Prevalence of, and risk factors for, hematogenous fungal endophthalmitis in patients with Candida bloodstream infection

Evaluating predictors of ocular complications and mortality in candidemia: Are repeat blood cultures key?

Candidemia can lead to ocular complications, including endophthalmitis and chorioretinitis. Management of candidemia traditionally included ophthalmic exams. However, due to concerns regarding the utility of performing ophthalmic exams in all patients, there is a need for prognostic factors suggestive of ocular complications. We sought to evaluate if positive follow-up blood cultures (FUBC) are associated with ocular involvement in candidemia. We conducted a single-center, retrospective review of candidemia cases at an academic medical center (2017-2022). Data on demographics, risk factors, ophthalmic exams, eye infection, and mortality outcomes were collected. Data was analyzed using descriptive statistics, χ2 tests, and multivariate logistic regression. A total of 238 episodes of candidemia among 199 patients were included. FUBC were obtained for 97% of cases and were positive in 35%. Ophthalmic exams were performed in 82% of cases and identified 10 endophthalmitis and 11 chorioretinitis cases. There was no significant association between positive FUBC and endophthalmitis or chorioretinitis. Ocular infections were associated with presence of any visual symptom (P < .001), Candida albicans (P = .02), C. dubliniensis (P = .003), and length of antifungal regimen (P = .007). Hospital mortality was associated with age (P < .001), C. lusitaniae (P = .056), acquisition of FUBC (P = .03), completion of an ophthalmic exam (P = .046), vasopressor use (P < .001), and length of antifungal regimen (P = .009). While positive FUBC did not correlate with ocular candidiasis, specific Candida species were associated with endophthalmitis and chorioretinitis. C. lusitaniae infections, acquisition of FUBC, and ophthalmic exam were predictors of hospital mortality. Other indications for ophthalmic evaluations and further identification of mortality risk factors need to be investigated.

From Bedside to Diagnosis: The Role of Ocular Fundus in Systemic Infections

In this comprehensive review, we delve into the significance of the ocular fundus examination in diagnosing and managing systemic infections at the bedside. While the utilization of advanced ophthalmological diagnostic technologies can present challenges in bedside care, especially for hospitalized patients confined to their beds or during infection outbreaks, the ocular fundus examination often emerges as an essential, and sometimes the only practical, diagnostic tool. Recent discussions have highlighted that the role of an ocular fundus examination might not always be advocated as a routine diagnostic procedure. With this context, we introduce a decision tree tailored for assessing the ocular fundus in inpatients with systemic infections. We also present an overview of systemic infections that impact the eye and elucidate key signs detectable through a bedside ocular fundus examination. Targeted primarily at non-ophthalmology clinicians, this review seeks to offer a comprehensive insight into a multifaceted approach and the enhancement of patient clinical outcomes.

Ocular candidiasis in a tertiary hospital in Japan: A 10-year single-center retrospective study

Ocular candidiasis is a major complication of candidemia that is sometimes sight-threatening. Although prompt ophthalmologic consultation and antifungal medication have been emphasized, recent changes in the causative species and drug susceptibilities make the picture unclear. This study aimed to determine whether there are trends among patients with ocular candidiasis and included 80 patients with candidemia who underwent ophthalmological screening at our hospital between 2010 and 2020. Data on the clinical characteristics, comorbidities, biochemical test results, causative Candida species, treatment, outcomes, visual acuity, and antifungal susceptibility were collected and analyzed. Statistical analyses were performed by comparing two groups, namely, the ocular candidiasis (n = 29) and non-ocular candidiasis (n = 51) groups. In the ocular candidiasis group, there were significantly more cases of central venous catheter insertion (82.8%, p = 0.026) and Candida albicans candidemia (72.4%, p < 0.001). Regarding ocular involvement, the majority of patients were asymptomatic. Most cases improved with antifungal therapy, but one case underwent vitrectomy. Between 2016 and 2020, there was a diversification of species, with a decrease in Candida parapsilosis and the emergence of Candida glabrata and Candida tropicalis. Regarding drug susceptibility, the minimum inhibitory concentrations of echinocandin and 5-fluorocytosine against Candida albicans, Candida parapsilosis, and Candida glabrata were slightly increased. In conclusion, in addition to appropriately performing ophthalmologic examinations, it is beneficial to select antifungal agents according to the diversity of species and drug susceptibilities.

Risk Factors for Legal Blindness in 77 Japanese Patients with Endogenous Endophthalmitis: A Multicenter Cohort Study from J-CREST

PURPOSE

We investigated potential predictive factors for visual prognosis in Japanese patients with endogenous endophthalmitis.

DESIGN

Retrospective observational multicenter cohort study.

METHODS

We examined the characteristics of 77 Japanese patients with endogenous endophthalmitis and performed statistical analyses of these real-world data. The primary endpoint was the identification of factors associated with visual prognosis. We examined differences between patients in the better vision and legal blindness groups at 12 weeks after treatment initiation.

RESULTS

The five risk factors for visual impairment at 12 weeks after treatment initiation were presence of pressure injuries, severe clinical symptoms (presence of eye pain and ciliary injection), pathogen identification, and poor best-corrected visual acuity at baseline. Staphylococcus aureus and fungus were associated with a better visual impairment outcome.

CONCLUSIONS

Endogenous endophthalmitis remains a severe ocular infection; however, it can be managed with rapid treatments, as well as other advances in medical knowledge and technology.

Endogenous Aspergillus thermomutatus Endophthalmitis in a Patient With Myelodysplastic Syndrome

This case report describes a diagnosis of Aspergillus thermomutatus endophthalmitis in a patient with a recent history of allogeneic stem cell transplant.

Intestinal bacteria-a powerful weapon for fungal infections treatment

The morbidity and mortality of invasive fungal infections are rising gradually. In recent years, fungi have quietly evolved stronger defense capabilities and increased resistance to antibiotics, posing huge challenges to maintaining physical health. Therefore, developing new drugs and strategies to combat these invasive fungi is crucial. There are a large number of microorganisms in the intestinal tract of mammals, collectively referred to as intestinal microbiota. At the same time, these native microorganisms co-evolve with their hosts in symbiotic relationship. Recent researches have shown that some probiotics and intestinal symbiotic bacteria can inhibit the invasion and colonization of fungi. In this paper, we review the mechanism of some intestinal bacteria affecting the growth and invasion of fungi by targeting the virulence factors, quorum sensing system, secreting active metabolites or regulating the host anti-fungal immune response, so as to provide new strategies for resisting invasive fungal infection.

Prevalence of Ocular Candidiasis and Candida Endophthalmitis in Patients With Candidemia: A Systematic Review and Meta-Analysis

BACKGROUND

Infectious diseases and ophthalmology professional societies have disagreed regarding ocular screening in patients with candidemia. We aimed to summarize the current evidence on the prevalence of ocular candidiasis (OC) and Candida endophthalmitis (CE) according to the standardized definitions.

METHODS

A literature search was conducted from the inception date through 16 October 2022 using PubMed, Embase, and SCOPUS. Pooled prevalence of ocular complications was derived from generalized linear mixed models (PROSPERO CRD42022326610).

RESULTS

A total of 70 and 35 studies were included in the meta-analysis for OC and concordant CE (chorioretinitis with vitreous involvement), respectively. This study represented 8599 patients with candidemia who underwent ophthalmologic examination. Pooled prevalences (95% CI) of OC, overall CE, concordant CE, and discordant CE were 10.7% (8.4-13.5%), 3.1% (2.1-4.5%), 1.8% (1.3-2.6%), and 7.4% (4.5-12%) of patients screened, respectively. Studies from Asian countries had significantly higher concordant CE prevalence (95% CI) of patients screened (3.6%; 2.9-4.6%) compared with studies from European countries (1.4%; .4-5%) and American countries (1.4%; .9-2.2%) (P <.01). Presence of total parenteral nutrition and Candida albicans was associated with CE, with pooled odds ratios (95% CI) of 6.92 (3.58-13.36) and 3.02 (1.67-5.46), respectively.

CONCLUSIONS

Prevalence of concordant CE overall and among Asian countries was 2 and 4 times higher than the prevalence previously reported by the American Academy of Ophthalmology (AAO) of <0.9%, respectively. There is an urgent need to study optimal screening protocols and to establish joint recommendations by the Infectious Diseases Society of America and AAO.

Risk factors for ophthalmologic involvement and ocular findings in patients diagnosed with fungemia in a high-complexity hospital in the city of Medellín, Colombia

PURPOSE

To describe the demographic clinical characteristics and to identify the risk factors of patients diagnosed with fungemia and secondary intraocular involvement.

METHODS

Retrospective cohort of 97 patients diagnosed with fungemia and with or without involvement of the posterior segment. Demographic, clinical and ophthalmological variables were identified to establish the risk of retinal seeding.

RESULTS

An incidence of ocular involvement of 22.68% was obtained and no clear risk factor was found for subsequent showings in patients with fungemia. A risk trend was only found in patients with diabetes with an OR: 2.85; CI 95%: (0.80-10.12) and history of HIV with an OR: 2.29 CI95%: (0.85-6.12).

CONCLUSIONS

In this first cohort carried out in Colombia according to our search, findings were obtained that agree with those of other authors worldwide, where there is no evidence of a decrease in incidence compared with older studies and the absence of risk factors for the compromise of the posterior pole in patients with fungemia.KEY MESSAGESSystematic fundus evaluation by an ophthalmologist in patients with candidaemia is a recommended practice based on low-quality evidence.The identification of real risk factors for retinal compromise in fungemia would allow us to be more selective with the population to be evaluated.Fungemia generally occurs in critically ill patients, where access and availability of ophthalmology evaluation are a resource that is not always available.

Systemic Candida albicans Infection in Mice Causes Endogenous Endophthalmitis via Breaching the Outer Blood-Retinal Barrier

Candida albicans is the leading cause of endogenous fungal endophthalmitis; however, its pathobiology studies are limited. Moreover, the contribution of host factors in the pathogenesis of Candida endophthalmitis remains unclear. In the present study, we developed a murine model of C. albicans endogenous endophthalmitis and investigated the molecular pathobiology of ocular candidiasis and blood-retinal barrier permeability. Our data show that intravenous injection of C. albicans in immunocompetent C57BL/6 mice led to endogenous endophthalmitis without causing mortality, and C. albicans was detected in the eyes at 3 days postinfection and persisted for up to 10 days. The intraocular presence of C. albicans coincided with a decrease in retinal function and increased expression of inflammatory mediators (tumor necrosis factor alpha [TNF-α], interleukin 1β [IL-1β], MIP2, and KC) and antimicrobial peptides (human β-defensins [hBDs] and LL37) in mouse retinal tissue. C. albicans infection disrupted the blood-retinal barrier (BRB) by decreasing the expression of tight junction (ZO-1) and adherens junction (E-cadherin, N/R-cadherin) proteins. In vitro studies using human retinal pigment epithelial (ARPE-19) cells showed time-dependent activation of eIF2α, extracellular signal-related kinase (ERK), and NF-κB signaling and decreased activity of AMP-activated protein kinase (AMPK) leading to the induction of an inflammatory response upon C. albicans infection. Moreover, C. albicans-infected cells exhibited increased cellular permeability coinciding with a reduction in cellular junction proteins. Overall, our study provides new insight into the molecular pathogenesis of C. albicans endogenous endophthalmitis. Furthermore, the experimental models developed in the study can be used to identify newer therapeutic targets or test the efficacy of drugs to treat and prevent fungal endophthalmitis. IMPORTANCE Patients with candidemia often experience endophthalmitis, a blinding infectious eye disease. However, the pathogenesis of Candida endophthalmitis is not well understood. Here, using in vivo and in vitro experimental models, we describe events leading to the invasion of Candida into the eye. We show that Candida from the systemic circulation disrupts the protective blood-retinal barrier and causes endogenous endophthalmitis. Our study highlights an important role of retinal pigment epithelial cells in evoking innate inflammatory and antimicrobial responses toward C. albicans infection. This study allows a better understanding of the pathobiology of fungal endophthalmitis, which can lead to the discovery of novel therapeutic targets to treat ocular fungal infections.

Endogenous Fungal Endophthalmitis: Causative Organisms, Treatments, and Visual Outcomes

Endogenous fungal endophthalmitis (EFE) is a vision-threatening intraocular infection and a rare complication of fungemia. Early diagnosis and prompt aggressive treatment are crucial to avoid vision loss. We retrospectively reviewed the data of 37 patients (49 eyes) with EFE who were treated at a tertiary referral hospital from January 2000 to April 2019. The most common risk factor was diabetes (24 patients; 65%), followed by recent hospitalization, urinary tract disease, liver disease, and immunosuppressive therapy. Two or more risk factors were detected in 24 patients (65%), and yeasts (29 patients; 78%) were more commonly detected than mold (8 patients; 22%). The most common fungal isolates were Candida spp. (78%), especially Candida albicans (70%). Moreover, 24 eyes in 21 patients underwent vitrectomy, and 2 eyes underwent evisceration. Retinal detachment (RD) occurred in 17 eyes (35%) in 14 patients, and eyes without RD exhibited significantly superior visual outcomes (p = 0.001). A comparison of the initial VA between the better (20/200 or better) and worse groups (worse than 20/200) revealed that better initial VA was related to a superior visual outcome (p = 0.003). Therefore, to achieve superior visual outcomes, early diagnosis and prompt treatment are necessary for patients with EFE.

Risk Factors and Clinical Characteristics of Patients with Ocular Candidiasis

Ocular candidiasis is a critical and challenging complication of candidemia. The purpose of this study was to investigate the appropriate timing for ophthalmologic examinations, risk factors for complications of ocular lesions, and their association with mortality. This retrospective cohort study applied, using multiple logistic regression analysis and Cox regression models, to cases of candidemia (age ≥ 18 years) for patients who underwent ophthalmologic consultation. Of the 108 candidemia patients who underwent ophthalmologic examination, 27 (25%) contracted patients had ocular candidiasis, and 7 experienced the more severe condition of endophthalmitis, which included subjective ocular symptoms. In most cases, the initial ophthalmologic examination was performed within one week of the onset of candidiasis with a diagnosis of ocular candidiasis, but in three cases, the findings became apparent only after a second examination within 7−14 days after onset of candidiasis. The independent risk factor extracted for the development of ocular candidiasis was the isolation of C. albicans (OR, 4.85; 95% CI, 1.58−14.90), unremoved CVC (OR, 10.40; 95% CI, 1.74−62.16), and a high βDG value (>108.2 pg/mL) (HR, 2.83; 95% CI = 1.24−6.27). Continuous ophthalmologic examination is recommended in cases of candidemia with the above risk factors with an initial examination within 7 days of onset and a second examination 7−14 days after onset.

The Incidence of Ocular Complications in Candidemic Patients and Implications for the Practice of Routine Eye Exams

Background

Ocular candidiasis is a known complication of candidemia. Given the poor ocular penetration of echinocandins, there is some concern that the increasing use of echinocandins may portend an increased incidence of ophthalmic complications. We examined the changing trends in antifungal prescribing patterns and the incidence of ophthalmic complications after candidemia.

Methods

Patients with blood cultures positive for Candida species between January 2014 and June 2020 who underwent screening fundoscopic examination by an ophthalmologist were analyzed. The χ² analysis was used to compare antifungal prescriptions and ocular exam findings before and after 2016. Trend analysis was also performed to assess temporal changes in prescribing practices and eye exam findings.

Results

There were 226 candidemia cases during the study period, 129 (57.1%) of which underwent screening eye exams. From 2014 to 2015, 24 of 37 (64.5%) patients received eye-penetrating antifungals compared to 36 of 92 (39.1%) from 2016 to 2020 (P = .008). Overall, 30 of 129 (23.3%) patients had abnormal eye exams with the prevalence of abnormal findings being 7 of 37 (18.9%) before 2016 compared to 23 of 92 (25%, P = .46) thereafter. A trend analysis revealed an increase in abnormal eye findings over the study period (P = .008). Of the 30 patients who had abnormal eye exams, 9 (30%) had a change in systemic antifungal therapy from echinocandins to eye-penetrating antifungals. Echinocandin use was associated with abnormal eye findings.

Conclusions

Prescription of eye-penetrating antifungals for candidemia has trended down since 2016. This was associated with a concomitant increase in abnormal findings on screening fundoscopy. Abnormal eye exams were not uncommon throughout our study period.

American Academy of Ophthalmology Recommendations on Screening for Endogenous Candida Endophthalmitis

The American Academy of Ophthalmology evaluated the practice of routine screening for intraocular infection from Candida septicemia. In the United States, ophthalmologists are consulted in the hospital to screen for intraocular infection routinely for patients with Candida bloodstream infections. This practice was established in the era before the use of systemic antifungal medication and the establishment of definitions of ocular disease with candidemia. A recent systematic review found a rate of less than 1% of routinely screened patients with endophthalmitis from Candida septicemia. Other studies found higher rates of endophthalmitis but had limitations in terms of inaccuracies in ocular disease classification, lack of vitreous biopsies, selection biases, and lack of longer-term visual outcomes. Some studies attributed ocular findings to Candida infections, rather than other comorbidities. Studies also have not demonstrated differences in medical management that are modified for eye disease treatment; therefore, therapy should be dictated by the underlying Candida infection, rather than be tailored on the basis of ocular findings. In summary, the Academy does not recommend a routine ophthalmologic consultation after laboratory findings of systemic Candida septicemia, which appears to be a low-value practice. An ophthalmologic consultation is a reasonable practice for a patient with signs or symptoms suggestive of ocular infection regardless of Candida septicemia.

Mind the gaps: challenges in the clinical management of invasive candidiasis in critically ill patients

PURPOSE OF REVIEW

Strict adherence to clinical practice guidelines is recognized to improve outcomes but the inconvenient truth is that only a small subset of what is done in medicine has been tested in appropriate, well designed studies. In this article, we aim to review controversial aspects of the clinical management of invasive candidiasis recommended by guidelines.

RECENT FINDINGS

Despite still being recommended by guidelines, we fail to identify a single randomized clinical trial documenting that the use of antifungal drugs in high-risk critically ill patients without microbiologic documentation of Candida infection decreases mortality. Regarding deep-seated Candida infections, most cohort studies of patients with candidemia found less than 5% of patients developed endophthalmitis and endocarditis. In this scenario, it is reasonable to reconsider routine universal screening of both complications in candidemic patients. Finally, a large number of studies have shown that critically ill patients usually have lower echinocandin exposure when compared with other populations. We need more data on the clinical relevance of this finding.

SUMMARY

We need robust studies to validate new strategies for the clinical management of candidemia in ICU, including: the use of fungal biomarkers in the early initiation or interruption of antifungal therapy in high-risk patients to replace the conventional empirical antifungal therapy driven by predictive rules; validation of targeted screening of eye infection and endocarditis with the aid of fungal biomarkers only in high-risk patients; we should clarify if higher doses of candins are necessary to treat invasive candidiasis in critically ill patients, especially in the case of intra-abdominal infections where drug penetration is suboptimal.

Factors associated with the development of ocular candidiasis and ocular prognosis with echinocandin therapy for candidemia

Purpose

To evaluate the factors associated with the development of ocular candidiasis (OC) and ocular prognosis with echinocandin therapy for candidemia.

Methods

The medical records of 56 consecutive patients with a positive blood culture for Candida species between November 2016 and October 2019 were retrospectively reviewed. Information on patient characteristics, isolated Candida species, treatment details for candidemia, and ocular findings were extracted to identify factors associated with OC development.

Results

The leading pathogen of candidemia was Candida albicans (C.albicans) (41.1%). Of 56 patients, 18 (32.1%) were diagnosed with chorioretinitis, categorized as either probable (8 patients) or possible OC (10 patients). There was no case of endophthalmitis with vitritis. The incidence of probable OC was not significantly different between the groups treated with echinocandins and other antifungal drugs (15.2% vs. 11.1%, p = 1.00). In all probable OC cases, systemic antifungal therapy was switched from echinocandins to azoles, and no case progressed to endophthalmitis. A multivariate logistic analysis revealed that female sex (adjusted odds ratio [aOR], 8.93; 95% confidence interval [CI], 1.09–72.9) and C. albicans (aOR, 23.6; 95% CI, 1.8–281) were independent factors associated with the development of probable OC.

Conclusion

One-seventh of patients with candidemia developed probable OC. Given the evidence of female and C. albicans as the factors associated with OC development, careful ophthalmologic management is required with these factors, especially in candidemia. Although echinocandins had no correlation with OC development and did not lead to the deterioration of ocular prognosis, further investigation is required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12348-021-00248-0.

CLINICAL UTILITY OF BETA-D-GLUCAN TESTING FOR ENDOGENOUS FUNGAL CHORIORETINITIS OR ENDOPHTHALMITIS

PURPOSE

To evaluate serum beta-D-glucan (BDG) as a biomarker for endogenous fungal eye infection.

METHODS

Retrospective case-control study of 88 patients with a BDG test and eye examination at UPenn (2013-2018). Cases had endogenous fungal chorioretinitis or endophthalmitis diagnosed by eye examination and confirmed with positive culture; controls were without these fungal eye findings. Charts were reviewed for BDG values, blood/vitreous cultures, and eye examinations. Outcomes were BDG sensitivity, specificity, positive predictive value, and negative predictive value for fungal chorioretinitis or endophthalmitis, using prespecified BDG cut-off points of ≥80, ≥250, and ≥500 pg/mL as test positive.

RESULTS

Cases included six chorioretinitis and four endophthalmitis patients. Controls included 78 patients without chorioretinitis or endophthalmitis. Defining BDG ≥80 pg/mL as test positive, the BDG sensitivity (95% confidence interval) was 66.7% (22.3%-95.7%) for chorioretinitis and 100% (39.8%-100%) for endophthalmitis. The specificity was 74.4% (63.2%-83.6%) when BDG values ≥80 pg/mL were test positive, and 85.9% (76.2%-92.7%) when values ≥250 pg/mL were test positive. For a 1% endophthalmitis prevalence and BDG cut-off value of ≥80 pg/mL, the positive predictive value was 3.8% (2.4%-5.2%) and negative predictive value was 100% (99.1%-100%).

CONCLUSION

For endogenous fungal endophthalmitis, BDG's sensitivity and specificity seem good and the negative predictive value is high; a larger ophthalmic study is indicated.

Endogenous Candida endophthalmitis: Who is really at risk?

OBJECTIVES

The Infectious Disease Society of America recommends that all patients with candidemia undergo a dilated retinal exam to exclude endogenous Candida endophthalmitis. Our objective was to determine if there are significant risk factors in candidemic patients for developing endogenous Candida endophthalmitis METHODS: We conducted a retrospective study of all candidemic patients at three academic medical centers between 2012 and 2017. We extracted risk factors for Candida endophthalmitis based on prior literature and compared them between patients with and without endophthalmitis. We then built a multivariate logistic regression model to assess which ones were significant.

RESULTS

We found 771 patients with candidemia. 120 (15.6%) of these patients were diagnosed with Candida endophthalmitis. In our logistic regression analysis, central venous catheter presence (OR 8.35), intravenous drug use (OR 4.76), immunosuppression (OR 2.40), total parenteral nutrition recipient (OR 2.28), race (OR 1.65), age (OR 1.02), and gender (OR 0.57) were risk factors for developing Candida endophthalmitis. Additionally, Candida albicans was more likely to result in Candida endophthalmitis (OR 1.86).

CONCLUSIONS

This cohort represents the largest study of risk factors for candidemic patients who developed endogenous Candida endophthalmitis. Based on our findings, clinicians should develop targeted and cost-effective strategies for endophthalmitis screening.

Prevalence and risk factors for endogenous fungal endophthalmitis in adult patients with candidemia at a tertiary care hospital in the Republic of Korea over 13 years

BACKGROUND

Endogenous fungal endophthalmitis (EFE) is a critical complication of candidemia. We conducted a study to investigate the prevalence and risk factors for EFE.

METHODS

Adult candidemia patients≥19years who underwent an ophthalmological examination at a tertiary care hospital in the Republic of Korea from 2006 to 2018 were enrolled.

RESULTS

There was a total of 152 adult candidemia patients analyzed. EFE was found in 29 patients (19.1%). Patients were categorized into two groups (Non-endophthalmitis [NE] and endophthalmitis [E]). Between the two groups, there was no significant difference in terms of age, sex, and underlying comorbidities. However, there were more Candida albicans candidemia, abnormal alanine aminotransferase (ALT) at the time of candidemia diagnosis, receipt of antifungal treatment≥48hours after onset of candidemia symptoms and blood culture sample (AOCS), and candidemia clearance≥5days after initiation of antifungal treatment (AIAT) in the E group. A predictive model for the E was created, which had an area of 0.811 under the receiver operating characteristics curve. In a multivariate logistic regression analysis, C. albicans candidemia, ALT at the time of candidemia diagnosis, receipt of antifungal treatment≥48hours AOCS, and candidemia clearance≥5days AIAT were significantly associated with EFE.

CONCLUSION

EFE occurred in 19% of adult patients with candidemia. Adult candidemia patients with C. albicans candidemia, abnormal ALT, receipt of antifungal treatment≥48hours AOCS, and candidemia clearance≥5days AIAT need to be closely monitored for the possibility of EFE.

Risk Factors for Endogenous Endophthalmitis in Hospitalized Patients with Candida Fungemia

PURPOSE

To use the 2002 through 2014 National Inpatient Sample (NIS) database to identify risk factors for endogenous endophthalmitis (EE) in hospitalized patients with candidemia.

DESIGN

Retrospective, cross-sectional study.

PARTICIPANTS

Hospitalized patients sampled in the NIS database.

METHODS

The NIS database (2002-2014) was used to identify patients with candidemia and EE and their comorbidities. Descriptive analysis was performed with chi-square testing, and risk factors for EE were identified using logistic regression analysis. Chi-square testing and regression analysis were performed using IBM SPSS software version 23 (IBM Corp, Armonk, NY) and R package software version 3.4.3 (R Foundation for Statistical Computing, Vienna, Austria), respectively.

MAIN OUTCOME MEASURE

Diagnosis of EE in hospitalized patients with candidemia.

RESULTS

We identified 98 783 hospitalized patients with candidemia; 529 patients (0.5%) had concurrent EE. Men constituted 48.0% of patients who did not demonstrate EE and 45.1% of those who did (P = 0.186). The average age of fungemia patients with EE was 54.6 years and of those without EE was 58.2 years (P < 0.001). Most EE cases (58.6%) occurred in patients 21 to 64 years of age. Hispanic (odds ratio [OR], 1.58), Asian or Pacific Islander (OR, 3.51), and Native American (OR, 5.22) patients with candidemia were at an increased risk of EE developing compared with White patients. Candida endocarditis (OR, 1.84), cirrhosis (OR, 1.93), diabetes with chronic complications (OR, 1.96), intravenous drug use (OR, 3.12), radiation therapy (OR, 5.28), and solid organ transplantation (OR, 2.48) increased the risk of seeding the infection into the eye. Conversely, chronic kidney disease (OR, 0.53) and invasive mechanical intubation (OR, 0.43) were associated with a decreased risk of EE. The mortality of inpatients with candidemia was significantly lower in the EE group (2.8% vs. 15.6%; P < 0.001).

CONCLUSIONS

Systemic comorbidities that increased the risk of EE in candidemia included endocarditis, cirrhosis, diabetes with chronic complications, intravenous drug use, radiation therapy, and solid organ transplantation. Racial disparity was observed with Hispanics, Asians and Pacific Islanders, and Native Americans at a higher risk than Whites of being diagnosed with EE in the setting of Candida fungemia.

An analysis of totally implantable central venous port system infections in an urban tertiary referral center

A frequent complication of central venous port systems (CVP) is infection (CVP-I), either local (CVP-LI) or a life-threatening blood stream infection (CVP-BSI). We examined the course of CVP-I including results of an antibiotic eradication attempt of CVP-BSI. We investigated adults with CVP-I from 2010 to 2018 who had to undergo port explantation or were treated by a combination of systemic antibiotics and antibiotic lock therapy (ALT). In nine years we diagnosed 206 CVP-I (CVP-LI: 52; CVP-BSI: 152). In 146 patients with CVP-I the port system was primary explanted, while 56 patients received antibiotics/ALT. 79% of Gram negative pathogens and 50% of coagulase negative staphylococci (CoNS) were eradicated. Failure of antibiotic treatment was more often associated with short time span since CVP implantation, neutropenia and polymicrobial infection. All patients with non-neoplastic disease survived, while 18/173 patients (10%) with underlying malignant disease had a fatal outcome in the same hospital stay.

Evaluation of Susceptibility and Innate Immune Response in C57BL/6 and BALB/c Mice During Candida albicans Endophthalmitis

PURPOSE

Candida remains the leading cause of fungal endophthalmitis. However, the pathobiology and innate immune responses in this disease are not well characterized. Here, we developed two murine models of candida endophthalmitis and evaluated their disease susceptibility and differential immune response.

METHODS

Endophthalmitis was induced in C57BL/6 (B6) and BALB/c mice by intravitreal injection of Candida albicans (CA). Disease progression was monitored by slit-lamp examination and clinical scoring, followed by retinal function assessment using electroretinography (ERG). Enucleated eyes were used to estimate fungal burden and retinal tissue damage by hematoxylin and eosin and TUNEL staining. The level of inflammatory mediators were determined by quantitative Polymerase Chain Reaction (qPCR) and enzyme-linked immunosorbent assay, whereas neutrophil infiltration was assessed by flow cytometry and immunostaining.

RESULTS

Intravitreal injection of CA at 6500 colony-forming units resulted in sustained (non-resolving) ocular inflammation in both B6 and BALB/c mice as evidenced by increased levels of inflammatory cytokines (tumor necrosis factor-α, interleukin-1β, and interleukin-6) and chemokine (CXCL2/MIP-2). In both mouse strains, fungal burden peaked at 24 to 48 hours post-infection (hpi) and decreased by 72 to 96 hpi. CA-infected eyes exhibited increased polymorphonuclear neutrophils (PMN) infiltration and retinal tissue damage. Overall retinal function declined rapidly, with a significant reduction in ERG response at 12 hpi and near-total loss by 24 hpi. Differential analyses revealed increased pathology in BALB/c versus B6 mice.

CONCLUSIONS

C. albicans was able to cause endophthalmitis in mice. Although BALB/c mice were found to be more susceptible to CA endophthalmitis, both BALB/c and B6 models could be used to study fungal endophthalmitis and test therapeutic modalities.

Interactions between invasive fungi and symbiotic bacteria

Infection rates and mortality associated with the invasive fungi Candida, Aspergillus, and Cryptococcus are increasing rapidly in prevalence. Meanwhile, screening pressure brought about by traditional antifungal drugs has induced an increase in drug resistance of invasive fungi, which creates a great challenge for the preservation of physical health. Development of new drugs and novel strategies are therefore important to meet these growing challenges. Recent studies have confirmed that the dynamic balance of microorganisms in the body is correlated with the occurrence of infectious diseases. This discovery of interactions between bacteria and fungi provides innovative insight for the treatment of invasive fungal infections. However, different invasive fungi and symbiotic bacteria interact with each other through various ways and targets, leading to different effects on their growth, morphology, and virulence. And the mechanism and implication of these interactions remains largely unknown. The present review aims to summarize the research progress into the interaction between invasive fungi and symbiotic bacteria with a focus on the anti-fungal mechanisms of symbiotic bacteria, providing a new strategy against drug-resistant fungal infections.

Teasaponin suppresses Candida albicans filamentation by reducing the level of intracellular cAMP

Background

Candidiasis has long been a threat to human health, but cytotoxicity and resistance always block the usefulness of antifungal agents. The ability to switch between yeast and hypha is one of the most discussed virulence trait attributes of the human pathogenic fungus Candida albicans. The morphological transition provides a novel target for developing antifungal drugs. The aim of the present study was to explore the activity and mechanism of teasaponin (TS), a generally regarded as safe natural product, in inhibiting filamentation of C. albicans, hoping to provide an experimental basis for its clinical application.

Methods

The effect of TS on filamentation and biofilm formation of C. albicans was evaluated by XTT reduction assay and microscopy. The level of intracellular cAMP was measured to further explore the underlying mechanism. In addition, cytotoxicity of TS was evaluated by using MTT assay in vitro and Caenorhabditis elegans model in vivo. The potential of TS-resistance induction was tested by a serial passage experiment.

Results

TS displayed a moderate antifungal activity against the wild type, efflux pump mutant and multi-resistance C. albicans strains, and could effectively retard filamentation and biofilm formation with a low MIC value. Further mechanism investigation revealed that the reduced cAMP level inhibited filamentation and biofilm formation. In addition, TS showed no significant cytotoxicity in vitro or in vivo, and had little potential to develop resistance during long-time induction.

Conclusions

Our work evaluated the antifungal activity of TS against filamentation and biofilms formation of C. albicans and disclosed the underlying mechanism, which might provide useful clues for the potential clinical application of TS in fighting clinical fungal infections by targeting the virulence factors.

Clinical characteristics and risk factors for complications of candidaemia in adults: Focus on endophthalmitis, endocarditis, and osteoarticular infections

OBJECTIVES

This study evaluated the incidence, risk factors, and clinical characteristics of complications of candidaemia in adults, with a focus on endophthalmitis, endocarditis, and osteoarticular infections.

METHODS

All patients ≥18 years old with candidaemia in two Korean tertiary hospitals from 2007 to 2016 were investigated. Complications of candidaemia were defined as the presence of endophthalmitis, endocarditis, or osteoarticular infections documented in patients with candidaemia. The clinical characteristics and risk factors for candidaemia with complications were analysed in the patients who underwent ophthalmological examinations.

RESULTS

Of 765 adult patients with candidaemia, 34 (4.4%) met the definition of complications, including endophthalmitis in 29 (3.8%), endocarditis in 4 (0.5%), and osteoarticular infections in 3 (0.4%). Of the 225 patients who underwent ophthalmological examinations, 29 (12.9%) had endophthalmitis. Candida albicans was an independent risk factor for complicated candidaemia (OR, 5.12; 95% CI, 2.17-12.09; P < 0.001). Although the mortality rate was no higher in complicated candidaemia, the duration of antifungal therapy was longer (23.1 ± 17.6 vs. 16.4 ± 10.8 days, P = 0.042), and 13 patients (39.3%) underwent additional procedures or surgery.

CONCLUSIONS

Complications of candidaemia occurred in 4.4% of adult patients. C. albicans was an independent risk factor for complicated candidaemia in adults. Complications of candidaemia might need prolonged treatment and additional procedures or surgery. Therefore, careful evaluation and active treatment of candidaemia with complications should be encouraged.

Effect of infectious disease consultation on mortality and treatment of patients with candida bloodstream infections: a retrospective, cohort study

BACKGROUND

Candida bloodstream infection is associated with high mortality. Infectious disease consultation improves outcomes in several infections, including Staphylococcus aureus and cryptococcosis, as well as multidrug-resistant organisms. We aimed to examine the association between infectious disease consultation and differences in management with mortality in candida bloodstream infections.

METHODS

In this retrospective, single-centre cohort study, we reviewed the medical charts of all patients admitted to Barnes-Jewish Hospital (St Louis, MO, USA), a tertiary referral centre, aged 18 years or older with candida bloodstream infection from 2002 to 2015. We collected data for demographics, comorbidities, predisposing factors, all-cause mortality, antifungal use, central-line removal, and ophthalmological and echocardiographic evaluation to assess 90-day all-cause mortality between individuals with and without an infectious disease consultation. For the survival analysis we used Cox proportional hazards model with inverse weighting by propensity score to assess the effects of infectious disease consultation on mortality and differences in management.

FINDINGS

Between Jan 1, 2002, and Dec 31, 2015, of 1794 patients assessed for eligibility, we analysed 1691 patients with candida bloodstream infection; 776 (45·9%) who had an infectious disease consultation and 915 (54·1%) who did not have an infectious disease consultation. All 1691 patients were included in the analysis. None were missing data. Most underlying comorbidities were evenly distributed between groups. 90-day mortality was lower in the infectious disease consultation group than in patients who did not receive an infectious disease consultation (29% [222/776] vs 51% [468/915]; p<0·0001). In the model with inverse weighting by the propensity score, infectious disease consultation was associated with a hazard ratio of 0·81 (95% CI 0·73-0·91; p<0·0001) for mortality. In the consultation group, median duration of antifungal therapy was longer (18 [IQR 14-35] vs 14 [6-20] days; p<0·0001) and central-line removal (587 [76%] of 776 vs 538 [59%] of 915; p<0·0001), echocardiography use (442 [57%] of 776 vs 305 [33%] of 915; p<0·0001), and ophthalmological examination (412 [53%] of 776 vs 160 [17%] of 915; p<0·0001) were more frequently done. Fewer patients in the infectious disease consultation group were not treated (13 [2%] of 776 vs 128 [14%] of 915; p<0·0001).

INTERPRETATION

Patients with candida bloodstream infection receiving an infectious disease consultation have lower mortality. This finding might be attributable to these individuals receiving a higher number of non-pharmacological, evidence-based interventions and lower amounts of non-treatment. These data suggest that an infectious disease consultation should be an integral part of clinical care of patients with candida bloodstream infection.

FUNDING

Astellas Global Development Pharma, Washington University Institute of Clinical and Translational Sciences, and the Agency for Healthcare Research and Quality.

Risk factors and outcomes of patients with ocular involvement of candidemia

Background

Ocular involvement of candidemia can result in serious complications, including vision loss. This study investigated the risk factors for ocular involvement in patients with candidemia and the outcomes of treatment.

Methods

Episodes of candidemia in hospitalized adults who underwent ophthalmic examinations within 2 weeks of candidemia onset between January 2014 and May 2017 were retrospectively reviewed. Their demographic characteristics, antifungal treatments, and visual outcomes were evaluated.

Results

During the study period, 438 adults were diagnosed with candidemia, with 275 (62.8%) undergoing ophthalmic examinations within 2 weeks. Of these 275 patients, 59 (21.5%) had fundoscopic abnormalities suggestive of ocular involvement, including 51 with chorioretinitis and eight with Candida endophthalmitis. Eleven patients were symptomatic. Persistent candidemia (adjusted odd ratio [aOR], 2.55; 95% confidence interval [CI], 1.29–5.08; P = 0.01), neutropenia during the preceding 2 weeks (aOR, 2.92; 95% CI, 1.14–7.53; P = 0.03), and C. albicans infection (aOR, 2.15; 95% CI, 1.09–4.24; P = 0.03) were independently associated with ocular involvement. Among the 24 patients with neutropenia, 41.7% had ocular involvements at the initial examination. Ophthalmologic examination even before the neutrophil recovery was positive in one-third of neutropenic patients. Out of the 37 patients in whom ocular outcomes after 6 weeks were available, 35 patients showed favorable or stable fundoscopic findings. Two patients had decreased visual acuity despite the stable fundoscopic finding.

Conclusion

Neutropenia within two weeks of candidemia was a risk factor for ocular involvement. More than 80 percent of patients with ocular involvements were asymptomatic, emphasizing the importance of routine ophthalmic examinations. The median 6 weeks of systemic antifungal treatment resulted in favorable outcomes in 89.2% of patients.

The incidence of endophthalmitis or macular involvement and the necessity of a routine ophthalmic examination in patients with candidemia

Background

The incidence of ocular candidiasis (OC) in patients with candidemia varies across different reports, and the issue of whether routine ophthalmoscopy improves outcomes has been raised. This study investigated the incidence of OC and evaluate whether the extent of OC impacts the clinical outcomes.

Methods

This retrospective study included non-neutropenic patients with candidemia who underwent treatment at one of 15 medical centers between 2010 and 2016. Chorioretinitis without other possible causes for the ocular lesions and endophthalmitis was classified as a probable OC. If signs of chorioretinitis were observed in patients with a systemic disease that causes similar ocular lesions, they were classified as a possible OC.

Results

In total, 781 of 1089 patients with candidemia underwent an ophthalmic examination. The prevalence of OC was 19.5%. The time from the collection of a positive blood culture to the initial ophthalmic examination was 5.0 ± 3.9 days in patients with OC. The leading isolate was Candida albicans (77.9%). Possible OC was associated with unsuccessful treatments (resolution of ocular findings) (odds ratio: 0.354, 95% confidence interval: 0.141–0.887), indicating an overdiagnosis in patients with a possible OC. If these patients were excluded, the incidence fell to 12.8%. Endophthalmitis and/or macular involvement, both of which require aggressive therapy, were detected in 43.1% of patients; a significantly higher incidence of visual symptoms was observed in these patients.

Conclusion

Even when early routine ophthalmic examinations were performed, a high incidence of advanced ocular lesions was observed. These results suggest that routine ophthalmic examinations are still warranted in patients with candidemia.