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Novy E, Rivière J, Nguyen M, Arfeuille G, Louis G, Bouhemad B, Pottecher J, Hecketsweiler S, Germain A, Laithier FX, Losser MR, Debourgogne A, Bernard Y, Rousseau H, Baumann C, Luc A, Birckener J, Machouart MC, Guerci P. Combination of serum and peritoneal 1.3-beta-D-glucan can rule out intra-abdominal candidiasis in surgical critically ill patients: a multicenter prospective study. Crit Care 2023; 27:470. [PMID: 38037130 PMCID: PMC10691030 DOI: 10.1186/s13054-023-04761-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/28/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Intra-abdominal candidiasis (IAC) is difficult to predict in critically ill patients with intra-abdominal infection, leading to the overuse of antifungal treatments. Serum and peritoneal 1.3-beta-D-glucan (sBDG and pBDG) have been proposed to confirm or invalidate the diagnosis of IAC, but clinical studies have reported inconsistent results, notably because of heterogeneous populations with a low IAC prevalence. This study aimed to identify a high-risk IAC population and evaluate pBDG and sBDG in diagnosing IAC. METHODS This prospective multicenter noninterventional French study included consecutive critically ill patients undergoing abdominal surgery for abdominal sepsis. The primary objective was to establish the IAC prevalence. The secondary objective was to explore whether sBDG and pBDG could be used to diagnose IAC. Wako® beta-glucan test (WT, Fujifilm Wako Chemicals Europe, Neuss, Germany) was used for pBDG measurements. WT and Fungitell® beta-D-glucan assay (FA, Associate of Cape Cod, East Falmouth, USA) were used for sBDG measurements. RESULTS Between 1 January 2020 and 31 December 2022, 199 patients were included. Patients were predominantly male (63%), with a median age of 66 [54-72] years. The IAC prevalence was 44% (87/199). The main IAC type was secondary peritonitis. Septic shock occurred in 63% of cases. After multivariate analysis, a nosocomial origin was associated with more IAC cases (P = 0.0399). The median pBDG level was significantly elevated in IAC (448 [107.5-1578.0] pg/ml) compared to non-IAC patients (133 [16.0-831.0] pg/ml), P = 0.0021. For a pBDG threshold of 45 pg/ml, the negative predictive value in assessing IAC was 82.3%. The median sBDG level with WT (n = 42) at day 1 was higher in IAC (5 [3.0-9.0] pg/ml) than in non-IAC patients (3 [3.0-3.0] pg/ml), P = 0.012. Similarly, median sBDG level with FA (n = 140) at day 1 was higher in IAC (104 [38.0-211.0] pg/ml) than in non-IAC patients (50 [23.0-141.0] pg/ml), P = 0.009. Combining a peritonitis score < 3, sBDG < 3.3 pg/ml (WT) and pBDG < 45 pg/ml (WT) yielded a negative predictive value of 100%. CONCLUSION In critically ill patients with intra-abdominal infection requiring surgery, the IAC prevalence was 44%. Combining low sBDG and pBDG with a low peritonitis score effectively excluded IAC and could limit unnecessary antifungal agent exposure. TRIAL REGISTRATION The study was registered with ClinicalTrials.gov (ID number 03997929, first registered on June 24, 2019).
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Affiliation(s)
- Emmanuel Novy
- Service d'Anesthésie-Réanimation et Médecine Péri-opératoire, CHRU Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France.
- SIMPA, UR7300, Université de Lorraine, 54500, Vandœuvre-Lès-Nancy, France.
| | - Jérémie Rivière
- Service d'Anesthésie-Réanimation et Médecine Péri-opératoire, CHRU Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France
- Service de Réanimation Polyvalente, CHR Metz-Thionville, 57000, Metz, France
| | - Maxime Nguyen
- Service d'Anesthésie-Réanimation et Médecine Péri-Opératoire, CHU Dijon, 21000, Dijon, France
- INSERM UMR1231, Université de Bourgogne-Franche Comté, 21000, Dijon, France
| | - Gaëlle Arfeuille
- Service d'Anesthésie-Réanimation et Médecine Péri-Opératoire, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 67200, Strasbourg, France
| | - Guillaume Louis
- Service de Réanimation Polyvalente, CHR Metz-Thionville, 57000, Metz, France
| | - Bélaïd Bouhemad
- Service d'Anesthésie-Réanimation et Médecine Péri-Opératoire, CHU Dijon, 21000, Dijon, France
- INSERM UMR1231, Université de Bourgogne-Franche Comté, 21000, Dijon, France
| | - Julien Pottecher
- Service d'Anesthésie-Réanimation et Médecine Péri-Opératoire, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 67200, Strasbourg, France
- UR3072, FMTS, Faculté de Médecine, Maïeutique et Science de la sante, Université de Strasbourg, 67000, Strasbourg, France
| | - Stéphane Hecketsweiler
- Service d'Anesthésie-Réanimation et Médecine Péri-Opératoire, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 67200, Strasbourg, France
| | - Adeline Germain
- Service de chirurgie digestive, CHRU Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France
- NGERE, U1256, Université de Lorraine, 54500, Vandœuvre-Lès-Nancy, France
| | - François-Xavier Laithier
- Service d'Anesthésie-Réanimation et Médecine Péri-opératoire, CHRU Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France
| | - Marie-Reine Losser
- Service d'Anesthésie-Réanimation et Médecine Péri-opératoire, CHRU Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France
- DCAC, INSERM 1116, Université de Lorraine, 54500, Vandœuvre-Lès-Nancy, France
| | - Anne Debourgogne
- SIMPA, UR7300, Université de Lorraine, 54500, Vandœuvre-Lès-Nancy, France
- Service de mycologie et parasitologie, CHRU Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France
| | - Yohann Bernard
- Délégation À la recherche et à l'innovation, CHRU de Nancy, 54500, Vandœuvre-Lès-Nancy, France
| | - Hélène Rousseau
- Unité de Méthodologie, data management et statistiques, DRCI, CHRU de Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France
| | - Cédric Baumann
- Unité de Méthodologie, data management et statistiques, DRCI, CHRU de Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France
| | - Amandine Luc
- Unité de Méthodologie, data management et statistiques, DRCI, CHRU de Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France
| | - Julien Birckener
- Service d'Anesthésie-Réanimation et Médecine Péri-opératoire, CHRU Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France
| | - Marie-Claire Machouart
- SIMPA, UR7300, Université de Lorraine, 54500, Vandœuvre-Lès-Nancy, France
- Service de mycologie et parasitologie, CHRU Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France
| | - Philippe Guerci
- Service d'Anesthésie-Réanimation et Médecine Péri-opératoire, CHRU Nancy - Hôpitaux de Brabois, 54500, Vandœuvre-Lès-Nancy, France
- DCAC, INSERM 1116, Université de Lorraine, 54500, Vandœuvre-Lès-Nancy, France
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Wang YS, Hsu JF, Lee WJ, Wang SH, Chu SM, Huang HR, Yang PH, Fu RH, Tsai MH. Invasive Candida parapsilosis Bloodstream Infections in Children: The Antifungal Susceptibility, Clinical Characteristics and Impacts on Outcomes. Microorganisms 2023; 11:1149. [PMID: 37317123 DOI: 10.3390/microorganisms11051149] [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: 03/08/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 06/16/2023] Open
Abstract
Background: Candida parapsilosis is the most common non-albicans candida species that causes invasive candidiasis, but little is known about its impacts on the outcomes of pediatric patients. We aimed to characterize the clinical characteristics, risk factors and outcomes of C. parapsilosis bloodstream infections (BSIs) in children. Methods: All pediatric patients with Candida parapsilosis BSIs between 2005 and 2020 from a medical center in Taiwan were enrolled and analyzed. The antifungal susceptibility, clinical manifestations, management and outcomes were investigated. Cases of Candida parapsilosis BSIs were compared between patients with C. albicans BSIs and other Candida spp. BSIs. Results: During the study period, 95 episodes (26.0% of total cases) of Candida parapsilosis BSIs were identified and analyzed. No significant difference was found between pediatric patients with C. parapsilosis BSIs and those with C. albicans BSIs in terms of patients' demographics, most chronic comorbidities or risk factors. Pediatric patients with C. parapsilosis BSIs were significantly more likely to have previous azole exposure and be on total parenteral nutrition than those with C. albicans BSIs (17.9 vs. 7.6% and 76.8 vs. 63.7%, p = 0.015 and 0.029, respectively). The duration of C. parapsilosis candidemia was relatively longer, and therefore patients often required a longer duration of antifungal treatment when compared with those of C. albicans candidemia, although the candidemia-attributable mortality rates were comparable. Of the C. parapsilosis isolates, 93.7% were susceptible to all antifungal agents, and delayed appropriate antifungal treatment was an independent factor in treatment failure. Conclusions: Pediatric patients with C. parapsilosis BSIs were more likely to have previous azole exposure and be on total parenteral nutrition, and the clinical significances included a longer duration of candidemia and patients often required a longer duration of antifungal treatment.
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Affiliation(s)
- Yao-Sheng Wang
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Jen-Fu Hsu
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 244, Taiwan
| | - Wei-Ju Lee
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Shao-Hung Wang
- Department of Microbiology Immunology and Biopharmaceuticals, National Chiayi University, Chiayi 613, Taiwan
| | - Shih-Ming Chu
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 244, Taiwan
| | - Hsuan-Rong Huang
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 244, Taiwan
| | - Peng-Hong Yang
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 244, Taiwan
| | - Ren-Huei Fu
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 244, Taiwan
| | - Ming-Horng Tsai
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin 638, Taiwan
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Yoon YK, Moon C, Kim J, Heo ST, Lee MS, Lee S, Kwon KT, Kim SW. Korean Guidelines for Use of Antibiotics for Intra-abdominal Infections in Adults. Infect Chemother 2022; 54:812-853. [PMID: 36596690 PMCID: PMC9840951 DOI: 10.3947/ic.2022.0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
The guidelines are intended to provide practical information for the correct use of antibiotics for intra-abdominal infections in Korea. With the aim of realizing evidence-based treatment, these guidelines for the use of antibiotics were written to help clinicians find answers to key clinical questions that arise in the course of patient care, using the latest research results based on systematic literature review. The guidelines were prepared in consideration of the data on the causative pathogens of intra-abdominal infections in Korea, the antibiotic susceptibility of the causative pathogens, and the antibiotics available in Korea.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Korean Society for Antimicrobial Therapy, Seoul, Korea
| | - Chisook Moon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea.,Korean Society of Infectious Diseases, Seoul, Korea
| | - Sang Taek Heo
- Korean Society of Infectious Diseases, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Korea
| | - Mi Suk Lee
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Shinwon Lee
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Ki-Tae Kwon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Shin-Woo Kim
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Pediatric Candida Bloodstream Infections Complicated with Mixed and Subsequent Bacteremia: The Clinical Characteristics and Impacts on Outcomes. J Fungi (Basel) 2022; 8:jof8111155. [PMID: 36354922 PMCID: PMC9695890 DOI: 10.3390/jof8111155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Pediatricians face a therapeutic challenge when patients with Candida bloodstream infections (BSIs) simultaneously have positive bacterial culture. We aim to characterize the clinical characteristics of pediatric Candida BSIs complicated with mixed bacteremia and subsequent bacterial infections, risk factors and impacts on outcomes. Methods: All episodes of pediatric Candida BSIs between 2005 and 2020 from a medical center in Taiwan were reviewed. Mixed Candida/bacterial BSIs were defined as isolation of a bacterial pathogen from blood cultures obtained within 48 h before or after the onset of Candida BSI. The clinical features and impacts of mixed Candida/bacterial BSIs were investigated. Results: During the study period, 320 patients with a total of 365 episodes of Candida BSIs were identified and analyzed. Mixed Candida/bacterial BSIs were 35 episodes (9.6%). No significant difference was found between mixed Candida/bacterial BSIs and monomicrobial Candida BSIs in terms of patient demographics, Candida species distributions, most chronic comorbidities or risk factors. Patients with mixed Candida/bacterial BSIs were associated with a significantly higher risk of subsequent bacteremia (51.4% vs. 21.2%, p < 0.001) and a relatively higher candidemia-attributable mortality rate (37.2% vs. 22.4%, p = 0.061) than those with monomicrobial Candida BSIs. Mixed Candida/bacterial BSIs were not an independent risk factor of treatment failure or final mortality according to multivariate logistic regression analyses. Conclusions: The clinical significance of mixed Candida/bacterial BSIs in children included a longer duration of septic symptoms, significantly higher likelihood to have subsequent bacteremia, and relatively higher risk of candidemia attributable mortality.
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Kanj SS, Omrani AS, Al-Abdely HM, Subhi A, Fakih RE, Abosoudah I, Kanj H, Dimopoulos G. Survival Outcome of Empirical Antifungal Therapy and the Value of Early Initiation: A Review of the Last Decade. J Fungi (Basel) 2022; 8:1146. [PMID: 36354913 PMCID: PMC9695378 DOI: 10.3390/jof8111146] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 10/03/2023] Open
Abstract
AIM This rapid systematic review aimed to collect the evidence published over the last decade on the effect of empirical antifungal therapy and its early initiation on survival rates. METHODS A systematic search was conducted in PubMed, Cochrane, Medline, Scopus, and Embase, in addition to a hand search and experts' suggestions. RESULTS Fourteen cohort studies and two randomized clinical trials reporting the survival outcome of empirical antifungal therapy were included in this review. Two studies reported the association between early empirical antifungal therapy (EAFT) and survival rates in a hematological cancer setting, and fourteen studies reported the outcome in patients in intensive care units (ICU). Six studies reported that appropriate EAFT decreases hospital mortality significantly; ten studies could not demonstrate a statistically significant association with mortality rates. DISCUSSION The inconsistency of the results in the literature can be attributed to the studies' small sample size and their heterogeneity. Many patients who may potentially benefit from such strategies were excluded from these studies. CONCLUSION While EAFT is practiced in many settings, current evidence is conflicting, and high-quality studies are needed to demonstrate the true value of this approach. Meanwhile, insights from experts in the field can help guide clinicians to initiate EAFT when indicated.
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Affiliation(s)
- Souha S. Kanj
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, Riad El Solh, Beirut P.O. Box 11-0236, Lebanon
| | - Ali S. Omrani
- Division of Infectious Diseases, Department of Medicine, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar
- College of Medicine, Qatar University, Doha P.O. Box 2713, Qatar
| | - Hail M. Al-Abdely
- Division of Infectious Diseases, Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Ahmad Subhi
- Division of Infectious Disease, Al-Qassimi Hospital, Emirates Health Services, Sharjah 61313, United Arab Emirates
| | - Riad El Fakih
- Department of Hematology, Stem Cell Transplant & Cellular Therapy, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Ibraheem Abosoudah
- Department of Oncology, King Faisal Specialist Hospital and Research Center, MBC J-64, Jeddah 21499, Saudi Arabia
| | - Hazar Kanj
- Faculty of Medicine, American University of Beirut Medical Center, Beirut P.O. Box 11-0236, Lebanon
| | - George Dimopoulos
- Department of Critical Care, “EVGENIDIO” Hospital, National and Kapodistrian University of Athens (NKUA), 10679 Athens, Greece
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Dalfino L, Grasso S. Personalized antimicrobial policies in severe peritonitis: opportunities not to be missed! Minerva Anestesiol 2022; 88:329-331. [PMID: 35315625 DOI: 10.23736/s0375-9393.22.16551-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Lidia Dalfino
- Intensive Care Unit II, Department of General Surgery, Gynaecology, Obstetrics and Anaesthesia, University Hospital Policlinico of Bari, Bari, Italy -
| | - Salvatore Grasso
- Division of Anaesthesiology and Resuscitation, Department of Emergency and Organ Transplantation (DETO), Aldo Moro University of Bari, Policlinico Hospital, Bari, Italy
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Pressiat C, Ait-Ammar N, Daniel M, Hulin A, Botterel F, Levesque E. Pharmacokinetics/Pharmacodynamics of Caspofungin in Plasma and Peritoneal Fluid of Liver Transplant Recipients. Antimicrob Agents Chemother 2022; 66:e0118721. [PMID: 34662185 PMCID: PMC8765281 DOI: 10.1128/aac.01187-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 10/06/2021] [Indexed: 01/08/2023] Open
Abstract
The weaker diffusion of echinocandins in the peritoneal fluid (PF) could promote Candida-resistant isolates. The aim of this study was to analyze the pharmacokinetics (PK)/pharmacodynamics (PD) of caspofungin in plasma and PF samples from liver transplant recipients. Liver transplant patients received caspofungin as postoperative prophylaxis. Caspofungin concentrations were quantified in plasma and PF samples on days 1, 3, and 8. Data were analyzed using nonlinear mixed-effect modeling and Monte Carlo simulations. Area under the curve (AUC) values for plasma and PF were simulated under three dosing regimens. Probabilities of target attainment (PTAs) were calculated using area under the unbound plasma concentration-time curve from 0 to 24 h at steady state (fAUC0-24)/MIC ratios, with MICs ranging from 0.008 to 8 mg/L. All of the patients included were monitored weekly for Candida colonization and for Candida infections. Twenty patients were included. The median daily dose of caspofungin was 0.81 mg/kg. Plasma (n = 395) and PF (n = 50) concentrations at steady state were available. A two-compartment model with first-order absorption and elimination was described. Our two-compartment model with first-order absorption and elimination produced an effective PK/PD relationship in plasma, achieving a PTA of ≥90% with MICs ranging from 0.008 to 0.12 mg/L for Candida albicans and Candida glabrata. In PF, PTAs at D8 were optimal only for a MIC of 0.008 mg/L in patients weighing 60 kg under the three dosing regimens. Among the 16 patients colonized, all MIC values were below the maximal concentration (Cmax) in plasma but not in PF. PF concentrations of caspofungin were low. Simulations showed that the PTAs for Candida spp. in PF were not optimal, which might suggest a potential risk of resistance.
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Affiliation(s)
- Claire Pressiat
- Pharmacology Unit, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Nawel Ait-Ammar
- Université Paris-Est Creteil, EnvA, DYNAMiC, Faculté de Santé de Créteil, Creteil, France
- Parasitology and Mycology Unit, Department of Prevention, Diagnosis, and Treatment of Infections, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Matthieu Daniel
- Department of Anaesthesia and Surgical Intensive Care, Liver Intensive Care Unit, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Anne Hulin
- Pharmacology Unit, AP-HP, Henri Mondor Hospital, Créteil, France
- EA 7375, EC2M3, Oncomix, Université Paris-Est Créteil, Faculté de Santé de Créteil, Institut Pasteur, Paris, France
| | - Françoise Botterel
- Université Paris-Est Creteil, EnvA, DYNAMiC, Faculté de Santé de Créteil, Creteil, France
- Parasitology and Mycology Unit, Department of Prevention, Diagnosis, and Treatment of Infections, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Eric Levesque
- Université Paris-Est Creteil, EnvA, DYNAMiC, Faculté de Santé de Créteil, Creteil, France
- Department of Anaesthesia and Surgical Intensive Care, Liver Intensive Care Unit, AP-HP, Henri Mondor Hospital, Créteil, France
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Abstract
PURPOSE OF REVIEW Timely and adequate management are the key priorities in the care of peritonitis. This review focuses on the cornerstones of the medical support: source control and antiinfective therapies. RECENT FINDINGS Peritonitis from community-acquired or healthcare-associated origins remains a frequent cause of admission to the ICU. Each minute counts for initiating the proper management. Late diagnosis and delayed medical care are associated to dramatically increased mortality rates. The diagnosis of peritonitis can be difficult in these ICU cases. The signs of organ failures are more relevant than biological surrogates. A delayed source control and a late anti-infective therapy are of critical importance. The quality of source control and medical management are other key elements of the prognosis. The conventional rules applied for sepsis are applicable for peritonitis, including hemodynamic support and anti-infective therapy. Growing proportions of multidrug resistant pathogens are reported from surgical samples, mainly related to Gram-negative bacteria. The increasing complexity in the care of these critically ill patients is a strong incentive for a multidisciplinary approach. SUMMARY Early clinical diagnosis, timely and adequate source control and antiinfective therapy are the essential pillars of the management of peritonitis in ICU patients.
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Xia R, Wang D. Risk factors of invasive candidiasis in critical cancer patients after various gastrointestinal surgeries: A 4-year retrospective study. Medicine (Baltimore) 2019; 98:e17704. [PMID: 31689800 PMCID: PMC6946494 DOI: 10.1097/md.0000000000017704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
For early diagnosis and treatment of invasive candidiasis (IC), the well-known risk factors may not apply in the intensive care unit (ICU). This retrospective study identified the risk factors predicting IC and candidemia in cancer patients under intensive care after gastrointestinal surgery.Enrolled were 229 cancer patients admitted to our oncology surgical ICU after gastrointestinal surgery between January 1, 2010 and October 31, 2014.The most common types of solid gastrointestinal cancers were gastric (49.8%), colon (20.1%), and esophageal (18.3%). The percentage of patients with corrected Candida colonization index (CCI) ≥0.4 was 31.9%. IC was confirmed in 19 patients (8.3%), and the ICU mortality was 15.8%. Candida albicans accounted for 52.6% of the total number of pathogenic Candida isolates. Among patients with CCI ≥0.4, the cancers with the highest prevalence were cardiac (45%) and gastric (36%), with ICU mortalities of 20% and 4.9%, respectively. For the diagnosis of candidemia, (1-3)-β-D-glucan (BDG) ≥80 pg/mL showed a sensitivity and specificity of 25% and 82.7%, respectively, positive and negative predictive values 6.7% and 95.7%, and area under the receiver operating characteristic curve 0.512. CCI ≥0.4 was the only significant predictor of IC, and number of organ failures was the only predictor of candidemia (P = .000 and .026).CCI ≥0.4 was the only significant risk factor predicting IC, with greater prediction of intra-abdominal candidiasis but failure to predict candidemia. Blood culture and BDG detection are recommended to supplement diagnosis. Patients may have multifocal and high-grade Candida colonization after cardiac surgery, and; therefore, are at high risk of IC, which should be taken seriously.
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Evaluation of anidulafungin in the treatment of intra-abdominal candidiasis: a pooled analysis of patient-level data from 5 prospective studies. Eur J Clin Microbiol Infect Dis 2019; 38:1849-1856. [PMID: 31280481 PMCID: PMC6778589 DOI: 10.1007/s10096-019-03617-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/14/2019] [Indexed: 10/30/2022]
Abstract
The incidence of nosocomial invasive fungal infections involving Candida spp. has increased markedly in recent years in patients undergoing abdominal surgery. This post hoc analysis aimed to determine the efficacy and safety of anidulafungin treatment in patients with intra-abdominal candidiasis (IAC) from five prospective studies (one comparative and four open-label) of adult surgical patients with microbiologically confirmed Candida intra-abdominal infection. Patients received an intravenous (IV) loading dose of anidulafungin 200 mg, followed by a daily 100-mg maintenance dose. Per study protocols, some patients could be switched to an oral azole after ≥ 5 or ≥ 10 days of IV treatment. Antifungal treatment was maintained for ≥ 14 days after the last positive Candida culture and resolution of symptoms. The global response rate (GRR) at the end of IV treatment (EOIVT) was the primary endpoint. GRR at the end of therapy (EOT), all-cause mortality at days 14 and 28, and safety was also evaluated. Seventy-nine patients had IAC from peritoneal fluid or hepatobiliary tract. C. albicans (72.2%) and C. glabrata (32.9%) were the most common pathogens. Overall GRR was 73.4% and 67.1% at EOIVT and EOT, respectively. All-cause mortality was 17.7% at day 14 and 24.1% at day 28 in the modified intent-to-treat population. Anidulafungin was well tolerated in this population, with most adverse events mild or moderate in severity. In these patients with IAC, anidulafungin showed a GRR at EOIVT similar to the anidulafungin registrational trial, and the results of our analysis confirmed the known safety profile of anidulafungin. ClinicalTrials.gov registration number NCT00496197, registered July 3, 2007, https://clinicaltrials.gov/ct2/show/study/NCT00496197 ; ClinicalTrials.gov registration number NCT00548262, registered October 19, 2007, https://clinicaltrials.gov/ct2/show/record/NCT00548262 ; ClinicalTrials.gov registration number NCT00537329, registered September 25, 2007, https://clinicaltrials.gov/ct2/show/record/NCT00537329 ; ClinicalTrials.gov registration number NCT00689338, registered May 29, 2008, https://clinicaltrials.gov/ct2/show/study/NCT00689338 ; ClinicalTrials.gov registration number NCT00805740, registered November 26, 2008, https://clinicaltrials.gov/ct2/show/NCT00805740.
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Detoc M, Touche C, Charles R, Lucht F, Gagneux-Brunon A, Botelho-Nevers E. Primary physicians' attitudes toward their patients receiving a proposal to participate in a vaccine trial. Hum Vaccin Immunother 2019; 15:2969-2979. [PMID: 31241393 DOI: 10.1080/21645515.2019.1625646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
A trustworthy relationship between primary physicians (PPs) and their patients is crucial for vaccine acceptance. Little is known about attitudes of PPs toward participation of their patients in a preventive vaccine trial (PVT) proposed by investigation sites.A cross-sectional study was conducted in Auvergne-Rhône-Alpes region (France) including an anonymous questionnaire for general practitioners (GPs) and other specialists as well as face-to-face interviews. A scenario of a patient, with chronic medical conditions, invited to participate in a PVT and reporting this situation to his/her PP was drawn up. PPs' attitudes were assessed in quantitative approach by a 5-point Likert scale and in qualitative approach by semi-directed individual interviews.Among the 521 respondents to the questionnaire, 429 (82.3%) were GPs and 92 (17.7%) were other specialists. Only 7.5% (39/521) of respondents regularly practice clinical research. Confronted with the scenario, 312 respondents (59.8%) declared they would give their opinion spontaneously. Before giving their opinion, PPs would like more information about the trial (91.4%, n = 476). Whatever their attitude, 488 (93.7%) would be influenced by available safety data. Face-to-face interviews confirmed that PPs lack of knowledge about clinical research, and would like to obtain information from investigators, particularly about safety.PPs seem to be concerned by the decision of their patients to participate or not in a PVT but would like more information about the trial and clinical research before giving their opinion. Getting PPs to be more involved in the enrollment of patients in PVT may improve recruitment.
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Affiliation(s)
- Maelle Detoc
- Clinical trial center, INSERM CICEC 1408, University Hospital of Saint-Etienne, Saint-Etienne, France.,Groupe Immunité Muqueuse et Agents Pathogènes (GIMAP), EA3064 - Medical School of Saint-Etienne, University of Lyon, Saint-Etienne, France
| | - Camille Touche
- General Practice Department, University of Lyon, Saint-Etienne, France
| | - Rodolphe Charles
- General Practice Department, University of Lyon, Saint-Etienne, France
| | - Frédéric Lucht
- Clinical trial center, INSERM CICEC 1408, University Hospital of Saint-Etienne, Saint-Etienne, France.,Groupe Immunité Muqueuse et Agents Pathogènes (GIMAP), EA3064 - Medical School of Saint-Etienne, University of Lyon, Saint-Etienne, France
| | - Amandine Gagneux-Brunon
- Clinical trial center, INSERM CICEC 1408, University Hospital of Saint-Etienne, Saint-Etienne, France.,Groupe Immunité Muqueuse et Agents Pathogènes (GIMAP), EA3064 - Medical School of Saint-Etienne, University of Lyon, Saint-Etienne, France
| | - Elisabeth Botelho-Nevers
- Clinical trial center, INSERM CICEC 1408, University Hospital of Saint-Etienne, Saint-Etienne, France.,Groupe Immunité Muqueuse et Agents Pathogènes (GIMAP), EA3064 - Medical School of Saint-Etienne, University of Lyon, Saint-Etienne, France
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12
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Martin-Loeches I, Antonelli M, Cuenca-Estrella M, Dimopoulos G, Einav S, De Waele JJ, Garnacho-Montero J, Kanj SS, Machado FR, Montravers P, Sakr Y, Sanguinetti M, Timsit JF, Bassetti M. ESICM/ESCMID task force on practical management of invasive candidiasis in critically ill patients. Intensive Care Med 2019; 45:789-805. [PMID: 30911804 DOI: 10.1007/s00134-019-05599-w] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 03/09/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The term invasive candidiasis (IC) refers to both bloodstream and deep-seated invasive infections, such as peritonitis, caused by Candida species. Several guidelines on the management of candidemia and invasive infection due to Candida species have recently been published, but none of them focuses specifically on critically ill patients admitted to intensive care units (ICUs). MATERIAL AND METHODS In the absence of available scientific evidence, the resulting recommendations are based solely on epidemiological and clinical evidence in conjunction with expert opinion. The task force used the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach to evaluate the recommendations and assign levels of evidence. The recommendations and their strength were decided by consensus and, if necessary, by vote (modified Delphi process). Descriptive statistics were used to analyze the results of the Delphi process. Statements obtaining > 80% agreement were considered to have achieved consensus. CONCLUSIONS The heterogeneity of this patient population necessitated the creation of a mixed working group comprising experts in clinical microbiology, infectious diseases and intensive care medicine, all chosen on the basis of their expertise in the management of IC and/or research methodology. The working group's main goal was to provide clinicians with clear and practical recommendations to optimize microbiological diagnosis and treatment of IC. The Systemic Inflammation and Sepsis and Infection sections of the European Society of Intensive Care Medicine (ESICM) and the Critically Ill Patients Study Group of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) therefore decided to develop a set of recommendations for application in non-immunocompromised critically ill patients.
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Affiliation(s)
- Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland. .,Hospital Clinic, Universidad de Barcelona, CIBERes, Barcelona, Spain.
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - George Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, National and Kapodistrian University of Athens, Athens, Greece
| | - Sharon Einav
- General Intensive Care Unit, Shaare Zedek Medical Centre and the Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain.,Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain
| | - Souha S Kanj
- Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
| | - Flavia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Philippe Montravers
- Paris Diderot, Sorbonne Cite University, and Anaesthesiology and Critical Care Medicine, Bichat-Claude Bernard University Hospital, HUPNSV, AP-HP, INSERM, UMR 1152, Paris, France
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
| | - Maurizio Sanguinetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Institute of Microbiology, Rome, Italy
| | - Jean-Francois Timsit
- UMR 1137, IAME Inserm/University Paris Diderot, Paris, France.,APHP, Bichat Hospital, Intensive Care Unit, Paris, France
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
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13
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Lai MY, Hsu JF, Chu SM, Wu IH, Huang HR, Chiang MC, Fu RH, Tsai MH. Risk Factors and Outcomes of Recurrent Candidemia in Children: Relapse or Re-Infection? J Clin Med 2019; 8:jcm8010099. [PMID: 30654524 PMCID: PMC6352033 DOI: 10.3390/jcm8010099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/07/2019] [Accepted: 01/11/2019] [Indexed: 12/30/2022] Open
Abstract
In this paper, our aim was to investigate the incidence, clinical characteristics, risk factors, and outcomes of recurrent candidemia in children. We retrospectively reviewed all children with candidemia from a medical center in Taiwan between 2004 and 2015. Two episodes of candidemia ≥30 days apart with clinical and microbiological resolution in the interim were defined as "late recurrence", and those that had 8⁻29 days apart from previous episodes were defined as "early recurrence". 45 patients (17.2%) had 57 episodes of recurrent candidemia, and 24 had 28 episodes of late recurrent candidemia. The median time between recurrences was 1.8 months (range: <1 month to 13 months). Of those, 29 had relapsed candidemia and 28 were re-infected by different Candida species (n = 24) or by different strains (n = 4). Recurrent candidemia patients were more likely to require echinocandins treatment, had a longer duration of candidemia, and higher rate of treatment failure (p = 0.001, 0.014, and 0.012, respectively). Underlying gastrointestinal diseases (Odds ratio (OR) 3.84; 95% Confidence interval (CI) 1.81⁻8.12) and neurological sequelae (OR 2.32; 95% CI 1.15⁻4.69) were independently associated with the development of recurrent candidemia. 17.2% of pediatric patients with candidemia developed recurrent candidemia, and approximately half were re-infected. Underlying gastrointestinal diseases and neurological sequelae were the independent risk factors for recurrent candidemia.
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Affiliation(s)
- Mei-Yin Lai
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Jen-Fu Hsu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Shih-Ming Chu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - I-Hsyuan Wu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Hsuan-Rong Huang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Ming-Chou Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Ren-Huei Fu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Ming-Horng Tsai
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin 333, Taiwan.
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Waele JJD. What every intensivist should know about the management of peritonitis in the intensive care unit. Rev Bras Ter Intensiva 2019; 30:9-14. [PMID: 29742214 PMCID: PMC5885225 DOI: 10.5935/0103-507x.20180007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/10/2017] [Indexed: 12/21/2022] Open
Affiliation(s)
- Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
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15
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Novy E, Laithier FX, Machouart MC, Albuisson E, Guerci P, Losser MR. Determination of 1,3-β-D-glucan in the peritoneal fluid for the diagnosis of intra-abdominal candidiasis in critically ill patients: a pilot study. Minerva Anestesiol 2018; 84:1369-1376. [PMID: 29991219 DOI: 10.23736/s0375-9393.18.12619-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Decision to start an anti-fungal therapy in intra-abdominal candidiasis (IAC) is complex. Yeast culture, considered the gold standard, suffers from a delayed response time and exposes the patient to delayed introduction of anti-fungal therapy. We sought to evaluate the performance and feasibility of measuring 1,3-β-D-glucan (1,3-BDG) in the peritoneal fluid (PF) for the diagnosis of IAC. METHODS We analyzed retrospectively all PF obtained during abdominal surgery for critically ill adult patients presenting intra-abdominal infections. For each PF sample, direct examination, bacterial and fungal culture, fungal PCR and 1,3-BDG measurements were performed. The diagnostic performance of each technique and the Peritonitis score were calculated considering the positive yeast culture as the reference. The levels of 1,3-BDG were compared between IAC and non-IAC patients. RESULTS During an 8-month period in 2016, 33 PF samples were recovered. Median (interquartile range) SAPS 2 and SOFA scores were 44 (9-94) and 9 (4-15), respectively. There were seven cases of IAC, 14 of bacterial peritonitis and 12 of undocumented peritonitis. All IAC cases were secondary peritonitis, with a 1,3-BDG level of 1461 (325-5000) versus 224 (68-1357) pg/mL in the non-IAC group (P=0.03). When the 1,3-BDG level was ≤310 pg/mL, its negative predictive value was 100%. CONCLUSIONS In secondary peritonitis, a peritoneal measurement of 1,3-BDG ≤310 pg/mL could rule out IAC.
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Affiliation(s)
- Emmanuel Novy
- Department of Anesthesiology and Critical Care Medicine, Regional University Hospital of Nancy, Nancy, France - .,Faculty of Medicine, University of Lorraine, Nancy, France -
| | - François-Xavier Laithier
- Department of Anesthesiology and Critical Care Medicine, Regional University Hospital of Nancy, Nancy, France
| | - Marie-Claire Machouart
- Department of Parasitology and Mycology, Regional University Hospital of Nancy, Nancy, France
| | - Eliane Albuisson
- Unit of Methodology, Data Management and Statistics (UMDS), Regional University Hospital of Nancy, Nancy, France
| | - Philippe Guerci
- Department of Anesthesiology and Critical Care Medicine, Regional University Hospital of Nancy, Nancy, France.,Faculty of Medicine, University of Lorraine, Nancy, France
| | - Marie-Reine Losser
- Department of Anesthesiology and Critical Care Medicine, Regional University Hospital of Nancy, Nancy, France.,Faculty of Medicine, University of Lorraine, Nancy, France
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16
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Clinical characteristics and prognosis of bacteraemia during postoperative intra-abdominal infections. Crit Care 2018; 22:175. [PMID: 29980218 PMCID: PMC6035454 DOI: 10.1186/s13054-018-2099-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/19/2018] [Indexed: 12/02/2022] Open
Abstract
Background Bloodstream infections of abdominal origin are usually associated with poor prognosis. We assessed the clinical and microbiological characteristics of critically ill patients admitted to the intensive care unit (ICU) for postoperative intra-abdominal infection (PIAI) and analysed the influence of bacteraemia on their outcome. Methods All consecutive PIAI patients admitted to the ICU between 1999 and 2014 were prospectively analysed. Bacteraemic patients (at least one positive blood culture in the 24 h preceding/following surgery) were compared with non-bacteraemic patients. Demographic characteristics, underlying disease, severity scores at the time of reoperation, microbiological results, therapeutic management, outcome, and survival were recorded. Results are expressed as median (interquartile range (IQR)) or proportions. Results Overall, 343 patients (54% male, 62 (49–73) years old) with PIAI were analysed, including 64 (19%) bacteraemic patients. Immunosuppression and cancer were more frequent in bacteraemic patients (p < 0.001 in both cases). No difference between groups was observed for the characteristics of initial surgery. Time to reoperation, site, and cause of PIAI were similar in both groups. At the time of reoperation, Sequential Organ Failure Assessment (SOFA) score was higher in bacteraemic patients (8 (6–10) versus 7 (4–10); p < 0.05). A predominance of Gram-positive (34%) and Gram-negative (47%) bacteria were recovered from blood cultures (polymicrobial bacteraemia in 9 (14%) patients and bacteraemia involving multidrug-resistant organisms in 14 (22%) patients). In multivariate analysis, risk factors for bacteraemia were immunosuppression or cancer, high SOFA score, and E. coli in peritoneal samples. Bacteraemia did not impact the management (with similar results for the adequacy of antibiotic therapy, anti-infective agents used, de-escalation or duration of therapy in both groups). Neither hospital mortality nor morbidity criteria differed between groups. Risk factors for mortality in multivariate analysis were urgent initial surgery, high Simplified Acute Physiology Score (SAPS) II score and documented antifungal therapy, but not perioperative bacteraemia. Conclusions In this ICU population, bacteraemia did not change the overall management of patients with PIAI. Our data suggest that bacteraemic patients do not require a specific management.
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17
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Abstract
Invasive candidiasis is an important health-care-associated fungal infection that can be caused by several Candida spp.; the most common species is Candida albicans, but the prevalence of these organisms varies considerably depending on geographical location. The spectrum of disease of invasive candidiasis ranges from minimally symptomatic candidaemia to fulminant sepsis with an associated mortality exceeding 70%. Candida spp. are common commensal organisms in the skin and gut microbiota, and disruptions in the cutaneous and gastrointestinal barriers (for example, owing to gastrointestinal perforation) promote invasive disease. A deeper understanding of specific Candida spp. virulence factors, host immune response and host susceptibility at the genetic level has led to key insights into the development of early intervention strategies and vaccine candidates. The early diagnosis of invasive candidiasis is challenging but key to the effective management, and the development of rapid molecular diagnostics could improve the ability to intervene rapidly and potentially reduce mortality. First-line drugs, including echinocandins and azoles, are effective, but the emergence of antifungal resistance, especially among Candida glabrata, is a matter of concern and underscores the need to administer antifungal medications in a judicious manner, avoiding overuse when possible. A newly described pathogen, Candida auris, is an emerging multidrug-resistant organism that poses a global threat.
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Affiliation(s)
- Peter G Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institutes of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Maiken Cavling Arendrup
- Unit for Mycology, Statens Serum Institute, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Luis Ostrosky-Zeichner
- Division of Infectious Diseases, University of Texas Health Science Center, Houston, TX, USA
| | - Bart Jan Kullberg
- Department of Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
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18
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Bassetti M, Righi E, Montravers P, Cornely OA. What has changed in the treatment of invasive candidiasis? A look at the past 10 years and ahead. J Antimicrob Chemother 2018; 73:i14-i25. [PMID: 29304208 PMCID: PMC5890781 DOI: 10.1093/jac/dkx445] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The treatment of invasive candidiasis has changed greatly in the past decade and must continue to evolve if we are to improve outcomes in this serious infection. A review of recent history may provide insights for the future. The morbidity and mortality of invasive candidiasis remain difficult to measure despite an obvious clinical burden. Current treatment guidelines now recommend echinocandins as first-line empirical treatment, with fluconazole as an acceptable alternative for selected patients, reflecting the efficacy demonstrated by echinocandins and increasing resistance observed with fluconazole. The selection of antifungal therapy now must consider not only resistance but also the shift in predominance from Candida albicans to non-albicans species, notably Candida glabrata. The recent emergence of Candida auris has been met with great interest, although the longer-term implications of this phenomenon remain unclear. The broad goal of treatment continues to be administration of safe, efficacious antifungal therapy as soon as possible. Diagnostic methods beyond traditional blood culture present an opportunity to shorten the time to an accurate diagnosis, and earlier treatment initiation based on prophylactic and empirical or pre-emptive strategies seeks to ensure timely therapeutic intervention. In addition, there are novel agents in the antifungal pipeline. These developments, as well as ongoing studies of dosing, toxicity and resistance development, are important items on the current research agenda and may play a role in future changes to the treatment of invasive candidiasis.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Udine, Italy
| | - Elda Righi
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Udine, Italy
| | - Philippe Montravers
- Paris Diderot Sorbonne Cite University, and Anesthesiology and Critical Care Medicine, Bichat-Claude Bernard University Hospital, HUPNSV, AP-HP, INSERM UMR 1152, Paris, France
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Department I of Internal Medicine, Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
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19
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Pagès A, Iriart X, Molinier L, Georges B, Berry A, Massip P, Juillard-Condat B. Cost Effectiveness of Candida Polymerase Chain Reaction Detection and Empirical Antifungal Treatment among Patients with Suspected Fungal Peritonitis in the Intensive Care Unit. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:1319-1328. [PMID: 29241891 DOI: 10.1016/j.jval.2017.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 06/01/2017] [Accepted: 06/18/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Mortality from intra-abdominal candidiasis in intensive care units (ICUs) is high. It takes many days for peritoneal-fluid fungal culture to become positive, and the recommended empirical antifungal therapy involves excessive costs. Polymerase chain reaction (PCR) should produce results more rapidly than fungal culture. OBJECTIVES To perform a cost-effectiveness analysis of the combination of several diagnostic and therapeutic strategies to manage Candida peritonitis in non-neutropenic adult patients in ICUs. METHODS We constructed a decision tree model to evaluate the cost effectiveness. Cost and effectiveness were taken into account in a 1-year time horizon and from the French National Health Insurance perspective. Six strategies were compared: fluconazole or echinocandin as an empirical therapy, plus diagnosis by fungal culture or detection by PCR of all Candida species, or use of PCR to detect most fluconazole-resistant Candida species (i.e., Candida krusei and Candida glabrata). RESULTS The use of fluconazole empirical treatment and PCR to detect all Candida species is more cost effective than using fluconazole empirical treatment without PCR (incremental cost-effectiveness ratio of €40,055/quality-adjusted life-year). Empirical treatment with echinocandin plus PCR to detect C. krusei and C. glabrata is the most effective strategy, but has an incremental cost-effectiveness ratio of €93,776/quality-adjusted life-year. If the cost of echinocandin decreases, then strategies involving PCR plus empirical echinocandin become more cost-effective. CONCLUSIONS Detection by PCR of all Candida species and of most fluconazole-resistant Candida species could improve the cost-effectiveness of fluconazole and echinocandin given to non-neutropenic patients with suspected peritoneal candidiasis in ICUs.
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Affiliation(s)
| | - Xavier Iriart
- CHU de Toulouse, Laboratoire de parasitologie et mycologie, Toulouse, France; Inserm U1043/CNRS UMR5282/CPTP, UPS Université de Toulouse III, Toulouse, France
| | - Laurent Molinier
- CHU de Toulouse, Département d'Information Médicale, Toulouse, France; Inserm, UMR1027, UPS Université de Toulouse III, Toulouse, France
| | - Bernard Georges
- CHU de Toulouse, Réanimation Polyvalente, Hôpital Rangueil, Toulouse, France
| | - Antoine Berry
- CHU de Toulouse, Laboratoire de parasitologie et mycologie, Toulouse, France; Inserm U1043/CNRS UMR5282/CPTP, UPS Université de Toulouse III, Toulouse, France
| | - Patrice Massip
- CHU de Toulouse, Service des Maladies Infectieuses et Tropicales, Toulouse, France
| | - Blandine Juillard-Condat
- CHU de Toulouse, Pharmacie, Toulouse, France; Inserm, UMR1027, UPS Université de Toulouse III, Toulouse, France
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20
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Montravers P, Tashk P, Tran Dinh A. Unmet needs in the management of intra-abdominal infections. Expert Rev Anti Infect Ther 2017; 15:839-850. [PMID: 28841096 DOI: 10.1080/14787210.2017.1372750] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Intra-abdominal infections remain a leading cause of death, morbidity and resource use in surgical wards and intensive care units. The growing complexity of their management has led to new paradigms and unresolved issues in anti-infective therapy described in the current review. Areas covered: We analyzed the literature, recent guidelines, and expert opinions published over the last decade. Expert commentary: Prospective randomized trials are difficult to perform and observational studies or database analyses should be encouraged. Epidemiologic and microbiologic reports should be promoted, especially in developing/resource-limited countries and in specific subpopulations such as children, older people and patients with underlying diseases. The diagnostic process, including imaging procedures, could be improved. The value of biomarkers for diagnosis, monitoring and discontinuation of therapy should be clarified and improved. New microbiologic techniques are needed to speed up the diagnostic process and to improve the adequacy of anti-infective therapy. Very little progress has been made in the detection of clinical failures. Many aspects of anti-infective management, both for bacteria and fungi, remain unresolved, such as the high inoculum, the type of microorganisms to be treated, the timing of therapy, the value of de-escalation, drug monitoring and duration of therapy. New antibiotics are expected.
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Affiliation(s)
- Philippe Montravers
- a Paris Diderot Sorbonne Cite University, and Anesthesiology and Critical Care Medicine , Bichat-Claude Bernard University Hospital, HUPNSV, AP-HP , Paris , France.,b INSERM UMR 1152 , Paris , France
| | - Parvine Tashk
- a Paris Diderot Sorbonne Cite University, and Anesthesiology and Critical Care Medicine , Bichat-Claude Bernard University Hospital, HUPNSV, AP-HP , Paris , France
| | - Alexy Tran Dinh
- a Paris Diderot Sorbonne Cite University, and Anesthesiology and Critical Care Medicine , Bichat-Claude Bernard University Hospital, HUPNSV, AP-HP , Paris , France.,c INSERM UMR 1148 , Paris , France
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21
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Doernberg SB, Chambers HF. Antimicrobial Stewardship Approaches in the Intensive Care Unit. Infect Dis Clin North Am 2017; 31:513-534. [PMID: 28687210 DOI: 10.1016/j.idc.2017.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antimicrobial stewardship programs aim to monitor, improve, and measure responsible antibiotic use. The intensive care unit (ICU), with its critically ill patients and prevalence of multiple drug-resistant pathogens, presents unique challenges. This article reviews approaches to stewardship with application to the ICU, including the value of diagnostics, principles of empirical and definitive therapy, and measures of effectiveness. There is good evidence that antimicrobial stewardship results in more appropriate antimicrobial use, shorter therapy durations, and lower resistance rates. Data demonstrating hard clinical outcomes, such as adverse events and mortality, are more limited but encouraging; further studies are needed.
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Affiliation(s)
- Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California, 513 Parnassus Avenue, Box 0654, San Francisco, CA 94143, USA.
| | - Henry F Chambers
- Division of Infectious Diseases, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, Room 3400, Building 30, 1001 Potrero Avenue, San Francisco, CA 94110, USA
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22
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Bretonnière C, Lakhal K, Lepoivre T, Boutoille D, Morio F. What is the role of empirical treatment for suspected invasive candidiasis in non-neutropenic non transplanted patients in the intensive care unit?-Empiricus strikes back! J Thorac Dis 2016; 8:E1719-E1722. [PMID: 28149623 DOI: 10.21037/jtd.2016.12.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Cédric Bretonnière
- CHU Nantes, PHU3, Medical Intensive Care Unit, place A. Ricordeau, Nantes, F-44093, France; ; Nantes University, UPRES EA 3826, Laboratory of clinical and experimental therapeutics of infections, IRS2-Nantes Biotech, F-44200, France
| | - Karim Lakhal
- CHU Nantes, PHU3, General Surgical Intensive Care Unit, Anesthesiology Department, Laënnec Hospital, place A. Ricordeau, Nantes, F-44093, France
| | - Thierry Lepoivre
- CHU Nantes, PHU3, Cardiac Surgery Intensive Care Unit, Anesthesiology Department, Laënnec Hospital, place A. Ricordeau, Nantes, F-44093, France
| | - David Boutoille
- Nantes University, UPRES EA 3826, Laboratory of clinical and experimental therapeutics of infections, IRS2-Nantes Biotech, F-44200, France; ; CHU Nantes, PHU3, Infectious Diseases, place A. Ricordeau, Nantes, F-44093, France
| | - Florent Morio
- CHU Nantes, PHU7, Laboratory of Parasitology and Medical Mycologie, Nantes, F-44093, France; ; Parasitology and Medical Mycology Department, Nantes University, Nantes Atlantique University, EA1155-IICiMed, IRS2-Nantes Biotech, Nantes, F-44200, France
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