Acute Meningoencephalitis Associated with Borrelia miyamotoi, Minnesota, USA.

Borrelia miyamotoi is an emerging tickborne pathogen that has been associated with central nervous system infections in immunocompromised patients, albeit infrequently. We describe a case-patient in Minnesota, USA, who had meningeal symptoms of 1 month duration. B. miyamotoi infection was diagnosed by Gram staining on cerebrospinal fluid and confirmed by sequencing.

Initial treatment and outcome of Candida glabrata versus Candida albicans bloodstream infection.

Candida glabrata is a common cause of bloodstream infection (BSI) and exhibits decreased susceptibility to fluconazole. We sought to determine whether patients with C. glabrata infection were at increased risk of inappropriate initial therapy and mortality compared with the more fluconazole-susceptible species Candida albicans by performing a matched case-control study using the Prospective Antifungal Therapy Alliance registry of invasive fungal infections. C. glabrata BSI patients were matched to those with C. albicans BSI by age, sex, and underlying illness after screening all C. glabrata patients entered into the registry from March 2004 through September 2007. Of 161 patients with C. glabrata BSI included and matched to 161 C. albicans patients, those with C. glabrata were less likely to receive an adequate dose of fluconazole as initial therapy (12% versus 52%, P < 0.05) and more likely to receive an echinocandin (44% versus 26%, P < 0.05) or inadequately dosed fluconazole (32% versus 8%, P < 0.05) as initial therapy. Although time to initiation of therapy did not differ by species (P = 0.2), time to receipt of adequate therapy was longer for those with C. glabrata BSI (P < 0.001). Overall, C. glabrata patients were more likely to receive inadequate initial therapy (34% versus 11%, P < 0.05), but 4-week mortality was no different between groups (30% for C. glabrata versus 29% for C. albicans, P = 0.80). We found hematologic malignancy, age greater than 60, the presence of a central venous catheter at diagnosis, mechanical ventilation, and dialysis dependence to be independent predictors of 4-week mortality. The lack of difference in mortality between species may reflect the overriding importance of host variables and/or a difference in virulence by species: further study is needed to investigate these hypotheses.

Therapy and outcome of Candida glabrata versus Candida albicans bloodstream infection.

Candida glabrata is a common cause of bloodstream infection (BSI) and exhibits reduced susceptibility to antifungal agents. Those with C. glabrata BSI may therefore be at increased risk for a delay in receiving appropriate therapy and poor treatment outcome. We compared treatment and outcome of patients with C. glabrata to controls with Candida albicans BSI. Each patient with C. glabrata BSI from July 1997 through December 2004 was matched with a control patient infected with C. albicans. Appropriateness of therapy was defined using current guidelines, and the mortality end point was 30 days following the initial positive blood culture. Overall, 78% of patients received appropriate therapy (39/54 [72%] for C. glabrata versus 45/54 [83%] for C. albicans, P = 0.2). Crude 30-day mortality was high for both groups (41% for C. glabrata versus 44% for C. albicans, P = 0.7). There was no trend in mortality according to time of therapy initiation, but mortality was lower for those who received appropriate therapy (35% versus 71% for inappropriate therapy, P = 0.002). Twelve percent of patients received no antifungal therapy and contributed disproportionately to overall crude mortality. Strategies to decrease the incidence of untreated candidemia may favorably impact outcome.

Disk diffusion testing using Candida sp. colonies taken directly from CHROMagar Candida medium may decrease time required to obtain results.

We compared results of disk diffusion antifungal susceptibility testing from Candida sp. strains passaged on CHROMagar and on potato dextrose agar. The overall categorical agreements for fluconazole and voriconazole disk testing were 95% and 98% with 0% and 0.5% very major errors, respectively. Disk diffusion testing by the CLSI (formerly NCCLS) M44-A method can be performed accurately by taking inocula directly from CHROMagar.