Malassezia furfur Emergence and Candidemia Trends in a Neonatal Intensive Care Unit During 10 Years: The Experience of Fluconazole Prophylaxis in a Single Hospital.

BACKGROUND: Because Candida spp is a major cause of mortality and morbidity in preterm infants, fluconazole prophylaxis has been suggested by some experts and hospital policy. In our hospital, fluconazole prophylaxis was used in eligible preterm infants and set as the neonatal intensive care unit (NICU) practice in 2014. PURPOSE: This study focused on fungal bloodstream infections and aimed to evaluate the benefit and harm of fluconazole prophylaxis. METHODS/SEARCH STRATEGY: This retrospective, descriptive study involved medical record reviews in our hospital from April 2005 to October 2016. NICU patients were included if Candida species, yeast-like organisms, or Malassezia species were cultured from their venous catheter tips or blood cultures. FINDINGS/RESULTS: After fluconazole prophylaxis, cases of Candida spp decreased and those of Malassezia furfur emerged. We reviewed 19 cases of catheter-related M furfur colonization and 1 case of M furfur fungemia. The gestational age was 27.3 ± 2.0 weeks and birth weight was 959.2 ± 229.8 g. Hyperalimentation with lipid infusion was used in all cases. All of the neonates survived with antifungal agent use. IMPLICATIONS FOR PRACTICE: This study highlights that prophylactic fluconazole may be an associated factor of Malassezia colonization; M furfur remains a potential concern for fungemia in the care of premature infants and thus requires our attention. IMPLICATIONS FOR RESEARCH: Future studies should further investigate the incidence and impact of noncandidal fungal infections with fluconazole prophylaxis use in premature infants.

Fatal course of Saprochaete capitata fungemia in children with acute lymphoblastic leukemia.

Saprochaete capitata (S. capitata) is a very rare fungal pathogen that causes disseminated opportunistic infections in patients with hematologic malignancies. Fever resistant to broad-spectrum antibiotic and antifungal treatment is common in the presence of fungemia during the period of profound neutropenia. We describe three cases of leukemic children who died from S. capitata fungemia following a first febrile neutropenic episode after the induction of chemotherapy. S. capitata fungemia is an emergent infection associated with high mortality and low susceptibility to fluconazole and echinocandins. Awareness of this emergent infection is needed to ensure that it can be properly treated.

Fungal DNA detected in blood samples of patients who received contaminated methylprednisolone injections reveals increased complexity of causative agents.

Using Exserohilum rostratum-specific and panfungal real-time PCR, we studied 24 blood samples and 2 synovial fluid specimens from 20 patients with persistent or worsening pain following injections of contaminated methylprednisolone. Seven blood specimens from 6 patients were significantly positive for fungal DNA by panfungal PCR, with multiple fungal species identified.

Saccharomyces cerevisiae fungemia, a possible consequence of the treatment of Clostridium difficile colitis with a probioticum.

The yeast Saccharomyces boulardii is a biotherapeutic agent used for the prevention and treatment of several gastrointestinal diseases, such as diarrhoea caused by Clostridium difficile, in addition to the antibiotic therapy. In this study we report a case of Saccharomyces cerevisiae fungemia in a patient with Clostridium difficile-associated diarrhoea (CDAD) treated orally with S. boulardii in association with vancomycin. The identification of the S. cerevisiae was confirmed by molecular technique. Fungemia is a rare, but a serious complication to treatment with probiotics. We believe it is important to remind the clinicians of this risk when prescribing probiotics, especially to immunocompromised patients.

Saccharomyces boulardii fungemia caused by treatment with a probioticum.

Saccharomyces cerevisiae, known as baker's yeast, is normally considered a non-pathogenic yeast. A genetically very similar subtype, S boulardii, is used in a probioticum (Sacchaflor) to prevent antibiotic-associated diarrhoea and in the treatment of recurrent Clostridium difficile associated diarrhoea. The authors present a case report of a 79-year-old woman with rheumatoid arthritis, who after a bowel resection developed S boulardii fungemia. Her postoperative course was complicated by nutritional problems, anaemia and several nosocomial infections including recurrent C difficile associated diarrhoea. The diarrhoea was treated with metronidazole, vancomycin and Sacchaflor. After 13 days of treatment, the patient developed fungemia with S boulardii. Treatment with Sacchaflor was immediately discontinued and the patient was successfully treated with amphotericin B. Fungemia is a rare, but a serious complication to treatment with probiotics. Accordingly, the authors find it important to remind the clinicians of this risk when prescribing probiotics especially to immunocompromised patients.

Invasive fungal infection following reduced-intensity cord blood transplantation for adult patients with hematologic diseases.

Invasive fungal infection (IFI) is a significant complication after allogeneic hematopoietic stem cell transplantation (HSCT); however, we have little information on its clinical features after reduced intensity cord blood transplantation (RICBT) for adults. We reviewed medical records of 128 patients who underwent RICBT at Toranomon Hospital between March 2002 and November 2005. Most of the patients received purine-analogbased preparative regimens. Graft-versus-host disease (GVHD) prophylaxis was a continuous infusion of either tacrolimus 0.03 mg/kg or cyclosporine 3 mg/kg. IFI was diagnosed according to the established EORTC/NIH-MSG criteria. IFI was diagnosed in 14 patients. Thirteen of the 14 had probable invasive pulmonary aspergillosis and the other had fungemia resulting from Trichosporon spp. Median onset of IFI was day 20 (range: 1-82), and no patients developed IFI after day 100. Three-year cumulative incidence of IA was 10.2%. Four of the 13 patients with invasive aspergillosis (IA) developed grade II-IV acute GVHD, and their IA was diagnosed before the onset of acute GVHD. The mortality rate of IFI was 86%. Multivariate analysis revealed that the use of prednisolone >0.2 mg/kg (relative risk 7.97, 95% confidence interval 2.24-28.4, P = .0014) was a significant risk factor for IA. This study suggests that IFI is an important cause of deaths after RICBT, and effective strategies are warranted to prevent IFI.

Bloodstream infections and invasive mycoses in children undergoing acute leukaemia treatment: a 13-year experience at a single Italian institution.

The incidence rate (IR) of bloodstream infections (BI) and invasive mycoses (IM) during chemotherapy for paediatric acute lymphoblastic (ALL) or non-lymphoblastic leukaemias (AnLL) was evaluated for 153 BI and 22 IM diagnosed during 143,668 patient-days at risk from January 1988 to December 2000. IR, the number of episodes/100 days at risk, was 0.315 for AnLL and 0.092 for ALL (P < 0.001) with significant changes reflecting the intensity of anti-ALL chemotherapy. IR was 0.097 for first-line less intensive, 0.136 during first-line intensive, 0.261 during second-line therapy (P < 0.001), and 0.021 during maintenance. During intensive chemotherapy, the IR for BI was 0.134 in ALL with 0.087 for first-line less intensive therapy, 0.110 for first-line intensive, 0.230 for second-line intensive therapy (P < 0.001) and 0.274 in AnLL (P = 0.001). IR was 0.021 in ALL and 0.048 in AnLL (P = 0.034) for IM. In conclusion, there is a correlation between intensity of chemotherapy and rate of infections in paediatric acute leukaemias.

[Systemic candidiasis and infliximab therapy]. / Candidiasis sistémica y tratamiento con infliximab.

The use of infliximab in patients with luminal or fistulizing Crohn's disease refractory to medical treatment (steroids and immunomodulatory drugs) is increasingly widespread. Although the incidence of serious infections in patients undergoing infliximab treatment is not higher than that of controls, systemic fungal infections in patients treated with this antibody have been anecdotally described. We report a case of systemic candidiasis in a patient with refractory Crohn's disease who was treated with infliximab associated with corticosteroids and azathioprine and discuss the role that infliximab could have played in the development of this complication.

Endogenous endophthalmitis following disseminated fungemia due to Fusarium solani in a patient with acute myeloid leukemia.

We report the case of a young man with a resistant acute myeloid leukemia (AML) who developed a disseminated fungemia due to Fusarium solani involving the skin and lungs, during the neutropenic phase following a chemotherapy course. Despite continuous therapy with liposomal amphotericin B, he developed a bilateral endophthalmitis that rapidly evolved to complete blindness. The patient underwent two procedures of vitrectomy, with detection of F. solani in the vitreous fluid, and continued antifungal therapy, without any recovery of visual acuity. When he eventually died due to recurrence of leukemia and hemorrhagic shock, autopsy revealed a diffuse fusarial involvement of the central nervous system.

Fusarium solani fungemia in a patient with acute lymphoblastic leukemia.

A patient with ALL on anticancer chemotherapy developed fever which was later attributed to be due to Fusarium fungemia. The details of the case & a review of literature follows.

Documented fungal infections after prophylaxis or therapy with wide spectrum antibiotics: relationship between certain fungal pathogens and particular antimicrobials?

Antibiotics are known to be one of the major risk factors for fungal infection. We investigated whether there was a relationship between particular documented fungal infections and therapeutically or prophylactically administered antimicrobials in 105 patients with fungemia or histologically proven invasive aspergillosis or fusariosis. Out of 105 patients, 82.9% received antimicrobials affecting anaerobic microbial gut flora such as: imipenem, vancomycin, ceftazidime, metronidazole, clindamycin or ampicillin-sulbactam. In addition, 44.5% of patients had received prophylaxis with ofloxacin. 31.5% of Candida albicans fungemias occurred despite empiric therapy with amphotericin B and 21.1% during prophylaxis with azoles. The incidence of C. albicans infections (fungemias) was significantly higher (58.9% vs 33.7%, p<0.04) in patients receiving antibiotics not affecting anaerobic gut flora such as ofloxacin, an aminoglycoside or azithromycin. On the other hand, patients treated with third generation cephalosporins, carbapenems, glycopeptides, and broad spectrum penicillins were more likely to develop proven invasive Aspergillus spp. infection (27.9% vs 5.3%, p<0.001) in comparison to those treated with antimicrobials which preserve anaerobic gut flora.