Approach of clinicians to candiduria and related outcome in the elderly.

OBJECTIVE: Candiduria is increasingly frequent in hospitalized debilitated patients. We aimed to evaluate the approach of clinicians to candiduria in the oldest old, and its effect on clearance and mortality. MATERIAL AND METHODS: An observational study without intervention was carried out during 2012 and 2013 in three Spanish hospitals over patients with nosocomial candiduria aged 80 and over. Following a diagnostic algorithm, we assessed the appropriateness of antifungal therapy and analyzed the impact of the clinical approach (antifungal therapy, antibiotics discontinuation and catheter removal or replacement) on the outcome (mortality at 60 days and resolution, persistence or recurrence of candiduria). RESULTS: Hundred and forty eight patients were included. Symptomatology was attributable to candiduria in 31 instances and 19 asymptomatic patients were found at risk of developing candidemia. In response to culture-results, 77 (52%) of patients were treated with antifungals, mainly fluconazole (97.4%). The use of pharmacological therapy was appropriate (P<0.05) but subtherapeutical doses of fluconazole were widely used and follow-up samples were scarcely submitted. At 60 days of diagnosis the mortality was high (29.7%). The replacement or removal of the catheter resulted in a decrease in mortality and the use of antifungal treatment was associated with recurrence (P<0.05). CONCLUSIONS: In the absence of clinical practice guidelines with enough evidence, our study suggests that catheter removal should always be tried in the elderly with candiduria, since it reduces the mortality. The repetition of culture should help to better characterize the asymptomatic episodes, which are predominant, and to reduce the use of antifungals.

[Antifungal susceptibility of clinical isolates of Scopulariopsis species]. / Sensibilidad a antifúngicos de especies de Scopulariopsis de origen clínico.

INTRODUCTION: Scopulariopsis is a common soil saprophyte. In the last years the infections caused by Scopulariopsis species have increased, included superficial and invasive mycoses. This fungi has been reported resistant in vitro to some antifungal agents, although there is little information about this. The aim of the study was to establish in vitro antifungal susceptibility of clinical isolates of Scopulariopsis species against to broad-spectrum antifungal agents. METHODS: A total of 28 Scopulariopsis strains (10 S. brevicaulis, 7 S. koningii, 3 S. acremonium, 3 S. candida, 3 S. flava, 1 S. brumptii and 1 S. fusca) were tested using Sensititre Yeast One and broth microdilution methods to determine the minimum inhibitory concentrations (MICs) to amphotericin B, fluconazole, itraconazole, posaconazole, voriconazole and 5-fluorocytosine, and minimun effective concentration (MECs) to anidulafungin, caspofungin and micafungin. RESULTS: Our data confirm the high in vitro resistance of Scopulariopsis to antifungal agents. Anidulafungin, caspofungin, micafungin (MICs ≥ 8 mg/L), 5-fluorocytosine (MICs ≥ 64 mg/L), and fluconazole (MICs ≥ 128 mg/L) were inactive in vitro in all species. MICs of amphotericin B (range 2 to ≥ 8 mg/L) and itraconazole (0.5 to ≥ 16 mg/L) were high. The best antifungal activity was observed for posaconazole and voriconazole (0.5 to ≥ 8 mg/L). With Sensititre Yeast One method MICs obtained slightly lower. Scopulariopsis candida, S. flava and S. fusca were the most resistant species, while S. acremonium and S. brevicaulis showed the lowest MICs. CONCLUSIONS: MICs of all tested antifungal agents for Scopulariopsis were very high. Infections caused by Scopulariopsis species may not respond to antifungal treatment. Voriconazole is the drug of choice for treatment. We consider it appropriate to add amphotericin B in serious infections.

Tubercoulosis en el área sanitaria de Cádiz: Evolución de la resistencia durante los úlitmos 15 años / Tuberculosis in Area Health of Cádiz, Spain: Evolution of Resistance during the Last 15 Years

Introducción: La tuberculosis sigue siendo frecuente en el mundo y la Resistencia constituye un problema importante. Este trabajo presenta los casos diagnosticados por cultivo con (..) (AU)

Introduction: Tuberculosis remains prevalent worldwide, and drug resistance is an important problem. This report presents the results of the study (..) (AU)

[Dermatophytoses due to anthropophilic fungi in Cadiz, Spain, between 1997 and 2008]. / Dermatofitosis por hongos antropofílicos en Cádiz (1997-2008).

BACKGROUND AND OBJECTIVES: Cutaneous fungal infections are a major public health problem. The distribution of the dermatophytoses varies between countries and geographical areas. The aim of this study was to determine the incidence, epidemiology, etiology, and clinical course of the dermatophytoses caused by anthropophilic fungi in Cadiz, Spain, over the past 12 years. MATERIAL AND METHODS: The study, conducted between 1997 and 2008, included 2,235 samples from lesions of the skin, hair, and nails of 2,220 patients with a clinical suspicion of mycosis. Samples were examined by microscopy using potassium hydroxide and were cultured on mycological media. The dermatophytes were identified by their macroscopic and microscopic characteristics. RESULTS: Cultures were positive in 283 cases (12.7%). Anthropophilic dermatophytes (53.3%) were more common than zoophilic (41.3%) and geophilic (5.3%) dermatophytes. Trichophyton rubrum (38.2%) was the predominant pathogen isolated, followed by Microsporum canis (22.3%) and Trichophyton mentagrophytes (15.5%). Five other species of anthropophilic fungi were identified: Trichophyton tonsurans (5.6%), Trichophyton violaceum (4.9%), Epidermophyton floccosum (2.8%), Trichophyton soudanense (1.0%), and Trichophyton schoenleinii (0.7%). Infections caused by the anthropophilic fungi included tinea unguium (29.1%), tinea corporis (25.8%), tinea pedis (19.2%), tinea cruris (11.9%), tinea capitis (5.3%), and tinea faciei (3.3%). CONCLUSIONS: The principal fungus responsible for dermatomycosis in Cadiz was T. rubrum, and its incidence has been rising since 2000. The prevalence of other anthropophilic fungi, such as T. tonsurans and T. violaceum, has increased, though this is not directly related to immigration. E. floccosum, T. soudanense, and T. schoenleinii are isolated occasionally.

Dermatofitosis por hongos antropofílicos en Cádiz (1997–2008) / Dermatophytoses due to anthropophilic fungi in Cadiz, Spain, between 1997 and 2008

Introducción y objetivos: Las infecciones cutáneas producidas por hongos constituyen un importante problema de salud pública. La distribución de las dermatofitosis varía en diferentes países y áreas geográficas. El objetivo de este estudio ha sido determinar la epidemiología, etiología y evolución de las dermatofitosis por hongos antropofílicos en Cádiz durante los últimos 12 años. Material y métodos: El estudio se realizó de 1997 – 2008 sobre 2.235 muestras de lesiones de piel, pelo y uñas de 2.220 pacientes con sospecha clínica de micosis. Las muestras fueron analizadas mediante examen microscópico con hidróxido potásico y cultivo en medios micológicos. Los dermatofitos se identificaron de acuerdo con las características macroscópicas y microscópicas. Resultados: El cultivo fue positivo en 283 muestras (12,7%). Los dermatofitos antropofílicos (53,3%) predominaron sobre los zoofílicos (41,3%) y geofílicos (5,3%). Trichophyton rubrum (38,2%) fue el patógeno más frecuente, seguido de Microsporum canis (22,3%) y Trichophyton mentagrophytes (15,5%). Se identificaron otras cinco especies de hongos antropofílicos: T. tonsurans (5,6%), T. violaceum (4,9%), Epidermophyton floccosum (2,8%), T. soudanense (1,0%) y T. schoenleinii (0,7%). Las infecciones por hongos antropofílicos fueron onicomicosis (29,1%), tiña corporal (25,8%), tiña del pie (19,2%), tiña crural (11,9%), tiña del cuero cabelludo (5,3%) y tiña facial (3,3%). Conclusiones: El principal responsable de dermatofitosis en Cádiz es Trichophyton rubrum. Su incidencia es ascendente desde el año 2000. Otros hongos antropofílicos como T. tonsurans y T. violaceum son cada vez más prevalentes, aunque no están directamente relacionados con la inmigración. Epidermophyton floccosum, T. soudanense y T. schoenleinii se aíslan ocasionalmente (AU)

Background and objectives: Cutaneous fungal infections are a major public health problem. The distribution of the dermatophytoses varies between countries and geographical areas. The aim of this study was to determine the incidence, epidemiology, etiology, and clinical course of the dermatophytoses caused by anthropophilic fungi in Cadiz, Spain, over the past 12 years. Material and methods: The study, conducted between 1997 and 2008, included 2,235 samples from lesions of the skin, hair, and nails of 2,220 patients with a clinical suspicion of mycosis. Samples were examined by microscopy using potassium hydroxide and were cultured on mycological media. The dermatophytes were identified by their macroscopic and microscopic characteristics. Results: Cultures were positive in 283 cases (12.7%). Anthropophilic dermatophytes (53.3%) were more common than zoophilic (41.3%) and geophilic (5.3%) dermatophytes. Trichophyton rubrum (38.2%) was the predominant pathogen isolated, followed by Microsporum canis (22.3%) and Trichophyton mentagrophytes (15.5%). Five other species of anthropophilic fungi were identified: Trichophyton tonsurans (5.6%), Trichophyton violaceum (4.9%), Epidermophyton floccosum (2.8%), Trichophyton soudanense (1.0%), and Trichophyton schoenleinii (0.7%). Infections caused by the anthropophilic fungi included tinea unguium (29.1%), tinea corporis (25.8%), tinea pedis (19.2%), tinea cruris (11.9%), tinea capitis (5.3%), and tinea faciei (3.3%). Conclusions: The principal fungus responsible for dermatomycosis in Cadiz was T. rubrum, and its incidence has been rising since 2000. The prevalence of other anthropophilic fungi, such as T. tonsurans and T. violaceum, has increased, though this is not directly related to immigration. E. floccosum, T. soudanense, and T. schoenleinii are isolated occasionally (AU)

Peritonitis fúngica en diálisis peritoneal continua ambulatoria: descripción de 10 casos / No disponible

Antecedentes: La peritonitis fúngica es una complicación infrecuente pero grave en pacientes en diálisis peritoneal continua ambulatoria (DPCA). Métodos: Durante un período de 10 años (1999-2008), de un total de 175 pacientes con insuficiencia renal crónica en tratamiento con DPCA, estudiamos retrospectivamente 10 casos de peritonitis fúngica, analizando los factores predisponentes, aspectos clínicos, agentes etiológicos y tratamiento. El diagnóstico se estableció por la presencia de efluente peritoneal turbio con recuento superior a 100 leucocitos/µl y aislamiento de hongos en el cultivo microbiológico. Resultados: La peritonitis fúngica representó un 3,6% del total de peritonitis. Nueve pacientes tenían historia de peritonitis bacteriana previa y todos habían recibido antibioterapia. Otros hallazgos destacables fueron: edad superior a70 años (50%) y diabetes mellitus (40%). El examen microscópico del líquido peritoneal fue de utilidad para sospechar la infección en 6 pacientes (60%). Los agentes responsables de peritonitis fueron: Candida parapsilosis (4), C. albicans(2), C. tropicalis(1), C. glabrata (1), C. famata (1) y Fusarium oxysporum(1). Los antifúngicos utilizados en el tratamiento fueron: fluconazol intraperitoneal y oral, vorizonazol intravenoso y oral y anfotericina B intravenosa. A consecuencia de la infección fúngica, 8 pacientes fueron transferidos a hemodiálisis. Un paciente murió antes de ser diagnosticado y otros tres durante el episodio de peritonitis. Conclusiones: Los pacientes con episodios de peritonitis bacteriana previos y tratamiento antibiótico presentaron un mayor riesgo de desarrollar peritonitis fúngica. C. parapsilosis fue el patógeno más frecuente. El tratamiento antifúngico junto con la retirada del catéter peritoneal fue eficaz en el 60% de los pacientes (AU)

Background: Fungal peritonitis is a rare but serious complication in patients undergoing continuous ambulatory peritoneal dialysis(CAPD). Methods: During a ten-year period (1999-2008), from a total of 175 patients with chronic renal failure undergoing CAPD, we retrospectively studied 10 cases of fungal peritonitis analyzing the predisposing factors, clinical aspects, etiological agents and treatment. Diagnosis was based on elevated CAPD effluent count(>100/µl) and isolation of fungi on culture. Results: Fungalperitonitis represented 3.6% of all peritonitis episodes. Nine patients had a history of previous bacterial peritonitis and all of them were under antibiotic therapy. Other common findings were: age higher than 70 years old (50%) and diabetes mellitus(40%). Direct microscopic examination of the peritoneal fluid was useful for the suspicion of fungal infection in six patients(60%). The responsible agents for peritonitis were: Candidaparapsilosis (4), C. albicans (2), C. tropicalis (1), C. glabrata (1), C.famata (1) and Fusarium oxysporum (1). Intraperitoneal and oralfluconazole, intravenous and oral voriconazole and intravenousamphotericin B were the antifungal agents used in the treatment. As a result of fungal infection, eight patients were transferred to hemodialysis. One patient died before the diagnosis and three other during the episode of peritonitis. Conclusions: Patients with previous bacterial peritonitis and antibiotic treatment were at greater risk of developing fungal peritonitis. C. parapsilosis was the most common pathogen. For the successful management of fungal peritonitis besides the antifungal therapy, peritoneal catheter removal was necessary in60% of patients (AU)

[Fungal peritonitis in ambulatory continuous peritoneal dialysis: description of 10 cases]. / Peritonitis fúngica en diálisis peritoneal continua ambulatoria: descripción de 10 casos.

BACKGROUND: Fungal peritonitis is a rare but serious complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). METHODS: During a ten-year period (1999-2008), from a total of 175 patients with chronic renal failure undergoing CAPD, we retrospectively studied 10 cases of fungal peritonitis analyzing the predisposing factors, clinical aspects, etiological agents and treatment. Diagnosis was based on elevated CAPD effluent count (>100/microl) and isolation of fungi on culture. RESULTS: Fungal peritonitis represented 3.6% of all peritonitis episodes. Nine patients had a history of previous bacterial peritonitis and all of them were under antibiotic therapy. Other common findings were: age higher than 70 years old (50%) and diabetes mellitus (40%). Direct microscopic examination of the peritoneal fluid was useful for the suspicion of fungal infection in six patients (60%). The responsible agents for peritonitis were: Candida parapsilosis (4), Candida albicans (2), Candida tropicales (1), Candida glabrata (1), Candida famata (1) and Fusarium oxysporum (1). Intraperitoneal and oral fluconazole, intravenous and oral voriconazole and intravenous amphotericin B were the antifungal agents used in the treatment. As a result of fungal infection, eight patients were transferred to hemodialysis. One patient died before the diagnosis and three other during the episode of peritonitis. CONCLUSIONS: Patients with previous bacterial peritonitis and antibiotic treatment were at greater risk of developing fungal peritonitis. Candida parapsilosis was the most common pathogen. For the successful management of fungal peritonitis besides the antifungal therapy, peritoneal catheter removal was necessary in 60% of patients.

Sensibilidad a los antimicrobianos de micobacterias de crecimiento rápido / Susceptibility to antimicrobial agents of rapidly growing mycobacteria

Las micobacterias de crecimiento rápido no cromógenas se asocian con frecuencia a infecciones humanas diseminadas y localizadas. Hemosdeterminado la sensibilidad in vitro a seis antimicrobianos de uso habitual de 40 cepas (17 Mycobacterium fortuitum, 11 M. chelonae y 12M. abscessus) aisladas de diversas fuentes clínicas: 29 secreciones respiratorias, cinco abscesos cutáneos, cuatro úlceras corneales y dos orinas,de pacientes atendidos en el Hospital Puerta del Mar, de Cádiz. El estudio de sensibilidad se realizó por el método de microdilución encaldo frente a amikacina, claritromicina, ciprofloxacino, levofloxacino, imipenem y cefoxitina. Los resultados sugieren que la amikacina es elantimicrobiano más efectivo para el tratamiento de las infecciones producidas por micobacterias de crecimiento rápido no cromógenas. Laclaritromicina y el imipenem presentan buena actividad frente a M. fortuitum y M. abscessus, pero no frente a M. chelonae. Las quinolonassolamente son efectivas frente a M. fortuitum. En las infecciones por micobacterias de crecimiento rápido es importante identificar el agenteetiológico para determinar el tratamiento más apropiado(AU)

Rapidly growing mycobacteria are often associated with human diseases. We investigated the in vitro susceptibilities of 40 isolates to six antimicrobialagents: 17 Mycobacterium fortuitum, 11 M. chelonae and 12 M. abscessus isolated from several human sources: 29 respiratorysecretions, 5 cutaneous abscesses, 4 corneal ulcers and 2 urine samples of patients treated at “Hospital Puerta del Mar” (Cádiz). Susceptibilitystudies were determined by the broth microdilution method for amikacin, clarithromycin, ciprofloxacin, levofloxacin, imipenem and cefoxitin.Results suggest that amikacin is the most effective antimicrobial agent for treating infections due to rapidly growing mycobacteria.Clarithromycin and imipenem show good activity against M. fortuitum and M. abscessus, but not against M. chelonae. Quinolones are onlyeffective against M. fortuitum. It’s important to identify, in rapidly growing mycobacteria infections, the etiologic agent to determine correcttreatment(AU)

[Susceptibility to antimicrobial agents of rapidly growing mycobacteria]. / Sensibilidad a los antimicrobianos de micobacterias de crecimiento rápido.

Rapidly growing mycobacteria are often associated with human diseases. We investigated the in vitro susceptibilities of 40 isolates to six antimicrobial agents: 17 Mycobacterium fortuitum, 11 M. chelonae and 12 M. abscessus isolated from several human sources: 29 respiratory secretions, 5 cutaneous abscesses, 4 corneal ulcers and 2 urine samples of patients treated at "Hospital Puerta del Mar" (Cádiz). Susceptibility studies were determined by the broth microdilution method for amikacin, clarithromycin, ciprofloxacin, levofloxacin, imipenem and cefoxitin. Results suggest that amikacin is the most effective antimicrobial agent for treating infections due to rapidly growing mycobacteria. Clarithromycin and imipenem show good activity against M. fortuitum and M. abscessus, but not against M. chelonae. Quinolones are only effective against M. fortuitum. It's important to identify, in rapidly growing mycobacteria infections, the etiologic agent to determine correct treatment.

[Antifungal susceptibility of Acremonium species using E-test and Sensititre]. / Sensibilidad a antifúngicos de especies de Acremonium mediante los metodos E-test y Sensititre.

Filamentous fungi have become a common cause of severe infections, especially in immunocompromised patients. In recent years, the number and diversity of the infections caused by Acremonium species have increased and numerous species have been implicated. As is the case for most emerging pathogens, the optimal therapeutic approach to Acremonium species remains to be determined. We used two methods to determine the in vitro susceptibility to amphotericin B, itraconazole and fluconazole for 15 clinical isolates of eight different species of Acremonium. The MICs were determined according to protocol M38-A of the National Committee for Clinical Laboratory Standards (NCCLS) document, using the Sensititre and E-test microdilution methods. Amphotericin B was effective in vitro for few species using the Sensititre method. However, high MICs were obtained with E-test. Fluconazole and itraconazole were ineffective according to both methods. Acremonium species are generally resistant to the most commonly used antifungal agents. Consequently, Acremonium susceptibility testing is recommended to assist in choosing adequate treatment of infections caused by this filamentous fungus.

Candidiasis orofaríngea / Oropharyngeal candidiasis

No disponible

Extracellular enzymatic activity in 11 Cryptococcus species.

The extracellular enzymatic activity of 36 strains of yeast belonging to 11 species of the genus Cryptococcus, has been investigated, using the API-ZYM (BioMérieux, France) commercial system, with the objective of determining the differences in the enzymatic profiles of the various species. The strains studied were: 9 of C. neoformans, 7 of C. albidus, 6 of C. laurentii, 5 of C. uniguttulatus, 3 of C. humicolus, and 1 each of C. ater, C. curvatus, C. dimennae, C. hungaricus, C. infirmo-miniatus and C. magnus. All the strains showed enzymatic activity with positivity to Phosphatase alkaline, Esterase lipase C8, Leucine arylamidase, Phosphatase acid and Naphthol-AS-BI-phosphohydrolase, and negativity to Lipase C14, Trypsin, Chemotrypsin, beta-galactosidase, beta-glucuronidase and alpha-manosidase. Variable enzymatic activity was shown to Esterase C4, Valine arylamidase, Cystine arylamidase, alpha-galactosidase, alpha-glucosidase, beta-glucosidase, N-acetyl-beta-glucosaminidase and alpha-fucosidase. This allowed 11 separate enzymatic patterns to be established. The species C. neoformans and C. laurentii each presented two distinct patterns; C. uniguttulatus, C. hungaricus and C. magnus shared the same pattern; C. albidus, C. ater, C. curvatus, C. dimennae, C. humicolus and C. infirmo-miniatus presented an individual enzymatic pattern. The results obtained suggest that the API-ZYM system could be useful for the identification of species of the genus Cryptococcus and for the differentiation of the enzymotypes for epidemiological purposes.