsible for immune reactions, influence activity of leukocytes, and produce cytokines, antimicrobial peptides, and paracrine intercellular signaling molecules. Via the complement system (CR1 receptor) and owing to their phagocytic properties (erythrophagocytosis), RBCs of Osteichthyes can eliminate pathogens. In addition, they are probably involved in the immune response as antigen-presenting cells via major histocompatibility complex class II antigens.

Anti-IFN-γ autoantibodies underlie disseminated Talaromyces marneffei infections.

Talaromyces marneffei causes life-threatening opportunistic infections, mainly in Southeast Asia and South China. T. marneffei mainly infects patients with human immunodeficiency virus (HIV) but also infects individuals without known immunosuppression. Here we investigated the involvement of anti-IFN-γ autoantibodies in severe T. marneffei infections in HIV-negative patients. We enrolled 58 HIV-negative adults with severe T. marneffei infections who were otherwise healthy. We found a high prevalence of neutralizing anti-IFN-γ autoantibodies (94.8%) in this cohort. The presence of anti-IFN-γ autoantibodies was strongly associated with HLA-DRB1*16:02 and -DQB1*05:02 alleles in these patients. We demonstrated that adult-onset acquired immunodeficiency due to autoantibodies against IFN-γ is the major cause of severe T. marneffei infections in HIV-negative patients in regions where this fungus is endemic. The high prevalence of anti-IFN-γ autoantibody-associated HLA class II DRB1*16:02 and DQB1*05:02 alleles may account for severe T. marneffei infections in Southeast Asia. Our findings clarify the pathogenesis of T. marneffei infection and pave the way for developing novel treatments.

Voriconazole therapeutic drug monitoring in critically ill patients improves efficacy and safety of antifungal therapy.

Since voriconazole plasma trough concentration (VPC) is related to its efficacy and adverse events, therapeutic drug monitoring (TDM) is recommended to perform. However, there is no report about the data of voriconazole TDM in critically ill patients in China. This retrospective study was performed to determine whether voriconazole TDM was associated with treatment response and/or voriconazole adverse events in critically ill patients, and to identify the potential risk factors associated with VPC. A total of 216 critically ill patients were included. Patients were divided into two groups: those underwent voriconazole TDM (TDM group, n = 125) or did not undergo TDM (non-TDM group, n = 91). The clinical response and adverse events were recorded and compared. Furthermore, in TDM group, multivariate logistic regression analysis was performed to identify the possible risk factors resulting in the variability in initial VPC. The complete response in the TDM group was significantly higher than that in the non-TDM group (P = .012). The incidence of adverse events strongly associated with voriconazole in the non-TDM group was significantly higher than that in the TDM group (19.8% vs 9.6%; P = .033). The factors, including age (OR 0.934, 95% CI: 0.906-0.964), male (OR 5.929, 95% CI: 1.524-23.062), serum albumin level (OR 1.122, 95% CI: 1.020-1.234), diarrhoea (OR 4.953, 95% CI: 1.495-16.411) and non-intravenous administration (OR 4.763, 95% CI: 1.576-14.39), exerted the greatest effects on subtherapeutic VPC (VPC < 1.5 mg/L) in multivariate analysis. Intravenous administration (OR 7.657, 95% CI: 1.957-29.968) was a significant predictor of supratherapeutic VPC (VPC > 4.0 mg/L). TDM can result in a favourable clinical efficacy and a lower incidence of adverse events strongly associated with voriconazole in critically ill patients. Subtherapeutic VPC was closely related to younger age, male, hyperalbuminaemia, diarrhoea and non-intravenous administration, and intravenous administration was a significant predictor of supratherapeutic VPC.

Nested multiplex PCR for detection of bacterial and fungal blood stream infections in patients with hematological malignancies.

INTRODUCTION: Bloodstream Infections (BSIs) are a main cause of life-threatening complications among patients with cancer. METHODOLOGY: This study aimed to identify microbial pathogens causing BSI in febrile neutropenic patients with hematologic malignancy and compare the results of conventional blood culture with a nested multiplex real time PCR assay done directly on whole blood samples. The nested multiplex PCR was based on 16S rDNA and 18S rDNA sequence-specific primers; hence, it allowed the identification of most species of bacteria and fungi. RESULTS: Forty adult patients with febrile neutropenia, admitted at Hematology ward of Ain Shams University Hospitals, were included in this study. Each patient was subjected to conventional blood culture and nested multiplex PCR. Blood culture was positive in 19 patients (47.5%). About 68.4% of the positive cultures were monomicrobial, while 31.6% were polymicrobial. A total number of 26 isolates were grown from positive cultures; Staphylococcus aureus was the most common (30.8%), followed by Klebsiella pneumoniae (19.2%). Regarding nested PCR, positive results were detected in 37/40 patients (92.5%) which was statistically significantly higher than that of blood culture. Eighteen samples that tested negative by culture were positive using the molecular approach. The agreement between the two approaches was 55%. CONCLUSION: nested multiplex real time PCR can be a promising tool in order to achieve rapid diagnosis in cancer patients clinically suspected of BSIs. Its utilization could affect the choice of antimicrobial treatment whether bacterial or fungal and, therefore avoid unnecessary use of antimicrobials.

Does concomitant bacteraemia hide the fungi in blood cultures? An in vitro study.

Introduction. Polymicrobial infections including yeasts and bacteria are not rare and patients with polymicrobial bloodstream infection have higher early and overall case fatality rates. The diagnosis of invasive fungal and bacterial infections is mainly based on blood culture.Aim. The aim was to reveal the effect of concomitant bacteraemia on the detection of fungi from blood cultures in the presence of polymicrobial bloodstream infections involving Candida and non-Candida fungi and to show the superiority of blood culture bottles including selective fungal media in such situations.Methodology. Twenty-four polymicrobial bloodstream infection models - involving one fungus and one bacterium - were constituted by using clinical blood culture isolates (Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, Candida albicans, Candida glabrata, Fusarium solani and Trichosporon asahii). The Plus Aerobic/F (PAF) and Mycosis IC/F (MICF) culture bottles were used with the BACTEC 9240 device. After a bottle signalled positive, direct microscopic examination and subcultures on agar plates were performed.Results. All of fungi that were inoculated alone and in combination were detected by both direct microscopic examination and subcultures on agar plates from MICF bottles, whereas direct microscopic examination only revealed the bacterial agents from PAF bottles including combinations. Furthermore, fungal growth was hidden by bacterial growth on blood agar subcultures from PAF bottles including combinations of F. solani, C. glabrata or T. asahii with bacteria.Conclusion. Blood culture bottles including selective fungal media that can allow selective growth of fungi and earlier detection of some species should be preferred in addition to non-selective blood culture bottles, especially in specific patient populations. Further, the use of selective agar plates such as inhibitory mould agar may contribute to the solution of this problem in clinical laboratories.

Hypercalcemia as an Early Finding of Opportunistic Fungal Pneumonia in Renal Transplantation: A Case Series Report.

BACKGROUND: Pneumonia caused by opportunistic fungi is a serious complication in immunocompromised patients. Hypercalcemia has been described in renal transplantation associated with Pneumocystis jirovecii (PJP) or Histoplasma capsulatum (HCP) pneumonia. METHODS: We describe 5 patients who underwent kidney transplant between 2014 and 2019 and developed hypercalcemia before the diagnosis of pulmonary fungal infection: 4 patients with PJP and 1 with HCP. We assessed calcium metabolism and kidney function by total and ionized calcium, phosphorus, intact parathormone (iPTH), 25-OH vitamin D, 1,25(OH)2 vitamin D, and serum creatinine levels. RESULTS: Mean albumin-corrected calcium and ionized calcium were 12.56 mg/dL (range, 10.8-13.8 mg/dL) and 1.57 mmol/L (range, 1.43-1.69 mmol/L). Patients were normocalcemic, at 10.12 mg/dL (range, 9.6-10.5 mg/dL), before diagnosis and resolved hypercalcemia after antifungal treatment, at 8.86 mg/dL (range, 8.0-9.5 mg/dL). All patients had low or normal iPTH values, at 29.1 pg/mL (range, <3-44 pg/mL), with higher PTH levels 3 months before diagnosis and after treatment, at 147.3 pg/mL (range, 28.1-479 pg/mL) and 117.5 pg/mL (range, 18.2-245 pg/mL), respectively. The mean value for 25-OH vitamin D was 30.8 ng/mL (range, 14.6-62.8 ng/mL). This supports a PTH-independent mechanism, and we postulated an extrarenal production of 1,25(OH)2 vitamin D. CONCLUSION: In kidney transplant patients, hypercalcemia independent of PTH and refractory to treatment should alert for the possibility of opportunistic fungal pneumonia.

Diagnostic efficacy of serum cytokines and chemokines in fungal bloodstream infection in febrile patients.

BACKGROUND: The role of serum cytokines/chemokines in early diagnosis of fungal infections has not been clearly clarified yet. This study aims to measure the serum levels of cytokines/chemokines in cases of fungemia and to compare them with culture-negative controls. METHODS: In total, fourteen types of serum cytokines and chemokines from 41 patients with fungemia were compared with 57 patients with negative blood culture results. The cytokine and chemokine levels were detected with multiplex platform. We then performed statistical analysis as a two-tailed P < .05. ROC analysis was performed, and an area under the curve (AUC), and sensitivity and specificity values were calculated to determine the efficacy of various cytokines and chemokines for fungemia. Binary logistic regression was performed to further explore the combination mode of cytokines and chemokines, which could increase the diagnostic efficiency. RESULTS: C-reactive protein and procalcitonin were significantly higher compared with those in negative control group, while white blood cell, percentage of neutrophil, percentage of lymphocyte, and ratio of neutrophil and lymphocyte did not differentiate between two groups. Serum levels of IFN-γ, TNF-α, MIP-1ß, IL-6, IL-8, IL-10, IL-12p70, and IL-17 were significantly higher in patients with fungemia compared with the control group. Combination of MIP-1ß and IL-17 could improve the AUC, sensitivity, and specificity for the diagnosis of fungemia. CONCLUSION: Our study demonstrates that serum cytokines and chemokines including IFN-γ, TNF-α, MIP-1ß, IL-6, IL-8, IL-10, IL-12p70, and IL-17 could be considered as diagnostic markers for fungemia. Combination of these biomarkers might improve the diagnostic efficiency of fungemia.

D-Index-Guided Early Antifungal Therapy Versus Empiric Antifungal Therapy for Persistent Febrile Neutropenia: A Randomized Controlled Noninferiority Trial.

PURPOSE: Empiric antifungal therapy (EAT) is recommended for persistent febrile neutropenia (FN), but in most patients, it is associated with overtreatment. The D-index, calculated as the area surrounded by the neutrophil curve and the horizontal line at a neutrophil count of 500/µL, reflects both the duration and depth of neutropenia and enables real-time monitoring of the risk of invasive fungal infection in individual patients at no cost. We investigated a novel approach for patients with persistent FN called D-index-guided early antifungal therapy (DET), in which antifungal treatment is postponed until a D-index reaches 5,500 or the detection of positive serum or imaging tests, and compared it with EAT in this multicenter open-label noninferiority randomized controlled trial. PATIENTS AND METHODS: We randomly assigned 423 patients who underwent chemotherapy or hematopoietic stem-cell transplantation for hematologic malignancies to the EAT or DET group. The prophylactic use of antifungal agents other than polyenes, echinocandins, or voriconazole was allowed. Micafungin at 150 mg per day was administered as EAT or DET. RESULTS: In an intent-to-treat analysis of 413 patients, the incidence of probable/proven invasive fungal infection was 2.5% in the EAT group and 0.5% in the DET group, which fulfilled the predetermined criterion of noninferiority of the DET group (-2.0%; 90% CI, -4.0% to 0.1%). The survival rate was 98.0% versus 98.6% at day 42 and 96.4% versus 96.2% at day 84. The use of micafungin was significantly reduced in the DET group (60.2% v 32.5%; P < .001). CONCLUSION: A novel strategy, DET, decreased the use and cost of antifungal agents without increasing invasive fungal infections and can be a reasonable alternative to empiric or preemptive antifungal therapy.

Histopathological study on the prevalence of trichosporonosis in formalin-fixed and paraffin-embedded tissue autopsy sections by in situ hybridization with peptide nucleic acid probe.

Trichosporon species are some of the most common pathogenic yeasts in Asia, and many are resistant to echinocandin antifungal drugs. Effective treatment of fungal infections requires the selection of appropriate antifungals and the accurate identification of the causal organism. However, in histopathological specimens Trichosporon spp. are often misidentified as Candida species due to morphological similarities. In situ hybridization (ISH) is a useful technique for identifying fungal species in formalin-fixed and paraffin-embedded (FFPE) tissue sections. Although many novel probes for ISH are available, the practical use of ISH for identification of fungi remains limited, in part due to the lack of adequate verifications. We conducted a two-center retrospective observational study in which the ISH technique was used to differentiate Trichosporon spp. and C. albicans in FFPE tissue from autopsy specimens. The study included 88 cases with blood stream yeast infection without Cryptococci extracted from 459 autopsy files of cases with proven invasive fungal infection (IFI). Positive signals for the Trichosporon spp. protein nucleic acid (PNA) probe and C. albicans PNA probe were seen for 7 and 35 cases, respectively, whereas the remaining 46 were negative for both. For the Trichosporon spp.- positive specimens, 5/7 were reported as candidiasis in autopsy records. Our results suggested that accurate histological identification of fungal infections remains challenging, but ISH may be a suitable approach to support histological findings. In addition, this retrospective study suggested that trichosporonosis may have high prevalence among cases of bloodstream yeast infections in Japan.