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Felix GN, de Freitas VLT, da Silva Junior AR, Magri MMC, Rossi F, Sejas ONE, Abdala E, Malbouisson LMS, Guimarães T, Benard G, Del Negro GMB. Performance of a Real-Time PCR Assay for the Detection of Five Candida Species in Blood Samples from ICU Patients at Risk of Candidemia. J Fungi (Basel) 2023; 9:635. [PMID: 37367571 DOI: 10.3390/jof9060635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/22/2023] [Accepted: 05/13/2023] [Indexed: 06/28/2023] Open
Abstract
The gold standard for diagnosing invasive candidiasis still relies on blood cultures, which are inefficient and time-consuming to analyze. We developed an in-house qPCR assay to identify the 5 major Candida species in 78 peripheral blood (PB) samples from ICU patients at risk of candidemia. Blood cultures and (1,3)-β-D-glucan (BDG) testing were performed concurrently to evaluate the performance of the qPCR. The qPCR was positive for DNA samples from all 20 patients with proven candidemia (positive PB cultures), showing complete concordance with Candida species identification in blood cultures, except for detection of dual candidemia in 4 patients, which was missed by blood cultures. Additionally, the qPCR detected Candida species in six DNA samples from patients with positive central venous catheters blood (CB) but negative PB cultures. BDG values were similarly high in these six samples and the ones with proven candidemia, strongly suggesting the diagnosis of a true candidemia episode despite the negative PB cultures. Samples from patients neither infected nor colonized yielded negative results in both the qPCR and BDG testing. Our qPCR assay was at least as sensitive as blood cultures, but with a shorter turnaround time. Furthermore, negative results from the qPCR provided strong evidence for the absence of candidemia caused by the five major Candida species.
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Affiliation(s)
- Gabriel N Felix
- Laboratory of Medical Mycology (LIM 53), Instituto de Medicina Tropical, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo 05403-000, Brazil
| | - Vera L T de Freitas
- Laboratório de Investigação Médica em Imunologia (LIM 48), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo 05403-000, Brazil
| | - Afonso R da Silva Junior
- Central Laboratory Division (LIM 03), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo 05403-010, Brazil
| | - Marcello M C Magri
- Central Laboratory Division (LIM 03), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo 05403-010, Brazil
- Departamento de Moléstias Infecciosas e Parasitárias, Faculdade de Medicina, Universidade de São Paulo, São Paulo 05403-010, Brazil
| | - Flavia Rossi
- Central Laboratory Division (LIM 03), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo 05403-010, Brazil
| | - Odeli N E Sejas
- Cancer Institute of São Paulo State (ICESP), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo 01246-000, Brazil
| | - Edson Abdala
- Cancer Institute of São Paulo State (ICESP), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo 01246-000, Brazil
| | - Luiz M S Malbouisson
- Discipline of Anesthesiology, Faculdade de Medicina, Universidade de São Paulo, São Paulo 05403-010, Brazil
| | - Thais Guimarães
- Infectious Diseases Department, Hospital do Servidor Público Estadual de São Paulo (IAMSPE), São Paulo 04029-000, Brazil
| | - Gil Benard
- Laboratory of Medical Mycology (LIM 53), Instituto de Medicina Tropical, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo 05403-000, Brazil
| | - Gilda M B Del Negro
- Laboratory of Medical Mycology (LIM 53), Instituto de Medicina Tropical, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo 05403-000, Brazil
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Abstract
The literature regarding COVID-19-associated pulmonary aspergillosis (CAPA) has shown conflicting observations, including survival of CAPA patients not receiving antifungal therapy and discrepancy between CAPA diagnosis and autopsy findings. To gain insight into the pathophysiology of CAPA, we performed a case-control study in which we compared Aspergillus test profiles in CAPA patients and controls in relation to intensive care unit (ICU) mortality. This was a multinational case-control study in which Aspergillus test results, use of antifungal therapy, and mortality were collected from critically ill COVID-19 patients. Patients were classified using the 2020 European Confederation for Medical Mycology and the International Society for Human and Animal Mycology (ECMM/ISHAM) consensus case definitions. We analyzed 219 critically ill COVID-19 cases, including 1 proven, 38 probable, 19 possible CAPA cases, 21 Aspergillus-colonized patients, 7 patients only positive for serum (1,3)-β-d-glucan (BDG), and 133 cases with no evidence of CAPA. Mortality was 53.8% in CAPA patients compared to 24.1% in patients without CAPA (P = 0.001). Positive serum galactomannan (GM) and BDG were associated with increased mortality compared to serum biomarker-negative CAPA patients (87.5% versus 41.7%, P = 0.046; 90.0% versus 42.1%, P = 0.029, respectively). For each point increase in GM or 10-point BDG serum concentration, the odds of death increased (GM, odds ratio [OR] 10.208, 95% confidence interval [CI], 1.621 to 64.291, P = 0.013; BDG, OR, 1.247, 95% CI, 1.029 to 1.511, P = 0.024). CAPA is a complex disease, probably involving a continuum of respiratory colonization, tissue invasion, and angioinvasion. Serum biomarkers are useful for staging CAPA disease progression and, if positive, indicate angioinvasion and a high probability of mortality. There is need for a biomarker that distinguishes between respiratory tract colonization and tissue-invasive CAPA disease.
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3
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Yan G, Chew KL, Chai LYA. Update on Non-Culture-Based Diagnostics for Invasive Fungal Disease. Mycopathologia 2021; 186:575-582. [PMID: 34213735 DOI: 10.1007/s11046-021-00549-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/19/2021] [Indexed: 02/06/2023]
Abstract
Diagnostic tests for fungi provide the mycological evidence to strengthen diagnosis of invasive fungal disease. Conventional microbiology and histopathology have their limitations. Recognizing this, there have been attempts at developing new methods to improve yield of diagnosing invasive fungal disease (IFD). The recent focus has been on non-culture-based antigen detection and molecular methods. The use of antigen detection of IFD through 1,3-β-D-glucan and galactomannan assay have been expanded, followed by development of lateral flow assays, and in combination with other diagnostic modalities to further increase diagnostic yield. The molecular diagnostic front has seen initiatives to standardize polymerase chain reaction methodologies to detect fungi and anti-fungal resistance, new platforms such as the T2Candida Biosystems and foray into fungal metagenomics. As these newer assays undergo stringent validation before incorporation into the diagnostic algorithm, the clinician needs to be mindful of their bedside utility as well as their limitation.
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Affiliation(s)
- Gabriel Yan
- Division of Microbiology, Department of Laboratory Medicine, National University Health System, Singapore, Singapore.,Division of Infectious Diseases, University Medicine Cluster, National University Health System, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Ka Lip Chew
- Division of Microbiology, Department of Laboratory Medicine, National University Health System, Singapore, Singapore
| | - Louis Yi Ann Chai
- Division of Infectious Diseases, University Medicine Cluster, National University Health System, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore. .,National University Cancer Institute, Singapore, Singapore. .,Department of Medicine, Faculty of Medicine, National University of Singapore, Singapore, Singapore.
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4
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Dinh TTH, Tummamunkong P, Padungros P, Ponpakdee P, Boonprakong L, Saisorn W, Leelahavanichkul A, Kueanjinda P, Ritprajak P. Interaction Between Dendritic Cells and Candida krusei β-Glucan Partially Depends on Dectin-1 and It Promotes High IL-10 Production by T Cells. Front Cell Infect Microbiol 2021; 10:566661. [PMID: 33552998 PMCID: PMC7862133 DOI: 10.3389/fcimb.2020.566661] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/27/2020] [Indexed: 12/12/2022] Open
Abstract
Host-Candida interaction has been broadly studied during Candida albicans infection, with a progressive shift in focus toward non-albicans Candida species. C. krusei is an emerging multidrug resistant pathogen causing rising morbidity and mortality worldwide. Therefore, understanding the interplay between the host immune system and C. krusei is critically important. Candia cell wall β-glucans play significant roles in the induction of host protective immune responses. However, it remains unclear how C. krusei β-glucan impacts dendritic cell (DC) responses. In this study, we investigated DC maturation and function in response to β-glucans isolated from the cell walls of C. albicans, C. tropicalis, and C. krusei. These three distinct Candida β-glucans had differential effects on expression of the DC marker, CD11c, and on DC maturation. Furthermore, bone-marrow derived DCs (BMDCs) showed enhanced cytokine responses characterized by substantial interleukin (IL)-10 production following C. krusei β-glucan stimulation. BMDCs stimulated with C. krusei β-glucan augmented IL-10 production by T cells in tandem with increased IL-10 production by BMDCs. Inhibition of dectin-1 ligation demonstrated that the interactions between dectin-1 on DCs and cell wall β-glucans varied depending on the Candida species. The effects of C. krusei β-glucan were partially dependent on dectin-1, and this dependence, in part, led to distinct DC responses. Our study provides new insights into immune regulation by C. krusei cell wall components. These data may be of use in the development of new clinical approaches for treatment of patients with C. krusei infection.
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Affiliation(s)
- Truc Thi Huong Dinh
- Medical Microbiology Interdisciplinary Program, Graduate School, Chulalongkorn University, Bangkok, Thailand
- Research Unit in Integrative Immuno-Microbial Biochemistry and Bioresponsive Nanomaterials, Department of Microbiology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Phawida Tummamunkong
- Research Unit in Integrative Immuno-Microbial Biochemistry and Bioresponsive Nanomaterials, Department of Microbiology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Panuwat Padungros
- Green Chemistry for Fine Chemical Productions STAR, Department of Chemistry, Faculty of Science, Chulalongkorn University, Bangkok, Thailand
| | - Pranpariya Ponpakdee
- Green Chemistry for Fine Chemical Productions STAR, Department of Chemistry, Faculty of Science, Chulalongkorn University, Bangkok, Thailand
| | - Lawan Boonprakong
- Oral Biology Research Center, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Wilasinee Saisorn
- Translational Research in Inflammation and Immunology Research Unit (TRIRU), Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Asada Leelahavanichkul
- Translational Research in Inflammation and Immunology Research Unit (TRIRU), Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Patipark Kueanjinda
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Patcharee Ritprajak
- Research Unit in Integrative Immuno-Microbial Biochemistry and Bioresponsive Nanomaterials, Department of Microbiology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
- Department of Microbiology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
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5
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Agnelli C, Bouza E, Del Carmen Martínez-Jiménez M, Navarro R, Valerio M, Machado M, Guinea J, Sánchez-Carrillo C, Alonso R, Muñoz P. Clinical Relevance and Prognostic Value of Persistently Negative (1,3)-β-D-Glucan in Adults With Candidemia: A 5-year Experience in a Tertiary Hospital. Clin Infect Dis 2021; 70:1925-1932. [PMID: 31680136 DOI: 10.1093/cid/ciz555] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/25/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The clinical relevance and the potential prognostic role of persistently negative (1,3)-β-D-glucan (BDG) in adults with proven candidemia is unknown. METHODS This retrospective study included all adults diagnosed with candidemia our tertiary university hospital from 2012-2017 who had at least 2 serum BDG determinations throughout the episode of fungemia (Fungitell Assay; positive cut-off ≥80pg/mL). Epidemiology and clinical outcomes were compared between patients with all negative versus any positive BDG tests. Poor clinical outcomes included complications due to candidemia or 30-day all-cause mortality. RESULTS Overall, 26/148 (17.6%) candidemic adults had persistently negative BDG tests. These patients were less likely to present Candida growth in all 3 sets of blood cultures (15.4% vs 45.1%; P = .005) and had less severe clinical presentations (median Pitt score, 0 [interquartile range {IQR} 0-1] vs 1 [IQR 0-2] in patients with any positive BDG test; P = .039). Although adequate treatment was equally provided to both groups (96.2% in persistently negative group vs 93.4 in positive group; P = .599), the persistently negative group had a higher rate of microbiological clearance in the first follow-up blood cultures (92.3% vs 69.7% in positive group; P = .005), fewer complications due to candidemia (7.7% vs 33.6% in positive group; P = .008), a lower 30-day mortality rate (3.8% vs 23.8% in positive group; P = .004), and a shorter in-hospital stay (34 days [IQR 18-55] vs 51 days [IQR 35-91] in positive group; P = .003). In the multivariate analysis, persistently negative BDG tests were independently associated with better prognoses (odds ratio 0.12, 95% confidence interval 0.03-0.49; P = .003). CONCLUSIONS Candidemic patients with persistently negative BDG tests present a better prognosis than the comparative group, probably due to a lower systemic fungal burden. In this context, the appropriate use of persistently negative BDG results could be an aid to individualize therapeutic management in the near future.
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Affiliation(s)
- Caroline Agnelli
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Medicine, Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CB06/06/0058), Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
| | - María Del Carmen Martínez-Jiménez
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Raquel Navarro
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Maricela Valerio
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Marina Machado
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
| | - Jesús Guinea
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CB06/06/0058), Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
| | - Carlos Sánchez-Carrillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
| | - Roberto Alonso
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CB06/06/0058), Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
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6
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Esteves P, Lopes Lima S, Salles de Azevedo Melo A, Maria Beirão E, Nucci M, Colombo AL. (1,3)-β-D-glucan is able to predict therapeutic failure of patients with candidemia and not only mortality. Mycoses 2020; 64:264-271. [PMID: 33274533 DOI: 10.1111/myc.13224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Candidemia is a major cause of bloodstream infection in tertiary hospitals worldwide and fungal biomarkers may provide early diagnosis. OBJECTIVES To evaluate the performance of (1-3)-β-D-glucan (BDG) in the diagnosis of candidemia and its ability to predict therapeutic failure. PATIENTS AND METHODS This was a prospective, multi-centre study conducted in 3 Brazilian hospitals. Clinical outcome was evaluated along 2 weeks of treatment, and therapeutic failure was defined as the occurrence of persistent candidemia, Candida deep-seated infection or death. Baseline BDG detection was performed with the Fungitell® assay (Associates of Cape Cod, Falmouth-USA). RESULTS We enrolled a total of 71 patients with candidemia and a control group with 110 healthy volunteers. The sensitivity and specificity of BDG for diagnosing candidemia were as follows: 71.8% (95% confidence interval [95% CI] 59.7% - 81.5%) and 98.2% (95% CI 92.9% - 99.7%), respectively. The only predictor of therapeutic failure was a higher BDG value at diagnosis of candidemia; a value > 226 pg/mL predicted failure with sensitivity and specificity of 75% and 78%, respectively. CONCLUSIONS A high baseline serum BDG value was associated with therapeutic failure.
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Affiliation(s)
- Patrícia Esteves
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Soraia Lopes Lima
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Analy Salles de Azevedo Melo
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Elisa Maria Beirão
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcio Nucci
- Department of Internal Medicine, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Arnaldo L Colombo
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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7
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Agnelli C, Valerio M, Bouza E, Muñoz P. Reply to Giacobbe et al. Clin Infect Dis 2020; 71:1126. [DOI: 10.1093/cid/ciz1055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Caroline Agnelli
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
- Division of Infectious Diseases, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maricela Valerio
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
- CIBER de Enfermedades Respiratórias–CIBERES (CB06/06/0058), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
- CIBER de Enfermedades Respiratórias–CIBERES (CB06/06/0058), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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8
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Alves PGV, Melo SGO, Bessa MADS, Brito MDO, Menezes RDP, Araújo LBD, Penatti MPA, Pedroso RDS, Röder DVDDB. Risk factors associated with mortality among patients who had candidemia in a university hospital. Rev Soc Bras Med Trop 2020; 53:e20190206. [PMID: 32578699 PMCID: PMC7310371 DOI: 10.1590/0037-8682-0206-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 04/27/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION: Bloodstream infection due to Candida spp. is a primary
cause of morbidity and mortality in tertiary hospitals. METHODS: In this retrospective study, we included patients with a positive blood
culture for Candida spp. after 48 h of hospitalization.
RESULTS A total of 335 patients who had candidemia were included in this study. Risk
factors associated with mortality were hospitalization in internal medicine
units and surgical clinics, age >60 years, mechanical ventilation,
orotracheal intubation, hemodialysis, corticosteroids use, and C.
parapsilosis infection. CONCLUSIONS: This study highlights the importance of health care related to invasive
procedures and actions to improve patient immunity.
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Affiliation(s)
| | | | | | | | | | | | | | - Reginaldo Dos Santos Pedroso
- Universidade Federal de Uberlândia, Faculdade de Medicina, Uberlândia, MG, Brasil.,Universidade Federal de Uberlândia, Escola Técnica de Saúde, Uberlândia, MG, Brasil
| | - Denise Von Dolinger de Brito Röder
- Universidade Federal de Uberlândia, Faculdade de Medicina, Uberlândia, MG, Brasil.,Universidade Federal de Uberlândia, Instituto de Ciências Biomédicas, Uberlândia, MG, Brasil
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9
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Giacobbe DR, Berruti M, Mikulska M. Prognostic Impact of Negative Serum (1,3)-β-D-glucan in Patients With Candidemia. Clin Infect Dis 2019; 71:1124-1126. [DOI: 10.1093/cid/ciz1051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniele Roberto Giacobbe
- Dipartimento di Scienze della Salute, University of Genoa, Genoa, Italy
- Clinica Malattie Infettive, Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Policlinico San Martino, Genoa, Italy
| | - Marco Berruti
- Dipartimento di Scienze della Salute, University of Genoa, Genoa, Italy
- Clinica Malattie Infettive, Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Policlinico San Martino, Genoa, Italy
| | - Malgorzata Mikulska
- Dipartimento di Scienze della Salute, University of Genoa, Genoa, Italy
- Clinica Malattie Infettive, Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Policlinico San Martino, Genoa, Italy
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10
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Tsai MH, Lin LC, Hsu JF, Lai MY, Huang HR, Chiang MC, Lu JJ. Rapid identification of invasive fungal species using sensitive universal primers-based PCR and restriction endonuclease digestions coupled with high-resolution melting analysis. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 52:728-735. [PMID: 31302087 DOI: 10.1016/j.jmii.2019.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 05/25/2019] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGOUND Conventional diagnosis of invasive fungal disease from blood cultures is often notoriously delayed and inadequately sensitive. We aimed to develop a universal primers-based polymerase chain reaction (PCR) assay and restriction fragment length polymorphisms (RFLP) for rapid identification of invasive fungal disease (IFD). METHODS We evaluated 16 clinical fungal species using a combination of PCR assays with 3 different restriction endonucleases targeting various internal transcribed spacer (ITS) regions and high resolution melting analysis (HRMA). Serial samples from 75 patients suspected to have IFD were analyzed for clinical verification. RESULTS We have designed a universal PCR capable of amplifying a portion of the 18S rRNA gene of 16 clinically important fungal species. The restriction patterns of most PCR products generated by EcoRI or double digested by ClaI and AvaI were different, except Aspergillus niger and Aspergillus flavus had a similar pattern, and Aspergillus fumigatus and Aspergillus terreus had a similar pattern. All these species had a unique melting curve shape using the HRMA. Both HRMA and universal PCR had adequate sensitivity, and all sixteen reference fungal species can be clearly distinguished by the universal PCR-RFLP-HRMA assay. With a reference library of 176 clinically relevant fungal strains, and 75 clinical samples from patients with suspicious IFD were tested, our assay identified 100% and 61.1% of isolates from the reference library and clinical samples, respectively. CONCLUSIONS Universal PCR and RFLP coupled with HRMA could be a highly discriminative and useful molecular diagnostic that could enhance the current diagnostic, treatment, and surveillance methods of invasive fungal disease.
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Affiliation(s)
- Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan; College of Medicine, Chang Gung University, Taiwan; Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taiwan
| | - Lee-Chung Lin
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taiwan
| | - Mei-Yin Lai
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taiwan
| | - Hsuan-Rong Huang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taiwan
| | - Ming-Chou Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taiwan
| | - Jang-Jih Lu
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan.
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11
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Giacobbe DR, Del Bono V, Viscoli C, Mikulska M. Use of 1,3-β-D-glucan in invasive fungal diseases in hematology patients. Expert Rev Anti Infect Ther 2017; 15:1101-1112. [PMID: 29125373 DOI: 10.1080/14787210.2017.1401467] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Invasive fungal diseases (IFD) remain a leading cause of morbidity and mortality in hematology patients. Within a diagnostic-driven approach, the use of the serum (1,3)-ß-D-glucan (BDG) test represents a valid tool for the early diagnosis and treatment of IFD. Areas covered: The available literature on the use of BDG in hematology patients was systematically retrieved. Then, it was reviewed and discussed, to identify key issues pertaining to a clinically-oriented narrative presentation of the topic. Expert commentary: The use of BDG in hematology patients at risk for invasive aspergillosis (IA) is secondary to the use of galactomannan. However, since BDG is not specific for IA, it offers an advantage of diagnosing also other IFD, such as candidiasis and pneumocystosis. The limitations of BDG include high costs and lower sensitivity in hematology patients compared to other cohorts. The risk of false positive results is possibly lower in real life than in theory, since glucan-free equipment is available and modern dialysis membranes and blood products usually do not release BDG. Thus, in experienced hands and selected clinical situations, BDG is a useful diagnostic tool, particularly due to short turnover time to results and versatility in diagnosing different IFD.
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Affiliation(s)
- Daniele Roberto Giacobbe
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Valerio Del Bono
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Claudio Viscoli
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Malgorzata Mikulska
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
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Vaquero-Herrero MP, Ragozzino S, Castaño-Romero F, Siller-Ruiz M, Sánchez González R, García-Sánchez JE, García-García I, Marcos M, Ternavasio-de la Vega HG. The Pitt Bacteremia Score, Charlson Comorbidity Index and Chronic Disease Score are useful tools for the prediction of mortality in patients with Candida
bloodstream infection. Mycoses 2017; 60:676-685. [DOI: 10.1111/myc.12644] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 05/02/2017] [Accepted: 05/22/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | - Silvio Ragozzino
- Department of Internal Medicine; University Hospital of Salamanca; Salamanca Spain
- Institute of Biomedical Research of Salamanca (IBSAL); Salamanca Spain
| | | | - María Siller-Ruiz
- Department of Microbiology; University Hospital of Salamanca; Salamanca Spain
| | | | - José Elías García-Sánchez
- Department of Microbiology; University Hospital of Salamanca; Salamanca Spain
- Institute of Biomedical Research of Salamanca (IBSAL); Salamanca Spain
- University of Salamanca (USAL); Salamanca Spain
| | - Inmaculada García-García
- Department of Microbiology; University Hospital of Salamanca; Salamanca Spain
- Institute of Biomedical Research of Salamanca (IBSAL); Salamanca Spain
| | - Miguel Marcos
- Department of Internal Medicine; University Hospital of Salamanca; Salamanca Spain
- Institute of Biomedical Research of Salamanca (IBSAL); Salamanca Spain
- University of Salamanca (USAL); Salamanca Spain
| | - Hugo Guillermo Ternavasio-de la Vega
- Department of Internal Medicine; University Hospital of Salamanca; Salamanca Spain
- Institute of Biomedical Research of Salamanca (IBSAL); Salamanca Spain
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Giacobbe DR, Mikulska M, Tumbarello M, Furfaro E, Spadaro M, Losito AR, Mesini A, De Pascale G, Marchese A, Bruzzone M, Pelosi P, Mussap M, Molin A, Antonelli M, Posteraro B, Sanguinetti M, Viscoli C, Del Bono V. Combined use of serum (1,3)-β-D-glucan and procalcitonin for the early differential diagnosis between candidaemia and bacteraemia in intensive care units. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:176. [PMID: 28693606 PMCID: PMC5504626 DOI: 10.1186/s13054-017-1763-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/19/2017] [Indexed: 01/02/2023]
Abstract
Background This study aimed to assess the combined performance of serum (1,3)-β-d-glucan (BDG) and procalcitonin (PCT) for the differential diagnosis between candidaemia and bacteraemia in three intensive care units (ICUs) in two large teaching hospitals in Italy. Methods From June 2014 to December 2015, all adult patients admitted to the ICU who had a culture-proven candidaemia or bacteraemia, as well as BDG and PCT measured closely to the time of the index culture, were included in the study. The diagnostic performance of BDG and PCT, used either separately or in combination, was assessed by calculating the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratios (LR+ and LR–). Changes from pre-test probabilities to post-test probabilities of candidaemia and bacteraemia were inferred from Fagan’s nomograms. Results One hundred and sixty-six patients were included, 73 with candidaemia (44%) and 93 with bacteraemia (56%). When both markers indicated candidaemia (BDG ≥80 pg/ml and PCT <2 ng/ml) they showed higher PPV (96%) compared to 79% and 66% for BDG or PCT alone, respectively. When both markers indicated bacteraemia (BDG <80 pg/ml and PCT ≥2 ng/ml), their NPV for candidaemia was similar to that of BDG used alone (95% vs. 93%). Discordant BDG and PCT results (i.e. one indicating candidaemia and the other bacteraemia) only slightly altered the pre-test probabilities of the two diseases. Conclusions The combined use of PCT and BDG could be helpful in the diagnostic workflow for critically ill patients with suspected candidaemia. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1763-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Infectious Diseases Division, University of Genoa (DISSAL) and Ospedale Policlinico San Martino - IRCCS per l'Oncologia, L.go R. Benzi, 10 - 16132, Genoa, Italy.
| | - Malgorzata Mikulska
- Infectious Diseases Division, University of Genoa (DISSAL) and Ospedale Policlinico San Martino - IRCCS per l'Oncologia, L.go R. Benzi, 10 - 16132, Genoa, Italy
| | - Mario Tumbarello
- Institute of Infectious Diseases, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Elisa Furfaro
- Infectious Diseases Division, University of Genoa (DISSAL) and Ospedale Policlinico San Martino - IRCCS per l'Oncologia, L.go R. Benzi, 10 - 16132, Genoa, Italy
| | - Marzia Spadaro
- Infectious Diseases Division, University of Genoa (DISSAL) and Ospedale Policlinico San Martino - IRCCS per l'Oncologia, L.go R. Benzi, 10 - 16132, Genoa, Italy
| | - Angela Raffaella Losito
- Institute of Infectious Diseases, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Alessio Mesini
- Infectious Diseases Division, University of Genoa (DISSAL) and Ospedale Policlinico San Martino - IRCCS per l'Oncologia, L.go R. Benzi, 10 - 16132, Genoa, Italy
| | - Gennaro De Pascale
- Department of Intensive Care and Anesthesiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Anna Marchese
- Microbiology Unit, University of Genoa (DISC) and Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Marco Bruzzone
- Clinical Epidemiology Unit, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Paolo Pelosi
- Anesthesiology and Intensive Care Unit, DIPEA, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy.,Anesthesiology and Intensive Care, University of Genoa (DISC), Genoa, Italy
| | - Michele Mussap
- Department of Bio-medical Laboratory, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Alexandre Molin
- Anesthesiology and Intensive Care Unit, DIPEA, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Brunella Posteraro
- Institute of Public Health (Section of Hygiene), Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Maurizio Sanguinetti
- Institute of Microbiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Claudio Viscoli
- Infectious Diseases Division, University of Genoa (DISSAL) and Ospedale Policlinico San Martino - IRCCS per l'Oncologia, L.go R. Benzi, 10 - 16132, Genoa, Italy
| | - Valerio Del Bono
- Infectious Diseases Division, University of Genoa (DISSAL) and Ospedale Policlinico San Martino - IRCCS per l'Oncologia, L.go R. Benzi, 10 - 16132, Genoa, Italy
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Angebault C, Lanternier F, Dalle F, Schrimpf C, Roupie AL, Dupuis A, Agathine A, Scemla A, Paubelle E, Caillot D, Neven B, Frange P, Suarez F, d'Enfert C, Lortholary O, Bougnoux ME. Prospective Evaluation of Serum β-Glucan Testing in Patients With Probable or Proven Fungal Diseases. Open Forum Infect Dis 2016; 3:ofw128. [PMID: 27419189 PMCID: PMC4942764 DOI: 10.1093/ofid/ofw128] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 06/14/2016] [Indexed: 11/22/2022] Open
Abstract
We evaluated the positivity of (1-3)-β-D-glucan, a serum marker of invasive fungal diseases (IFD), at diagnosis and during treatment. (1-3)-β-D-Glucan may not be an early marker but could prove useful for diagnosis of chronic IFD. Background. Early diagnosis and treatment are crucial in invasive fungal diseases (IFD). Serum (1-3)-β-d-glucan (BG) is believed to be an early IFD marker, but its diagnostic performance has been ambiguous, with insufficient data regarding sensitivity at the time of IFD diagnosis (TOD) and according to outcome. Whether its clinical utility is equivalent for all types of IFD remains unknown. Methods. We included 143 patients with proven or probable IFD (49 invasive candidiasis, 45 invasive aspergillosis [IA], and 49 rare IFD) and analyzed serum BG (Fungitell) at TOD and during treatment. Results. (1-3)-β-d-glucan was undetectable at TOD in 36% and 48% of patients with candidemia and IA, respectively; there was no correlation between negative BG results at TOD and patients' characteristics, localization of infection, or prior antifungal use. Nevertheless, patients with candidemia due to Candida albicans were more likely to test positive for BG at TOD (odds ratio = 25.4, P = .01) than patients infected with other Candida species. In 70% of the patients with a follow-up, BG negativation occurred in >1 month for candidemia and >3 months for IA. A slower BG decrease in patients with candidemia was associated with deep-seated localizations (P = .04). Thirty-nine percent of patients with rare IFD had undetectable BG at TOD; nonetheless, all patients with chronic subcutaneous IFD tested positive at TOD. Conclusions. Undetectable serum BG does not rule out an early IFD, when the clinical suspicion is high. After IFD diagnostic, kinetics of serum BG are difficult to relate to clinical outcome.
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Affiliation(s)
- Cécile Angebault
- Unitéde Parasitologie-Mycologie, Service de Microbiologie Clinique; Université Paris Descartes, Sorbonne Paris-Cité
| | - Fanny Lanternier
- Centre d'Infectiologie Necker Pasteur; Université Paris Descartes, Sorbonne Paris-Cité,; Unité de Mycologie Médicale, Centre National de Référence Mycoses Invasives et Antifongiques, Institut Pasteur, Paris
| | | | | | | | - Aurélie Dupuis
- Unité de Parasitologie-Mycologie, Service de Microbiologie Clinique
| | - Aurélie Agathine
- Unité de Parasitologie-Mycologie, Service de Microbiologie Clinique
| | - Anne Scemla
- Service de Néphrologie et Transplantation Adulte; Université Paris Descartes, Sorbonne Paris-Cité,; Réseau Thématique de Recherche et de SoinsCentaure, Labex Transplantex, Paris
| | - Etienne Paubelle
- Service d'Hématologie Adulte; Université Paris Descartes, Sorbonne Paris-Cité
| | - Denis Caillot
- Service d'Hématologie Clinique , Centre Hospitalier Universitaire Dijon Bourgogne
| | - Bénédicte Neven
- Unité d'Immunologie, Hématologie et Rhumatologie Pédiatriques
| | - Pierre Frange
- Unité d'Immunologie, Hématologie et Rhumatologie Pédiatriques; Unité d'Hygiène, Service de Microbiologie Clinique, Hôpital Necker-Enfants malades, Assistance Publique des Hôpitaux de Paris
| | - Felipe Suarez
- Service d'Hématologie Adulte; Université Paris Descartes, Sorbonne Paris-Cité
| | - Christophe d'Enfert
- Unité Biologie et Pathogénicité Fongiques, Département de Mycologie, Institut Pasteur, Paris; Institut National de la Recherche Agronomique, Unité Sous Contrat 2019, Paris, France
| | - Olivier Lortholary
- Centre d'Infectiologie Necker Pasteur; Université Paris Descartes, Sorbonne Paris-Cité,; Unité de Mycologie Médicale, Centre National de Référence Mycoses Invasives et Antifongiques, Institut Pasteur, Paris
| | - Marie-Elisabeth Bougnoux
- Unitéde Parasitologie-Mycologie, Service de Microbiologie Clinique; Université Paris Descartes, Sorbonne Paris-Cité,; Unité Biologie et Pathogénicité Fongiques, Département de Mycologie, Institut Pasteur, Paris; Institut National de la Recherche Agronomique, Unité Sous Contrat 2019, Paris, France
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15
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Giacobbe DR, Viscoli C, Furfaro E, Colombo AL, Del Bono V. Is initial serum (1,3)-β-d-glucan truly associated with mortality in patients with candidaemia? Authors' response. Clin Microbiol Infect 2016; 22:579. [PMID: 26970047 DOI: 10.1016/j.cmi.2016.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 02/27/2016] [Indexed: 11/19/2022]
Affiliation(s)
- D R Giacobbe
- Clinica Malattie Infettive, DIPMI, DISSAL, IRCCS San Martino-IST, Università di Genova, Genova, Italy.
| | - C Viscoli
- Clinica Malattie Infettive, DIPMI, DISSAL, IRCCS San Martino-IST, Università di Genova, Genova, Italy
| | - E Furfaro
- Clinica Malattie Infettive, DIPMI, DISSAL, IRCCS San Martino-IST, Università di Genova, Genova, Italy
| | - A L Colombo
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - V Del Bono
- Clinica Malattie Infettive, DIPMI, DISSAL, IRCCS San Martino-IST, Università di Genova, Genova, Italy
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Abe M, Kimura M, Araoka H, Taniguchi S, Yoneyama A. Is initial serum (1,3)-β-d-glucan truly associated with mortality in patients with candidaemia? Clin Microbiol Infect 2016; 22:576. [PMID: 26928201 DOI: 10.1016/j.cmi.2016.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 01/26/2016] [Accepted: 02/13/2016] [Indexed: 10/22/2022]
Affiliation(s)
- M Abe
- Department of Infectious Diseases, Toranomon Hospital, Tokyo, Japan.
| | - M Kimura
- Department of Infectious Diseases, Toranomon Hospital, Tokyo, Japan
| | - H Araoka
- Department of Infectious Diseases, Toranomon Hospital, Tokyo, Japan; Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - S Taniguchi
- Department of Haematology, Toranomon Hospital, Tokyo, Japan
| | - A Yoneyama
- Department of Infectious Diseases, Toranomon Hospital, Tokyo, Japan; Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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Abstract
Bloodstream infections (BSI) carry a heavy burden of morbidity and mortality in modern internal medicine wards (IMW). These wards are often filled with elderly subjects with several risk factors for BSI, such as multiple comorbidities, polypharmacy, immunosuppression, and indwelling devices. Diagnosing BSI in such a setting might require a high degree of suspicion, since the clinical presentation could be affected by underlying conditions and concomitant medications, which might delay the administration of an appropriate antimicrobial therapy, an event strongly and unfavorably influencing survival. Furthermore, selecting the appropriate antimicrobial therapy to treat these patients is becoming an increasingly complex task in which all possible benefits and costs should be carefully analyzed from patient and public health perspectives. Only a specialized, continuous, and interdisciplinary approach could really improve the management of IMW patients in an era of increasing antimicrobial resistance and complexity of care.
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Affiliation(s)
- Valerio Del Bono
- a Clinica Malattie Infettive, IRCCS AOU San Martino-IST, Università di Genova , Genova , Italy
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