Secular trends in nosocomial primary bloodstream infections in the United States, 1980-1989. National Nosocomial Infections Surveillance System

Candidaemia: A 9-Year Retrospective Analysis of Epidemiology and Antimicrobial Susceptibility in Tertiary Care Hospitals in Western China

Purpose

This investigation endeavors to scrutinize the resistance profiles to antifungal agents, alongside the clinical distribution of Candida isolates that yielded positive results in blood cultures at Suining Central Hospital spanning the years 2015 to 2023. The objective is to provide crucial epidemiological insights that may aid in early clinical intervention and judicious deployment of antifungal therapies.

Methods

This retrospective analysis analyses data on 182 different Candida strains with positive clinical blood cultures obtained from the Microbiology Laboratory of Suining Central Hospital over a period of nine consecutive years. The study involved identification of Candida species and assessment of resistance patterns to fungal drugs.

Results

Our analysis revealed that the median age of patients diagnosed with Candidaemia from the 182 strains was 62 years, with a distribution of 63.7% females and 36.3% males. Within the cohort of 182 Candida strains, Candida albicans constituted 32.4%, while non-albicans Candida species comprised 67.6% of the cases. Specifically, Candida tropicalis represented 37.4%, Candida glabrata 12.1%, Candida parapsilosis 11.0%,Candida guilliermondii 3.8%, and both Candida krusei and Candida Dublin accounted for 1.6% each. These Candida species were predominantly identified in intensive care units (ICU), hematology, gastroenterology, neurology centers, and endocrine metabolism units.

Conclusion

The findings of this investigation suggest a shift in the prevalence of non-Candida albicans species, notably C. tropicalis, as the predominant cause of Candidaemia at Suining Central Hospital, surpassing C. albicans. Although instances of antifungal resistance are infrequent, there has been a notable rise in resistance to azoles. This study provides important insights into the local epidemiology, which will be essential for informing the selection of empirical antifungal therapy and contributing to the global surveillance of antifungal resistance.

The changing epidemiology of fungal infections

Invasive fungal diseases are common complications in critically ill patients and in those with significant underlying imbalanced immune systems. Fungal co-, and/or super-infections are emerging and have become a rising concern within the last few years. In Europe, cases of candidiasis and aspergillosis dominate, followed by mucormycosis in India. Epidemiological studies show an increasing trend in the incidence of all three entities. Parallel to this, a shift within the underlying fungal pathogens is observed. More non-albicans Candida infections and aspergillosis with cryptic species are on the rise; cryptic species may cover intrinsic resistance to azoles and other antifungal drugs. The recent COVID-19 pandemic led to a significantly increasing incidence of invasive fungal diseases among hospitalized patients.

Fungal carriage of hospital trapped cockroaches: A prospective study

Cockroaches are considered parasite carriers, and their nocturnal habits and regular contact with various environments make them ideal carriers of diverse fungal species. The aim of this study was to isolate superficial fungi carried by cockroaches trapped at our health care institution. A total of 100 cockroaches were captured from 6 wards of the hospital and were investigated for the presence of fungi on their external surface by using SDA medium. In this survey, 78% of the sampled cockroaches were contaminated with 96 fungi of medical importance, and the fungal prevalence was linked to some hospital areas, such as nephroplogy-haemodialysis p = 0,013 OR = 1367 IC95% (1199-1558), which could be explained by the presence of dialysis devices in which cockroaches can hide. Correlations were found between cockroach fungal contamination and the following variables: kitchen p = 0,026, OR = 1,349, IC95% (1190-1530); toilets p = 0,011, OR = 2,813, IC95% (0,868-9112); and patient rooms p = 0,01, OR = 3,621, IC95% (1322-9920), probably due to cockroaches searching for food among waste, garbage, skin flakes, and hair. The main fungi isolated were Rhizopus sp (21,9%), Candida non candida (16,7%), Aspergillus niger (15,6%), and Lichtheimia sp (12,5%). These results suggest that cockroaches act as carriers of several medically important fungi and could be involved in their transfer to hospital settings. There is a need for better control of these insects, especially in kitchens, bathrooms, and patient rooms.

Anaerobic conditions are a major influence on Candida albicans chlamydospore formation

Candidiasis now represents the fourth most frequent nosocomial infection both in the USA and worldwide. Candida albicans is an increasingly common threat to human health as a consequence of AIDS, steroid therapy, organ and tissue transplantation, cancer therapy, broad-spectrum antibiotics, and other immune defects. Unfortunately, these infections carry unacceptably high morbidity, mortality rates and important economic repercussions (estimated total direct cost of approximately 2 billion dollars in 1998 in US hospitals alone). This pathogen can grow both in yeast and filamentous forms and the pathogenic potential of C. albicans is intimately related to certain key processes including filamentation. Chlamydospores are considered to be a dormant form of C. albicans that remain understudied. Chlamydospores have been widely used as a diagnostic tool to separate C. albicans and C. dubliniensis from other Candida species. More recently, media have been developed that use chlamydopsore formation to separate C. albicans and C. dubliniensis from each other. Chlamydospore formation can be stimulated by hypoxic conditions but only on limited specific media types. Here, we show that anaerobic conditions are enough to drive chlamydospore formation in C. albicans on the surface of nutrient-rich agar.

Chemical composition, antifungal activity, antifungal mechanism and interaction manner of the fatty acid of Prunus mahaleb L. with fluconazole

The interaction manner of Prunus mahaleb L. (P. mahaleb) seed oil (MSO) and fluconazole (FLC: antimycotic) combinations (MSO*FLC) against C. albicans and C. parapsilosis were evaluated using the microdilution technique. The most representative compounds of mahaleb oil were found to be conjugated linolenic acid (34.39%), oleic acid (31.76%), and linoleic acid (25.54%) by GC-MS. In antimicrobial activity study, P. mahaleb had an inhibition zone (IZ) of C. albicans and C. parapsilosis with 6.89 mm and 11.39 mm and a minimum inhibitory concentration (MIC) with 35.3 µgmL^-1 and 23.9 µgmL^-1, respectively. The strongest indifferent effect was observed as 57.14% for C. albicans and 100% for C. parapsilosis in fluconazole-mahaleb oil combinations. An increase in DNA and protein leakage was observed when yeast was exposed to the FA. The destruction on the cell surface was visualized using Scanning Electron Microscopy (SEM) analysis.

WCK 4034: A promising oxazolidinone for treating gram positive infections

Increased resistance to gram positive infections have highlighted the limitations of currently available drug treatments including penicillins, macrolides and glycopeptides. As an alternative to address these challenges; Linezolid, the first antibiotic from oxazolidinone class, have shown the promising activities against such infections, although associated toxicological issues limiting the use of linezolid for prolonged treatments. In order to circumvent disadvantages allied with the marketed drugs, we herein reporting the synthesis of WCK 4034, an oxazolidinone antibiotic through our structure activity relationship (SAR) program. Through this exercise, WCK 4034, has shown competitive MIC values against Methicillin Sensitive S. aureus (MSSA, Sta-001), Methicillin Resistant S. aureus (MRSA, Sta-032), S. pneumoniae ATCC 49619 and H. influenza ATCC 35054 species as like linezolid. Although with an additional advantage; WCK 4034 has been found superior during dog PK studies as compare to Linezolid. With the preliminary studies in our hand, we herein assuming these improved pharmacokinetic values would be helpful. Moreover, WCK 4034 has successfully completed pre-clinical studies and ready to enter the clinical space, and paved the way for in house development of other oxazolidinone NCEs.

Continuing Shifts in Epidemiology and Antifungal Susceptibility Highlight the Need for Improved Disease Management of Invasive Candidiasis

Invasive candidiasis (IC) is a systemic life-threatening infection of immunocompromised humans, but remains a relatively neglected disease among public health authorities. Ongoing assessments of disease epidemiology are needed to identify and map trends of importance that may necessitate improvements in disease management and patient care. Well-established incidence increases, largely due to expanding populations of patients with pre-disposing risk factors, has led to increased clinical use and pressures on antifungal drugs. This has been exacerbated by a lack of fast, accurate diagnostics that have led treatment guidelines to often recommend preventative strategies in the absence of proven infection, resulting in unnecessary antifungal use in many instances. The consequences of this are multifactorial, but a contribution to emerging drug resistance is of primary concern, with high levels of antifungal use heavily implicated in global shifts to more resistant Candida strains. Preserving and expanding the utility and number of antifungals should therefore be of the highest priority. This may be achievable through the development and use of biomarker tests, bringing about a new era in improved antifungal stewardship, as well as novel antifungals that offer favorable profiles by targeting Candida pathogenesis mechanisms over cell viability.

Incidence of Monomicrobial Staphylococcus aureus Bacteremia: A Population-Based Study in Olmsted County, Minnesota – 2006 to 2020

Background

Population-based studies of Staphylococcus aureus bacteremia (SAB) in the United States are limited. We provide a contemporary evaluation of SAB incidence in Olmsted County, Minnesota, from 2006 to 2020.

Methods

This was a retrospective population-based study of all adult patients with SAB residing in Olmsted County from 1 January 2006 through 31 December 2020. Initial episodes of SAB were identified using the microbiology laboratory databases at both Olmsted Medical Center and Mayo Clinic Rochester.

Results

Overall, 541 incident SAB cases were identified with a median age of 66.8 (interquartile range, 54.4–78.5) years, and 60.4% were male. Among these cases, 298 (56.2%) were due to methicillin-susceptible S aureus (MSSA) and 232 (43.8%) cases of methicillin-resistant S aureus (MRSA). The overall age- and sex-adjusted SAB incidence rate (IR) was 33.9 (95% confidence interval [CI], 31.0–36.8) cases/100 000 person-years (PY). Males had a higher age-adjusted IR of 46.0 (95% CI, 41.0–51.0) cases/100 000 PY compared to females (IR, 24.4 [95% CI, 21.1–27.7] cases/100 000 PY). Age- and sex-adjusted SAB IRs due to MSSA and MRSA were 18.7 and 14.6 cases/100 000 PY, respectively, and the percentage of incident SAB cases due to MRSA fluctuated across the study period. There was no apparent temporal trend in SAB incidence over the study period (P = .093).

Conclusions

Our investigation represents the only contemporary population-based study in the United States. Despite the impression that SAB incidence may have increased based on Centers for Disease Control and Prevention surveillance data, our finding of no change in SAB incidence was somewhat unanticipated.

Candida Bloodstream Infections: Changes in Epidemiology and Increase in Drug Resistance

The literature on bloodstream infections (BSIs) have predominantly been biased towards bacteria, given their superior clinical significance in comparison with the other types of microorganisms. Fungal pathogens have epidemiologically received relatively less attention, although they constitute an important proportion of BSI aetiologies. In this review, the authors discuss the clinical relevance of fungal BSIs in the context of Candida species, as well as treatment options for the infections, emphasizing the compelling need to develop newer antifungals and strengthen antimicrobial stewardship programmes in the wake of the rapid spread of antifungal resistance.

Deciphering the epidemiology of invasive candidiasis in the intensive care unit: is it possible?

Invasive candidiasis (IC) has emerged in the last decades as an important cause of morbidity, mortality, and economic load in the intensive care unit (ICU). The epidemiology of IC is still a difficult and unsolved enigma for the literature. Accurate estimation of the true burden of IC is difficult due to variation in definitions and limitations inherent to available case-finding methodologies. Candidemia and intra-abdominal candidiasis (IAC) are the two predominant types of IC in ICU. During the last two decades, an increase in the incidence of candidemia has been constantly reported particularly in the expanding populations of elderly or immunosuppressed patents, with a parallel change in Candida species (spp.) distribution worldwide. Epidemiological shift in non-albicans spp. has reached worrisome trends. Recently, a novel, multidrug-resistant Candida spp., Candida auris, has globally emerged as a nosocomial pathogen causing a broad range of healthcare-associated invasive infections. Epidemiological profile of IAC remains imprecise. Though antifungal drugs are available for Candida infections, mortality rates continue to be high, estimated to be up to 50%. Increased use of fluconazole and echinocandins has been associated with the emergence of resistance to these drugs, which affects particularly C. albicans and C. glabrata. Crucial priorities for clinicians are to recognize the epidemiological trends of IC as well as the emergence of resistance to antifungal agents to improve diagnostic techniques and strategies, develop international surveillance networks and antifungal stewardship programmes for a better epidemiological control of IC.

Analysis of Genome Sequences of Coagulase-Negative Staphylococci Isolates from South Africa and Nigeria Highlighted Environmentally Driven Heterogeneity

Here, we report high-quality annotated draft genomes of eight coagulase-negative staphylococci (CoNS) isolates obtained from South Africa and Nigeria. We explored the prevalence of antibiotic resistance and virulence genes, their association with mobile genetic elements. The pan-genomic analysis highlighted the environmentally driven heterogeneity of the isolates. Isolates from Nigeria had at least one gene for cadmium resistance/tolerance, these genes were not detected in isolates from South Africa. In contrast, isolates from South Africa had a tetM gene, which was not detected among the isolates from Nigeria. The observed genomic heterogeneity correlates with anthropogenic activities in the area where the isolates were collected. Moreover, the isolates used in this study possess an open pan-genome, which could easily explain the environmentally driven heterogeneity.

Spectrum of candidal species isolated from neonates admitted in an Intensive Care Unit of teaching hospital of Kashmir, North India

BACKGROUND:

Candidal infections are an important cause of morbidity and mortality in Neonatal Intensive Care Unit. Neonatal candidiasis is increasing in frequency, mainly because of increase in the survival of babies with low-birth weight, preterm births, advancement in medical field, life support systems, relative immunodeficiency, and extensive use of broad-spectrum antibiotics. Over the past few decades, there has been a progressive shift from the predominance of Candida albicans to nonalbicans Candida species.

AIMS AND OBJECTIVES:

The objective of the current study was to know the prevalence of non albicans candidemia in neonates and their antifungal susceptibility pattern.

MATERIALS AND METHODS:

In this study, a total of 424 samples from clinically diagnosed septicemic neonates were included. Identification of Candida isolates from these samples as well as their antifungal sensitivity testing was performed with Vitek 2 Compact (Biomerieux France) using Vitek 2 cards for identification of yeast and yeast-like organisms (ID-YST cards).

RESULTS:

A total of 246/424 (58.01%) cases were blood culture positive. Out of these, 80/246 samples tested positive for candidemia (32.5%). Candida tropicalis (13.8%) was the predominant species isolated among the non-albicans Candida followed by Candida krusei (4.8%), Candida parapsilosis (3.2%), Candida guilliermondii (2.8%), and Candida dubliniensis (2.0%). We found an increase in the antifungal drug resistance, especially for the azole group of drugs, both in C. albicans and non-albicans Candida species. All the isolates were uniformly sensitive to micafungin, voriconazole, and caspofungin.

CONCLUSION:

Candidemia in neonates is an ominous prognostic sign and is an important entity in our region. The present study highlights the mycological shift of Candida species in neonatal candidemia with a preponderance of nonalbicans Candida species.

Repositionable Compounds with Antifungal Activity against Multidrug Resistant Candida auris Identified in the Medicines for Malaria Venture's Pathogen Box

Background. Candida auris has spread rapidly around the world as a causative agent of invasive candidiasis in health care facilities and there is an urgent need to find new options for treating this emerging, often multidrug-resistant pathogen. Methods. We screened the Pathogen Box^® chemical library for inhibitors of C. auris strain 0390, both under planktonic and biofilm growing conditions. Results. The primary screen identified 12 compounds that inhibited at least 60% of biofilm formation or planktonic growth. After confirmatory dose-response assays, iodoquinol and miltefosine were selected as the two main leading repositionable compounds. Iodoquinol displayed potent in vitro inhibitory activity against planktonic C. auris but showed negligible inhibitory activity against biofilms; whereas miltefosine was able to inhibit the growth of C. auris under both planktonic and biofilm-growing conditions. Subsequent experiments confirmed their activity against nine other strains C. auris clinical isolates, irrespective of their susceptibility profiles against conventional antifungals. We extended our studies further to seven different species of Candida, also with similar findings. Conclusion. Both drugs possess broad spectrum of activity against Candida spp., including multiple strains of the emergent C. auris, and may constitute promising repositionable options for the development of novel therapeutics for the treatment of candidiasis.

Population-Based Active Surveillance for Culture-Confirmed Candidemia - Four Sites, United States, 2012-2016

PROBLEM/CONDITION

Candidemia is a bloodstream infection (BSI) caused by yeasts in the genus Candida. Candidemia is one of the most common health care-associated BSIs in the United States, with all-cause in-hospital mortality of up to 30%.

PERIOD COVERED

2012-2016.

DESCRIPTION OF SYSTEM

CDC's Emerging Infections Program (EIP), a collaboration among CDC, state health departments, and academic partners that was established in 1995, was used to conduct active, population-based laboratory surveillance for candidemia in 22 counties in four states (Georgia, Maryland, Oregon, and Tennessee) with a combined population of approximately 8 million persons. Laboratories serving the catchment areas were recruited to report candidemia cases to the local EIP program staff. A case was defined as a blood culture that was positive for a Candida species collected from a surveillance area resident during 2012-2016. Isolates were sent to CDC for species confirmation and antifungal susceptibility testing. Any subsequent blood cultures with Candida within 30 days of the initial positive culture in the same patient were considered part of the same case. Trained surveillance officers collected clinical information from the medical chart for all cases, and isolates were sent to CDC for species confirmation and antifungal susceptibility testing.

RESULTS

Across all sites and surveillance years (2012-2016), 3,492 cases of candidemia were identified. The crude candidemia incidence averaged across sites and years during 2012-2016 was 8.7 per 100,000 population; important differences in incidence were found by site, age group, sex, and race. The crude annual incidence was the highest in Maryland (14.1 per 100,000 population) and lowest in Oregon (4.0 per 100,000 population). The crude annual incidence of candidemia was highest among adults aged ≥65 years (25.5 per 100,000 population) followed by infants aged <1 year (15.8). The crude annual incidence was higher among males (9.4) than among females (8.0) and was approximately 2 times greater among blacks than among nonblacks (13.7 versus 5.8). Ninety-six percent of cases occurred in patients who were hospitalized at the time of or during the week after having a positive culture. One third of cases occurred in patients who had undergone a surgical procedure in the 90 days before the candidemia diagnosis, 77% occurred in patients who had received systemic antibiotics in the 14 days before the diagnosis, and 73% occurred in patients who had had a central venous catheter (CVC) in place within 2 days before the diagnosis. Ten percent were in patients who had used injection drugs in the past 12 months. The median time from admission to candidemia diagnosis was 5 days (interquartile range [IQR]: 0-16 days). Among 2,662 cases that were treated in adults aged >18 years, 34% were treated with fluconazole alone, 30% with echinocandins alone, and 34% with both. The all-cause, in-hospital case-fatality ratio was 25% for any time after admission; the all-cause in-hospital case-fatality ratio was 8% for <48 hours after a positive culture for Candida species. Candida albicans accounted for 39% of cases, followed by Candida glabrata (28%) and Candida parapsilosis (15%). Overall, 7% of isolates were resistant to fluconazole and 1.6% were resistant to echinocandins, with no clear trends in resistance over the 5-year surveillance period.

INTERPRETATION

Approximately nine out of 100,000 persons developed culture-positive candidemia annually in four U.S. sites. The youngest and oldest persons, men, and blacks had the highest incidences of candidemia. Patients with candidemia identified in the surveillance program had many of the typical risk factors for candidemia, including recent surgery, exposure to broad-spectrum antibiotics, and presence of a CVC. However, an unexpectedly high proportion of candidemia cases (10%) occurred in patients with a history of injection drug use (IDU), suggesting that IDU has become a common risk factor for candidemia. Deaths associated with candidemia remain high, with one in four cases resulting in death during hospitalization.

PUBLIC HEALTH ACTION

Active surveillance for candidemia yielded important information about the disease incidence and death rate and persons at greatest risk. The surveillance was expanded to nine sites in 2017, which will improve understanding of the geographic variability in candidemia incidence and associated clinical and demographic features. This surveillance will help monitor incidence trends, track emergence of resistance and species distribution, monitor changes in underlying conditions and predisposing factors, assess trends in antifungal treatment and outcomes, and be helpful for those developing prevention efforts. IDU has emerged as an important risk factor for candidemia, and interventions to prevent invasive fungal infections in this population are needed. Surveillance data documenting that approximately two thirds of candidemia cases were caused by species other than C. albicans, which are generally associated with greater antifungal resistance than C. albicans, and the presence of substantial fluconazole resistance supports 2016 clinical guidelines recommending a switch from fluconazole to echinocandins as the initial treatment for candidemia in most patients.

Nano-biofilm Arrays as a Novel Universal Platform for Microscale Microbial Culture and High-Throughput Downstream Applications

Biofilms are the predominant mode of microbial growth and it is now fully accepted that a majority of infections in humans are associated with a biofilm etiology. Biofilms are defined as attached and structured microbial communities surrounded by a protective exopolymeric matrix. Importantly, sessile microorganisms growing within a biofilm are highly resistant to antimicrobial agents. Thus, there is an urgent need to develop new and improved anti-biofilm therapies. Unfortunately, most of the current techniques for in-vitro biofilm formation are not compatible with high throughput screening techniques that can speed up discovery of new drugs with anti-biofilm activity. To try to overcome this major impediment, our group has developed a novel technique consisting of micro-scale culture of microbial biofilms on a microarray platform. Using this technique, hundreds to thousands of microbial biofilms, each with a volume of approximately 30-50 nanolitres, can be simultaneously formed on a standard microscope slide. Despite more than three orders of magnitude of miniaturization over conventional biofilms, these nanobiofilms display similar growth, structural and phenotypic properties, including antibiotic drug resistance. These nanobiofilm chips are amenable to automation, drastically reducing assay volume and costs. This technique platform allows for true high-throughput screening in search for new anti-biofilm drugs.

Non-Toxic and Ultra-Small Biosilver Nanoclusters Trigger Apoptotic Cell Death in Fluconazole-Resistant Candida albicans via Ras Signaling

Silver-based nanostructures are suitable for many biomedical applications, but to be useful therapeutic agents, the high toxicity of these nanomaterials must be eliminated. Here, we biosynthesize nontoxic and ultra-small silver nanoclusters (rsAg@NCs) using metabolites of usnioid lichen (a symbiotic association of algae and fungi) that exhibit excellent antimicrobial activity against fluconazole (FCZ)-resistant Candida albicans that is many times higher than chemically synthesized silver nanoparticles (AgNPs) and FCZ. The rsAg@NCs trigger apoptosis via reactive oxygen species accumulation that leads to the loss of mitochondrial membrane potential, DNA fragmentation, chromosomal condensation, and the activation of metacaspases. The proteomic analysis clearly demonstrates that rsAg@NCs exposure significantly alters protein expression. Most remarkable among the down-regulated proteins are those related to glycolysis, metabolism, free radical scavenging, anti-apoptosis, and mitochondrial function. In contrast, proteins involved in plasma membrane function, oxidative stress, cell death, and apoptosis were upregulated. Eventually, we also established that the apoptosis-inducing potential of rsAg@NCs is due to the activation of Ras signaling, which confirms their application in combating FCZ-resistant C. albicans infections.

Disease-associated genotypes of the commensal skin bacterium Staphylococcus epidermidis

Some of the most common infectious diseases are caused by bacteria that naturally colonise humans asymptomatically. Combating these opportunistic pathogens requires an understanding of the traits that differentiate infecting strains from harmless relatives. Staphylococcus epidermidis is carried asymptomatically on the skin and mucous membranes of virtually all humans but is a major cause of nosocomial infection associated with invasive procedures. Here we address the underlying evolutionary mechanisms of opportunistic pathogenicity by combining pangenome-wide association studies and laboratory microbiology to compare S. epidermidis from bloodstream and wound infections and asymptomatic carriage. We identify 61 genes containing infection-associated genetic elements (k-mers) that correlate with in vitro variation in known pathogenicity traits (biofilm formation, cell toxicity, interleukin-8 production, methicillin resistance). Horizontal gene transfer spreads these elements, allowing divergent clones to cause infection. Finally, Random Forest model prediction of disease status (carriage vs. infection) identifies pathogenicity elements in 415 S. epidermidis isolates with 80% accuracy, demonstrating the potential for identifying risk genotypes pre-operatively.

Antibiotic lock therapy for salvage of tunneled central venous catheters with catheter colonization and catheter-related bloodstream infection

Central venous catheters (CVCs) represent a significant source of infection in patients undergoing hematopoietic stem cell transplantation and can add to the cost of care, morbidity, and mortality. Organisms forming biofilms on the inner surface of catheters require a much higher local antibiotic concentration to clear the pathogen growth. Antibiotic lock therapy (ALT) represents one such strategy to achieve such high intraluminal concentrations of antibiotics and can facilitate catheter salvage. Patients with catheter colonization (CC) or hemodynamically stable catheter-related bloodstream infection (CRBSI) received ALT per institutional policy. We analyzed the incidence of CC and CRBSI and salvage rate of tunneled CVCs (Hickman) with ALT in patients undergoing hematopoietic stem cell transplant in this retrospective study. Catheter colonization was noted in 9.8% and CRBSI in 10.7% patients. Gram-negative bacilli (GNB) accounted for 45% and 83% of isolates in CC and CRBSI, respectively. In patients with CRBSI, the rate of catheter salvage with the use of ALT in addition to systemic antibiotics was 86% compared to 55% in patients with systemic antibiotics use only (P = 0.06). There was no CRBSI related mortality, and no increase in resistant strains was noted at subsequent CRBSI. In conclusion, ALT represents an important strategy for catheter salvage, especially for gram-negative infections, in a carefully selected patient population.

Ceftriaxone treatment of complicated urinary tract infections as a risk factor for enterococcal re-infection and prolonged hospitalization: A 6-year retrospective study

A frequent complication during hospital stay of patients with urinary tract infections (UTIs) is a re-infection of the urinary tract after the initial improvement. In this study, we investigated the impact of two empirical antibiotic therapies on the outcomes of complicated bacterial UTIs. We retrospectively evaluated 325 adult patients hospitalized during 6 years period with a diagnosis of complicated bacterial UTIs. The patients were classified into two groups according to the antibiotic therapy: ceftriaxone- and co-amoxiclav+gentamicin-treated group. Clinical data were collected from the patient records into a designed form. Output data included information on the treatment outcome, length of stay (LOS), development of complications, and cause of re-infections. The patients treated with ceftriaxone had significantly longer LOS (p = 0.012), as well as higher occurrence of complications (p = 0.023) and urinary tract re-infections (p < 0.001), compared to co-amoxiclav+gentamicin-treated group. No significant difference was observed in the treatment outcome between the two groups (p = 0.137). The most common complication in both investigated groups were re-infections of the urinary tract, and Enterococcus spp. was detected as the cause of re-infections only in patients from ceftriaxone-treated group (40/69 patients). Out of the 40 ceftriaxone-treated patients with enterococcal urinary tract re-infections, 35 patients had one or more chronic diseases and 29 patients had urinary catheter inserted. Ceftriaxone therapy should be considered carefully in patients with complicated UTIs due to the possibility of enterococcal re-infection and consequent prolonged hospital stay.

Screening a Repurposing Library for Inhibitors of Multidrug-Resistant Candida auris Identifies Ebselen as a Repositionable Candidate for Antifungal Drug Development

Since its original isolation in 2009, Candida auris has spread across the globe as a causative agent of invasive candidiasis. C. auris is typically intrinsically resistant to fluconazole and can also be resistant to echinocandins and even amphotericin B. Thus, there is an urgent need to find new treatment options against this emerging pathogen. To address this growing problem, we performed a screen of the Prestwick Chemical library, a repurposing library of 1,280 small molecules, consisting mostly of approved off-patent drugs, in search of those with activity against a multidrug-resistant C. auris isolate. Our initial screen, using standardized susceptibility testing methodologies, identified nine miscellaneous compounds with no previous clinical indication as antifungals or antiseptics that displayed activity against C. auris Confirmation and follow-up studies identified ebselen as the drug displaying the most potent activity, with 100% inhibition of growth detected at concentrations as low as 2.5 μM. We further evaluated the ability of ebselen to inhibit C. auris biofilm formation and examined the effects of combination therapies of ebselen with clinically used antifungals. We extended our studies to different C. auris strains with various susceptibility patterns and also confirmed its antifungal activity against Candida albicans and clinical isolates of multiple other Candida species. Furthermore, ebselen displayed a broad spectrum of antifungal actions on the basis of its activity against a variety of medically important fungi, including yeasts and molds. Overall, our results indicate the promise of ebselen as a repositionable agent for the treatment of candidiasis and possibly other mycoses and, in particular, for the treatment of infections refractory to conventional treatment with current antifungals.

Metal TiO2 Nanotube Layers for the Treatment of Dental Implant Infections

Titanium oxide nanotube layers with silver and zinc nanoparticles are attracting increasing attention in the design of bone and dental implants due to their antimicrobial potential and their ability to control host cell adhesion, growth, and differentiation. However, recent reports indicate that the etiology of dental infections is more complex than has been previously considered. Therefore, the antimicrobial potential of dental implants should be evaluated against at least several different microorganisms cooperating in human mouth colonization. In this study, Ag and Zn nanoparticles incorporated into titanium oxide nanotubular layers were studied with regard to how they affect Candida albicans, Candida parapsilosis, and Streptococcus mutans. Layers of titanium oxide nanotubes with an average diameter of 110 nm were fabricated by electrochemical anodization, annealed at 650 °C, and modified with approx. 5 wt % Ag or Zn nanoparticles. The surfaces were examined with the scanning electron microscopy-energy dispersive X-ray analysis, scanning transmission electron microscopy, and X-ray photoelectron spectroscopy techniques and subjected to evaluation of microbial-killing and microbial adhesion-inhibiting potency. In a 1.5 h long adhesion test, the samples were found more effective toward yeast strains than toward S. mutans. In a release-killing test, the microorganisms were almost completely eliminated by the samples, either within 3 h of contact (for S. mutans) or 24 h of contact (for both yeast strains). Although further improvement is advisable, it seems that Ag and Zn nanoparticles incorporated into TiO₂ nanotubular surfaces provide a powerful tool for reducing the incidence of bone implant infections. Their high bidirectional activity (against both Candida species and S. mutans) makes the layers tested particularly promising for the design of dental implants.

Implantable Device-Related Infection

Over half of the nearly two million healthcare-associated infections can be attributed to indwelling medical devices. In this review, we highlight the difficulty in diagnosing implantable device-related infection and how this leads to a likely underestimate of the prevalence. We then provide a length-scale conceptualization of device-related infection pathogenesis. Within this conceptualization we focus specifically on biofilm formation and the role of host immune and coagulation systems. Using this framework, we describe how current and developing preventative strategies target specific processes along the entire length-scale. In light of the significant time horizon for the development and translation of new preventative technologies, we also emphasize the need for parallel development of in situ treatment strategies. Specific examples of both preventative and treatment strategies and how they align with the length-scale conceptualization are described.

Prevalence of fungemia in a tertiary hospital: Analysis of the last decade

INTRODUCTION

The prevalence of nosocomial fungemia has increased worldwide, and mortality caused by this disease is high.

OBJECTIVE

To assess progress in the last decade, and the prevalence and profile of fungal agents isolated in blood cultures performed in a tertiary university hospital.

METHOD

All the results of blood cultures processed at Hospital das Clínicas, Universidade Federal de Minas Gerais (HC-UFMG), in the time intervals 2001-2003 and 2011-2013 were analyzed retrospectively. For each three-year period, the number of collected blood cultures, the overall positivity rate and the percentage of fungemia were recorded. In addition, all identified fungal species were cataloged. All blood samples were incubated in the BacT/ALERT® (bioMérieux) automation system.

RESULTS

In 2001-2003, 34,822 samples were evaluated, with 5,510 (15.8%) positive results. In 2011-2013, the number of blood cultures processed increased to 55,052 samples, with 4,873 (8.9%) positive results. There was an increase in the number of positive cultures for fungi in the analyzed period (2001-2003: 4.16%; 2011-2013: 5.95%; p<0.001). Among the agents, candidemias were predominant, especially those caused by non-albicans Candida species (2001-2003: 57.64%; 2011-2013: 65.17%; p<0.05). There was also an increase in fungemia caused by other genera (2001-2003: 2.62%; 2011-2013: 4.48%; p<0.01).

CONCLUSION

There was an increase in the prevalence of fungemia in the last decade at HC-UFMG. Although candidemias have been responsible for most of the cases, there has been an increase in fungemias caused by other species.

Nanoparticle-Based Mycosis Vaccine

Many diseases that were considered major affliction of mankind in the past have been successfully eradicated with introduction of appropriate vaccine strategies. In order to expedite new challenges coming up to deal with various infectious diseases, nano-particulate-based subunit vaccines seem to be the demand of ordeal. The nano-vaccines can find better scope for the diseases that were not rampant in the semi-advanced world few years back. For example in present-day circumstances that corroborate with advancement in the field of medical sciences in terms of cancer chemotherapy, organ transplantation, therapy of autoimmune diseases, etc.; along with prevalence of altogether unheard diseases such as HIV infection, people are at risk of infliction with many more pathogens. In this regard, development of an effective prophylactic strategy against many opportunistic infections primarily caused by fungal pathogens needs better understanding of host pathogen relation and role of active immunity against pathogenic fungi. In the present study, we have tried to decipher effectiveness of a nano-sized vaccine delivery system in imparting protection against fungal pathogens.

New Biofunctional Loading of Natural Antimicrobial Agent in Biodegradable Polymeric Films for Biomedical Applications

The study focuses on the development of novel Aloe vera based polymeric composite films and antimicrobial suture coatings. Polyvinyl alcohol (PVA), a synthetic biocompatible and biodegradable polymer, was combined with Aloe vera, a natural herb used for soothing burning effects and cosmetic purposes. The properties of these two materials were combined together to get additional benefits such as wound healing and prevention of surgical site infections. PVA and Aloe vera were mixed in a fixed quantity to produce polymer based films. The films were screened for antibacterial and antifungal activity against bacterial (E. coli, P. aeruginosa) and fungal strains (Aspergillus flavus and Aspergillus tubingensis) screened. Aloe vera based PVA films showed antimicrobial activity against all the strains; the lowest Aloe vera concentration (5%) showed the highest activity against all the strains. In vitro degradation and release profile of these films was also evaluated. The coating for sutures was prepared, in vitro antibacterial tests of these coated sutures were carried out, and later on in vivo studies of these coated sutures were also performed. The results showed that sutures coated with Aloe vera/PVA coating solution have antibacterial effects and thus have the potential to be used in the prevention of surgical site infections and Aloe vera/PVA based films have the potential to be used for wound healing purposes.

Hickman to central venous catheter: A case of difficult venous access in a child suffering from acute lymphoblastic leukemia

Chemotherapy in children suffering from cancer usually requires placement of an indwelling central venous catheter (CVC). A child may need to undergo repeated procedures because of infection and occlusion of previous access devices. We present a case of CVC insertion in a child suffering from acute lymphoblastic leukemia where an innovative technique was employed.

Evaluation of PNA FISH® Yeast Traffic Light in identification of Candida species from blood and non-blood culture specimens

PNA FISH(®) (peptide nucleic acid fluorescent in situ hybridization) Yeast Traffic Light (PNA FISH(®) YTL) assay is a commercially avaliable method for rapid identification of Candida spp. directly from positive blood cultures. This report provides a one-year experience in identification of yeasts from 25 specimens (15 positive blood cultures and 10 other clinically significant specimens) using PNA FISH(®) YTL and comparing it to VITEK 2 System. Overall, assay identification compatibility with VITEK 2 System was found among 21/25 (84%) isolates tested. Only 3/25 (12%) of the isolates were not identified, and one isolate was misidentified by the PNA FISH(®) YTL assay. Our results show that the assay is a reliable method in identification of Candida spp. not only from blood cultures, but even from other clinically significant specimens (urine cultures, catheter tip cultures, peritoneal fluid cultures) when compared to automated method like VITEK 2 System. This novel application of the PNA FISH(®) YTL assay could therefore contribute to cost savings and significant benefit to patients, as rapid information about isolated yeast species is provided.

Lysine enhances the effect of amphotericin B against Candida albicans in vitro

Amphotericin B (AmB) is a polyene antibiotic produced by Streptomyces nodosus and has been used for >50 years in the treatment of acute systemic fungal infections. In the present study, we demonstrated that lysine, an essential amino acid, could enhance the effect of AmB against Candida albicans in vitro, although lysine itself did not exert a fungicidal effect. In addition, the combination of AmB with lysine could provide an enhanced action against Candida parapsilosis and Cryptococcus neoformans compared with AmB alone. Lysine could also enhance the antifungal effect of caspofungin or nystatin. An enhanced effect of the combination of lysine with AmB was observed for the prevention of biofilm and hypha formation. Furthermore, our results demonstrated that lysine-mediated oxidative damage, such as the generation of endogenous reactive oxygen species, may be the mechanism underlying the enhancing effect of lysine on AmB. Our results also showed that CaMCA1 gene plays an important role in increasing the sensitivity of C. albicans cells upon AmB treatment. Using AmB together with lysine may be a promising strategy for the therapy of disseminated candidiasis.

Fluconazole Resistant Candida Oesophagitis in Immunocompetent Patients: Is Empirical Therapy Justifiable?

INTRODUCTION

C. albicans (Candida albicans) is the foremost cause of fungal oesophagitis, however other species such as Candida tropicalis, Candida krusei and Candida stellatoidea have also been implicated to cause this condition. Although, numerous studies have identified risk factors for C. albicans oesophagitis, data for non- C. albicans species is still sparse.

AIM

To determine the aetiology of Candida oesophagitis in our medical centre over a two year period. Additionally, to investigate predisposing conditions for oesophageal candidiasis caused by different Candida species.

MATERIAL AND METHODS

All consecutive patients posted for upper gastrointestinal endoscopy at the endoscopy unit of a tertiary care hospital in north India with findings consistent with oesophagitis were screened for the presence of Candida oesophagitis by performing KOH (potassium hydroxide) examination and culture on SDA (Sabouraud's dextrose agar). Antifungal susceptibility testing as per CLSI guidelines was performed for fluconazole, a most common empirically prescribed antifungal for the condition.

RESULTS

A total of 1868 patients with no known immune-compromised condition underwent upper gastroscopy at our centre during the study period. The prevalence of Candida oesophagitis was 8.7% (n = 163). C. albicans was recovered from majority of infections (52.1%), followed by C. tropicalis (24%), C. parapsilosis (13.4%), C. glabrata (6.9%) and C. krusei (3.6%). Alarmingly, among the C. albicans isolates 8.6% were resistant to fluconazole.

CONCLUSION

With rising reports of antifungal drug resistance among the isolates of Candida species, an increasing prevalence of this organism could have an impact on the treatment of Candidal oesophagitis and it should be approached with caution by the clinician.

Isolation and Identification of Pathogenic Filamentous Fungi and Yeasts From Adult House Fly (Diptera: Muscidae) Captured From the Hospital Environments in Ahvaz City, Southwestern Iran

Musca domestica L., 1758 is capable of transferring a number of pathogenic viruses, bacteria, fungi, and parasites to animals and humans. The objective of this study was to isolate and identify medically important filamentous fungi and yeasts from adult M. domestica collected from two wards of three hospital environments in Ahvaz city, Khuzestan Province, southwestern Iran. The common house flies were caught by a sterile net. These insects were washed in a solution of 1% sodium hypochlorite for 3 min and twice in sterile distilled water for 1 min. The flies were individually crushed with sterile swabs in sterile test tubes. Then 2 ml of sterile normal saline (0.85%) was added to each tube, and the tube was centrifuged for 5 min. The supernatant was then discarded, and the remaining sediment was inoculated with a sterile swab in the Sabouraud's dextrose agar medium containing chloramphenicol. Isolation and identification of fungi were made by standard mycological methods. In this research, totally 190 M. domestica from hospital environments were captured. In total, 28 fungal species were isolated. The main fungi isolated were Aspergillus spp. (67.4%), Penicillium sp. (11.6%), Mucorales sp. (11%), Candida spp. (10.5%), and Rhodotorula sp. (8.4%). Among the house flies caught at the hospitals, about 80% were found to carry one or more medically important species of fungi. This study has established that common house flies carry pathogenic fungi in the hospital environments of Ahvaz. The control of M. domestica in hospitals is essential in order to control the nosocomial fungal infections in patients.

Comparative Analysis of Disc Diffusion and E-test with Broth Micro-dilution for Susceptibility Testing of Clinical Candida Isolates Against Amphotericin B, Fluconazole, Voriconazole and Caspofungin

BACKGROUND

Antifungal susceptibility testing remains an area of intense interest because of the increasing number of clinical isolates resistant to antifungal therapy. Clinical and Laboratory Standards Institute has proposed reference broth micro dilution (BMD) method for susceptibility testing. The reference method is time-consuming and poorly suited for the routine clinical laboratory setting. Agar-based susceptibility testing methods, disk diffusion (DD) method and the E-test method can be an easier, reliable and less time consuming alternative for the BMD method.

AIM

To compare the results of Amphotericin B, fluconazole, voriconazole, and Caspofungin susceptibility testing by DD, and the E-test method with the CLSI reference method for clinical Candida isolates.

MATERIALS AND METHODS

Broth Microdilution (BMD), E-test and Disk diffusion testing of the various clinical Candida isolates was performed in accordance with CLSI documents. The results obtained were analysed and compared.

RESULTS

The categorical agreement for Amphotericin B, fluconazole, voriconazole, and Caspofungin susceptibility results by E-test and DD method was 65.2%, 67.4%; 100%, 82.6%; 100%, 100%; 100%, 97.8% respectively.

CONCLUSION

The agar-based E-test and disk diffusion methods are reliable alternatives to the BMD method for Candida isolates when test susceptible to fluconazole, voriconazole, and Caspofungin, however the susceptibility testing results must be interpreted with caution in case of Amphotericin B.

Airborne Dispersal as a Novel Transmission Route of Coagulase-Negatwe Staphylococci Interaction Between Coagulase-Negative Staphylococci and Rhinovirus Infection

Objective:

To investigate whether rhinovirus infection leads to increased airborne dispersal of coagulase-negative staphylococci (CoNS).

Design:

Prospective nonrandomized intervention trial.

Setting:

Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Participants:

Twelve nasalStaphylococcus aureus-CoNS carriers among 685 students screened forS. aureusnasal carriage.

Interventions:

Participants were studied for airborne dispersal of CoNS in a chamber under three conditions (street clothes, sterile gown with a mask, and sterile gown without a mask). After 2 days of pre-exposure measurements, volunteers were inoculated with a rhinovirus and observed for 14 days. Daily quantitative nasal and skin cultures for CoNS and nasal cultures for rhinovirus were performed. In addition, assessment of cold symptoms was performed daily, mucous samples were collected, and serum titers before and after rhinovirus inoculation were obtained. Sneezing, coughing, and talking events were recorded during chamber sessions.

Results:

All participants had at least one nasal wash positive for rhinovirus and 10 developed a symptomatic cold. Postexposure, there was a twofold increase in airborne CoNS (P= .0004), peaking at day 12. CoNS dispersal was reduced by wearing a gown (57% reduction,P< .0001), but not a mask (P= .7). Nasal and skin CoNS colonization increased after rhinovirus infection (P<.05).

Conclusions:

We believe this is the first demonstration that a viral pathogen in the upper airways can increase airborne dispersal of CoNS in nasalS. aureuscarriers. Gowns, gloves, and caps had a protective effect, whereas wearing a mask did not further reduce airborne spread.

An Outbreak of Methicillin-ResistantStaphylococcus aureusInfections Related to Central Venous Catheters for Hemodialysis

Objectives:

To determine risk factors for hemodialysis catheter-related bloodstream infections (HCRBSIs) and investigate whether use of maximal sterile barrier precautions would prevent HCRBSIs.

Setting:

Tertiary-care medical center hemodialysis unit.

Design:

Open trial with historical comparison and case-control study of risk factors for HCRBSIs.

Methods:

Prospective surveillance was used to compare HCRBSI rates for 1 year before and after implementation of maximal sterile barrier precautions. A case–control study compared 50 case-patients with HCRBSI with 51 randomly selected control-patients.

Results:

The HCRBSI rate was 1.6% per 100 dialysis runs (CI95, 1.1%–2.3%) in the first year and 0.77% (CI95, 0.5%–1.1%) in the second year (P= .0106). The most frequent cause of HCRBSI was MRSA in the first year (15 of 32) and MSSA in the second year (13 of 18). Ten MRSA blood isolates in the first year were identical by PFGE. Diabetes mellitus was a risk factor for HCRBSI. Age, gender, site of hemodialysis central venous catheter (CVC), other underlying diseases, coma score, APACHE II score, serum albumin level, and cholesterol level were not associated with HCRBSI and did not change between the 2 years. Hospital stay was prolonged for case-patients (32.78 ± 20.96 days) versus control-patients (22.75 ± 17.33 days), but mortality did not differ.

Conclusions:

Use of maximal sterile barrier precautions during the insertion of CVCs reduced HCRBSIs in dialysis patients and seemed cost-effective. Diabetes mellitus was associated with HCRBSI. An outbreak of MRSA in the first year was likely caused by cross-infection via medical personnel.

Guideline for Prevention of Intravascular-Device–Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Epidemiology of Hospital-Acquired Infections in Veterans With Spinal Cord Injury and Disorder

Objective.

To describe the epidemiology of hospital-acquired infections (HAIs) in veterans with spinal cord injury and disorder (SCI&D).

Design.

Retrospective medical record review.

Setting.

Midwestern Department of Veterans Affairs spinal cord injury center.

Participants.

A total of 226 patients with SCI&D hospitalized at least once during a 2-year period (October 1, 2001, through September 30, 2003).

Results.

A total of 549 hospitalizations were included in the analysis (mean duration of hospitalization, 33.7 days); an HAI occurred during 182 (33.2%) of these hospitalizations. A total of 657 HAIs occurred during 18,517 patient-days in the hospital (incidence rate, 35.5 HAIs per 1,000 patient-days). Almost half of the 226 patients had at least 1 HAI; the mean number of HAIs among these patients was 6.0 HAIs per patient. The most common HAIs were urinary tract infection (164 [25.0%] of the 657 HAIs; incidence rate, 8.9 cases per 1,000 patient-days), bloodstream infection (111 [16.9%]; incidence rate, 6.0 cases per 1,000 patient-days), and bone and joint infection (103 [15.7%]; incidence rate, 5.6 cases per 1,000 patient-days). The most common culture isolates were gram-positive bacteria (1,082 [45.6%] of 2,307 isolates), including Staphylococcus aureus, and gram-negative bacteria (1,033 [43.6%] of isolates), including Pseudomonas aeruginosa. Multivariate regression demonstrated that predictors of HAI were longer length of hospital stay (P = .002), community-acquired infection (P = .007), and use of a urinary invasive device (P = .01) or respiratory invasive device (P = .04).

Conclusions.

The overall incidence of HAIs in persons with SCI&D was higher than that reported for other populations, confirming the increased risk of HAI in persons with spinal cord injury. The increased risk associated with longer length of stay and with community-acquired infection suggests that strategies are needed to reduce the duration of hospitalization and to effectively treat community-acquired infection, to decrease infection rates. There is significant room for improvement in reducing the incidence of HAIs in this population.

Epidemiology, Diagnosis, and Therapy of Fungal Infections in Surgery

Over the past decade, the incidence of hospital-acquired bloodstream infections caused byCandidastrains has risen, while the implicated species have changed.Candida tropicalis, Candida parapsilosis, andCandida glabrataall have increased in incidence. Data from the Centers for Disease Control and Prevention reveal that, between 1980 and 1990,Candidaemerged as the sixth most common nosocomial pathogen (7.2.%) and was the fourth most common pathogen in nosocomial bloodstream infections, surpassed only by coagulase-negative staphylococci,Staphylococcus aureus, and enterococci. The incidence of candidemia is dramatically higher in high-risk critical-care units: 25% of cases occur in surgical intensive-care units (ICUs) versus 25% in bone marrow transplantation units, 20% in medical ICUs, 20% in general medical wards, and 10% in oncology-hematology units. Burns and gastrointestinal surgery predispose to nosocomial candidemia. Independent risk factors include prior therapy with multiple antibiotics, isolation ofCandidafrom sites other than blood, and prior hemodialysis. Crude mortality exceeds 55% and is associated with older age and concomitant renal failure, hepatic failure, acute respiratory diseases, or postoperative shock. In addition to extreme vigilance for early recognition ofCandidasepsis in critically ill surgical patients, the high risk for candidemia probably necessitates fungal surveillance cultures and initiation of preemptive antifungal therapy in high-risk surgical patients.

Guidelines for the Prevention of Intravascular Catheter–Related Infections

Background:

Although many catheter-related blood-stream infections (CRBSIs) are preventable, measures to reduce these infections are not uniformly implemented.

Objective:

To update an existing evidenced-based guideline that promotes strategies to prevent CRBSIs.

Data Sources:

The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles.

Studies Included:

Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiologic investigations.

Outcome Measures:

Reduction in CRBSI, catheter colonization, or catheter-related infection.

Synthesis:

The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis).

Conclusion:

Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

Secular Trends in Candidemia-Related Hospitalization in the United States, 2000–2005

In the United States, from January 1, 2000, through December 31, 2005, the incidence of candidemia-related hospitalization per 100,000 population rose by 52%, from 3.65 to 5.56 cases; and the incidence per 1,000 hospitalizations rose by 49%, from 0.28 to 0.42 cases. The proportion of all candidemia-related hospitalizations in which candidemia was the principal diagnosis remained stable at approximately 14%.

A predictive rule for mortality of inpatients with Staphylococcus aureus bacteraemia: A classification and regression tree analysis

OBJECTIVE

To create a predictive rule to identify risk factors for mortality among patients with Staphylococcus aureus bacteraemia (SAB).

DESIGN, SETTING AND PATIENTS

This was a retrospective cohort study of all adult patients with SAB at a large community hospital in Tokyo, Japan, from April 1, 2004 to March 31, 2011. Baseline data and clinically relevant factors were collected from electronic charts. The primary outcome was in-hospital mortality. All candidate predictors were included in a classification and regression tree (CART) analysis. A receiver operating characteristic (ROC) curve was drawn, and the area under the curve (AUC) was obtained. A cross-validation analysis was performed.

MEASUREMENTS AND MAIN RESULTS

A total of 340 patients had SAB during the study period. Of these, 118 (34.7%) patients died in hospital. Among 41 potential variables, the CART analysis revealed that underlying malignancy, serum blood glucose level, methicillin resistance, and low serum albumin were predictors of mortality. The AUC was 0.73 (95% CI: 0.67-0.79). For validation, the estimated risk was 0.26 (± SE: 0.02) in the resubstitution analysis and 0.33 (± SE: 0.03) in the cross-validation analysis.

CONCLUSION

We propose a predictive model for the mortality of patients with SAB consisting of four predictors: underlying malignancy, low serum albumin, high glucose, and methicillin resistance. This model may facilitate appropriate preventative management for patients with SAB who are at high risk of mortality.

Incidence and clinical predictors of ocular candidiasis in patients with Candida fungemia

Purpose. The aim of this study is to determine the incidence and the predictors of ocular candidiasis among patient with Candida fungemia. Methods. We retrospectively reviewed the charts of all patients diagnosed with candidemia at the University of Kansas Medical Center during February 2000–March 2010. Data regarding patients' demographics, clinical characteristics, laboratory results, and ophthalmology examination findings were collected. Results. A total of 283 patients with candidemia were enrolled. The mean age (± standard deviation) was 55 ± 18 years; 66% were male. The most commonly isolated Candida species were C. albicans (54%), C. parapsilosis (20%), C. glabrata (13%), and C. tropicalis (8%). Only 144 (51%) patients were evaluated by ophthalmology; however, the proportion of patients who were formally evaluated by an ophthalmologist increased during the study period (9%in 2000 up to 73%in 2010; P < 0.0001). Evidence of ocular candidiasis was present in 18 (12.5%) patients. Visual symptoms were reported by 5 of 18 (28%) patients. In multivariable analysis, no predictors of ocular candidiasis were identified. Conclusions. The incidence of ocular candidiasis among patients with fungemia remains elevated. Most patients are asymptomatic and therefore all patients with candidemia should undergo fundoscopic examination to rule out ocular involvement.

An automated high-throughput cell-based multiplexed flow cytometry assay to identify novel compounds to target Candida albicans virulence-related proteins

Although three major classes of systemic antifungal agents are clinically available, each is characterized by important limitations. Thus, there has been considerable ongoing effort to develop novel and repurposed agents for the therapy of invasive fungal infections. In an effort to address these needs, we developed a novel high-throughput, multiplexed screening method that utilizes small molecules to probe candidate drug targets in the opportunistic fungal pathogen Candida albicans. This method is amenable to high-throughput automated screening and is based upon detection of changes in GFP levels of individually tagged target proteins. We first selected four GFP-tagged membrane-bound proteins associated with virulence or antifungal drug resistance in C. albicans. We demonstrated proof-of-principle that modulation of fluorescence intensity can be used to assay the expression of specific GFP-tagged target proteins to inhibitors (and inducers), and this change is measurable within the HyperCyt automated flow cytometry sampling system. Next, we generated a multiplex of differentially color-coded C. albicans strains bearing C-terminal GFP-tags of each gene encoding candidate drug targets incubated in the presence of small molecules from the Prestwick Chemical Library in 384-well microtiter plate format. Following incubation, cells were sampled through the HyperCyt system and modulation of protein levels, as indicated by changes in GFP-levels of each strain, was used to identify compounds of interest. The hit rate for both inducers and inhibitors identified in the primary screen did not exceed 1% of the total number of compounds in the small-molecule library that was probed, as would be expected from a robust target-specific, high-throughput screening campaign. Secondary assays for virulence characteristics based on null mutant strains were then used to further validate specificity. In all, this study presents a method for the identification and verification of new antifungal drugs targeted to fungal virulence proteins using C. albicans as a model fungal pathogen.