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Salmanton-García J, Reinhold I, Prattes J, Bekaan N, Koehler P, Cornely OA. Questioning the 14-day dogma in candidemia treatment duration. Mycoses 2024; 67:e13672. [PMID: 37897148 DOI: 10.1111/myc.13672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/19/2023] [Accepted: 10/26/2023] [Indexed: 10/29/2023]
Abstract
The growing threat of antimicrobial resistance (AMR) is a global concern. With AMR directly causing 1.27 million deaths in 2019 and projections of up to 10 million annual deaths by 2050, optimising infectious disease treatments is imperative. Prudent antimicrobial use, including treatment duration, can mitigate AMR emergence. This is particularly critical in candidemia, a severe condition with a 45% crude mortality rate, as the 14-day minimum treatment period has not been challenged in randomised comparison. A comprehensive literature search was conducted in August 2023, revealing seven original articles and two case series discussing treatment durations of less than 14 days for candidemia. No interventional trials or prospective observational studies assessing shorter durations were found. Historical studies showed varying candidemia treatment durations, questioning the current 14-day minimum recommendation. Recent research observed no significant survival differences between patients receiving shorter or longer treatment, emphasising the need for evidence-based guidance. Treatment duration reduction post-blood culture clearance could decrease exposure to antifungal drugs, limiting selection pressure, especially in the context of emerging multiresistant Candida species. Candidemia's complexity, emerging resistance and potential for shorter in-hospital stays underscore the urgency of refining treatment strategies. Evidence-driven candidemia treatment durations are imperative to balance efficacy with resistance prevention and ensure the longevity of antifungal therapies. Further research and clinical trials are needed to establish evidence-based guidelines for candidemia treatment duration.
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Affiliation(s)
- Jon Salmanton-García
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Institute of Translational Research, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Ilana Reinhold
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Zurich, Switzerland
| | - Juergen Prattes
- Division of Infectious Disease, Department of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Medical University of Graz, Graz, Austria
| | - Nico Bekaan
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Institute of Translational Research, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Philipp Koehler
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Institute of Translational Research, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Institute of Translational Research, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
- Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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Effective Rapid Diagnosis of Bacterial and Fungal Bloodstream Infections by T2 Magnetic Resonance Technology in the Pediatric Population. J Clin Microbiol 2022; 60:e0029222. [PMID: 36069557 PMCID: PMC9580347 DOI: 10.1128/jcm.00292-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Children are prone to bloodstream infections (BSIs), the rapid and accurate diagnosis of which is an unmet clinical need. The T2MR technology is a direct molecular assay for identification of BSI pathogens, which can help to overcome the limits of blood culture (BC) such as diagnostic accuracy, blood volumes required, and turnaround time. We analyzed results obtained with the T2Bacteria (648) and T2Candida (106) panels in pediatric patients of the Bambino Gesù Children's Hospital between May 2018 and September 2020 in order to evaluate the performance of the T2Dx instrument with respect to BC. T2Bacteria and T2Candida panels showed 84.2% and 100% sensitivity with 85.9% and 94.1% specificity, respectively. The sensitivity and specificity of the T2Bacteria panel increased to 94.9% and 98.7%, respectively, when BC was negative but other laboratory data supported the molecular result. T2Bacteria sensitivity was 100% with blood volumes <2 mL in neonates and infants. T2Bacteria and T2Candida provided definitive microorganism identification in a mean time of 4.4 and 3.7 h, respectively, versus 65.7 and 125.5 h for BCs (P < 0.001). T2 panels rapidly and accurately enable a diagnosis of a pediatric BSI, even in children under 1 year of age and for very small blood volumes. These findings support their clinical use in life-threatening pediatric infections, where the time to diagnosis is of utmost importance, in order to improve survival and minimize the long-term sequalae of sepsis. The T2 technology could be further developed to include more bacteria and fungi species that are involved in the etiology of sepsis.
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Thompson GR, Boulware DR, Bahr NC, Clancy CJ, Harrison TS, Kauffman CA, Le T, Miceli MH, Mylonakis E, Nguyen MH, Ostrosky-Zeichner L, Patterson TF, Perfect JR, Spec A, Kontoyiannis DP, Pappas PG. Noninvasive Testing and Surrogate Markers in Invasive Fungal Diseases. Open Forum Infect Dis 2022; 9:ofac112. [PMID: 35611348 PMCID: PMC9124589 DOI: 10.1093/ofid/ofac112] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/02/2022] [Indexed: 02/04/2023] Open
Abstract
Invasive fungal infections continue to increase as at-risk populations expand. The high associated morbidity and mortality with fungal diseases mandate the continued investigation of novel antifungal agents and diagnostic strategies that include surrogate biomarkers. Biologic markers of disease are useful prognostic indicators during clinical care, and their use in place of traditional survival end points may allow for more rapid conduct of clinical trials requiring fewer participants, decreased trial expense, and limited need for long-term follow-up. A number of fungal biomarkers have been developed and extensively evaluated in prospective clinical trials and small series. We examine the evidence for these surrogate biomarkers in this review and provide recommendations for clinicians and regulatory authorities.
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Affiliation(s)
- George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California-Davis Medical Center, Sacramento California, USA
- Department of Medical Microbiology and Immunology, University of California-Davis, Davis, California, USA
| | - David R Boulware
- Division of Infectious Diseases, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Thomas S Harrison
- Centre for Global Health, Institute of Infection and Immunity, St George’s University of London, London, United Kingdom
- Clinical Academic Group in Infection, St George’s Hospital NHS Trust, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Carol A Kauffman
- VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, USA
| | - Thuy Le
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - M Hong Nguyen
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Thomas F Patterson
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center, San Antonio, Texas, USA
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Infectious Diseases, Department of Molecular Genetics and Microbiology, Duke University, Durham, North Carolina, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Dimitrios P Kontoyiannis
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter G Pappas
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Burillo A, Bouza E. Faster infection diagnostics for intensive care unit (ICU) patients. Expert Rev Mol Diagn 2022; 22:347-360. [PMID: 35152813 DOI: 10.1080/14737159.2022.2037422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : The patient admitted to intensive care units (ICU) is critically ill, to some extent immunosuppressed, with a high risk of infection, sometimes by multidrug-resistant microorganisms. In this context, the intensivist expects from the microbiology service quick and understandable information so that appropriate antimicrobial treatment for that particular patient and infection can be initiated. AREAS COVERED : In this review of recent literature (2015-2021), we identified diagnostic methods for the most prevalent infections in these patients through a search of the databases Pubmed, evidence-based medicine online, York University reviewers group, Cochrane, MBE-Trip, and Sumsearch using the terms: adult, clinical laboratory techniques, critical care, early diagnosis, microbiology, molecular diagnostic techniques, spectrometry and metagenomics. EXPERT OPINION : There has been an exponential surge in diagnostic systems used directly on blood and other samples to expedite microbial identification and antimicrobial susceptibility testing of pathogens. Few studies have thus far assessed their clinical impact; final outcomes will also depend on preanalytical and post-analytical factors. Besides, many of the resistance mechanisms cannot yet be detected with molecular techniques, which impairs the prediction of the actual resistance phenotype. Nonetheless, this is an exciting field with much yet to explore.
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Affiliation(s)
- Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, Ciudad Universitaria, 28040 Madrid, Spain.,Gregorio Marañón Health Research Institute, Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, Ciudad Universitaria, 28040 Madrid, Spain.,Gregorio Marañón Health Research Institute, Doctor Esquerdo 46, 28007, Madrid, Spain.,CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Av. Monforte de Lemos 3-5, Pabellón 11, Planta, 28029 Madrid, Spain
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5
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Quirino A, Scaglione V, Marascio N, Mazzitelli M, Garofalo E, Divenuto F, Serapide F, Bruni A, Lionello R, Pavia G, Costa C, Giancotti A, Peronace C, Longhini F, Russo A, Liberto MC, Matera G, Torti C, Trecarichi EM. Role of the T2Dx magnetic resonance assay in patients with suspected bloodstream infection: a single-centre real-world experience. BMC Infect Dis 2022; 22:113. [PMID: 35105333 PMCID: PMC8805379 DOI: 10.1186/s12879-022-07096-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND T2Dx was approved by the US Food and Drug Administration for the rapid detection of a modified panel of ESKAPE bacterial species or Candida spp. causing bloodstream infection (BSI). PATIENTS AND METHODS We performed a retrospective, observational study from January 1, 2018 to December 31, 2019 of all hospitalised patients with suspected BSI who underwent assessment using T2Dx in addition to standard blood culture (BC). T2-positive patients (cases) were compared to a matched group of patients with BSI documented only by BC (1:2 ratio) to investigate the possible impact of T2Dx on the appropriateness of empirical antimicrobial therapy and 21-day mortality. RESULTS In total, 78 T2Dx-analysed samples (49 patients) were analysed. The T2Dx assay result was positive for18 patients and negative for 31 patients. The concordance rates of the T2Bacteria Panel and T2Candida Panel results with those of standard BC were 74.4% and 91.4%, respectively. In the matched analysis, inappropriate empiric antimicrobial therapy administration was significantly less frequent in cases than in comparators (5.5% vs. 38.8%). The 21-day mortality rate was twofold lower in cases than in comparators (22.2% vs. 44.4%), although the difference was not significant. No other analysed variables were significantly different between the two groups. CONCLUSIONS This study illustrated that T2Dx might be associated with an increase in the appropriateness of empiric antimicrobial therapy in patients with BSI. Further studies are needed to evaluate whether the T2Dx assay can improve patient outcomes.
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Affiliation(s)
- Angela Quirino
- Unit of Clinical Microbiology, Department of Health Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Vincenzo Scaglione
- Unit of Infectious and Tropical Diseases, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Nadia Marascio
- Unit of Clinical Microbiology, Department of Health Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Maria Mazzitelli
- Unit of Infectious and Tropical Diseases, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Eugenio Garofalo
- Unit of Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | | | - Francesca Serapide
- Unit of Infectious and Tropical Diseases, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Andrea Bruni
- Unit of Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Rosaria Lionello
- Unit of Infectious and Tropical Diseases, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Grazia Pavia
- "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Chiara Costa
- "Mater Domini" Teaching Hospital, Catanzaro, Italy
| | | | - Cinzia Peronace
- Unit of Clinical Microbiology, Department of Health Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Federico Longhini
- Unit of Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Alessandro Russo
- Unit of Infectious and Tropical Diseases, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Maria Carla Liberto
- Unit of Clinical Microbiology, Department of Health Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Giovanni Matera
- Unit of Clinical Microbiology, Department of Health Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
| | - Carlo Torti
- Unit of Infectious and Tropical Diseases, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy.
| | - Enrico Maria Trecarichi
- Unit of Infectious and Tropical Diseases, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro-"Mater Domini" Teaching Hospital, Catanzaro, Italy
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Helweg-Larsen J, Steensen M, Møller Pedersen F, Bredahl Jensen P, Perch M, Møller K, Riis Olesen B, Søderlund M, Cavling Arendrup M. Intensive Care Antifungal Stewardship Programme Based on T2Candida PCR and Candida Mannan Antigen: A Prospective Study. J Fungi (Basel) 2021; 7:jof7121044. [PMID: 34947026 PMCID: PMC8705527 DOI: 10.3390/jof7121044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 12/17/2022] Open
Abstract
Non-culture-based biomarkers may improve diagnosis and antifungal treatment (AFT) of invasive candidiasis (IC). We evaluated an antifungal stewardship programme (AFSP) in a prospective intensive care unit (ICU) study, which included T2Candida and Candida mannan antigen (MAg) screening of patients with sepsis and a high risk of IC. Patients with non-neutropenic sepsis and a high risk of IC from two large tertiary ICUs were prospectively included, during a one-year period. IC was classified as proven, likely, possible or unlikely. The AFSP, diagnostic values of T2Candida and MAg, and the consumption of antifungals were evaluated. An amount of 219 patients with 504 T2Candida/MAg samples were included. IC was classified as proven in 29 (13.2%), likely in 7 (3.2%) and possible in 10 (5.5%) patients. Sensitivity/specificity/PPV/NPV values, comparing proven/likely versus unlikely IC, were 47%/100%/94%/90% for BC alone, 50%/97%/75%/90% for T2Candida alone, and 39%/96%/67%/88% for MAg alone. For the combination of T2Candida/MAg taken ≤3 days after AFT initiation, sensitivity/specificity/PPV/NPV was 70%/90%/63%/93%. T2Candida/MAg contributed to early (<3 days) AFT initiation in 13%, early AFT discontinuation in 25% and abstaining from AFT in 24% of patients. No reduction in overall use of AFT during the study period compared with the previous year was observed. An AFSP based on T2Candida and MAg screening contributed to a reduction of unnecessary treatment, but not overall AFT use. The diagnostic performance of T2Candida was lower than previously reported, but increased if T2Candida was combined with MAg.
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Affiliation(s)
- Jannik Helweg-Larsen
- Department of Infectious Diseases, Rigshospitalet, 2100 Copenhagen, Denmark;
- Correspondence:
| | - Morten Steensen
- Department of Intensive Care, Rigshospitalet, 2100 Copenhagen, Denmark;
| | - Finn Møller Pedersen
- Department of Thoracic Anesthesiology, Rigshospitalet, 2100 Copenhagen, Denmark; (F.M.P.); (P.B.J.)
| | - Pia Bredahl Jensen
- Department of Thoracic Anesthesiology, Rigshospitalet, 2100 Copenhagen, Denmark; (F.M.P.); (P.B.J.)
| | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, 2100 Copenhagen, Denmark;
| | - Kirsten Møller
- Department of Neuro Anesthesiology, Rigshospitalet, 2100 Copenhagen, Denmark;
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark;
| | | | - Mathias Søderlund
- Department of Infectious Diseases, Rigshospitalet, 2100 Copenhagen, Denmark;
| | - Maiken Cavling Arendrup
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark;
- Unit of Mycology, Statens Serum Institut, 2300 Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark
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7
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Culture independent detection systems for bloodstream infection. Clin Microbiol Infect 2021; 28:195-201. [PMID: 34687856 DOI: 10.1016/j.cmi.2021.09.039] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/30/2021] [Accepted: 09/28/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sepsis and bloodstream infection are associated with significant morbidity and mortality, and early effective antimicrobial therapy has been demonstrated to improve patient outcomes. Traditional culture-based methods, however, have several limitations which hamper a prompt diagnosis in bloodstream infection, including long turnaround times and limited sensitivity. In the last years, advances have been made in the development of several technologies which allow the identification of pathogens and their resistance markers directly from whole blood, possibly representing promising alternatives to conventional culture methods. OBJECTIVES To review the currently commercially available emerging assays for the diagnosis of bloodstream infections directly from whole blood, including their performance and the available data about their impact on patients' outcome. SOURCES Peer-reviewed publications relevant to the topic have been searched through PubMed; manufacturers' websites have also been consulted as a data source. CONTENT We have reviewed available data about the following technologies: multiplex real-time PCR working directly from whole blood (Magicplex Sepsis Real-Time test, Seegene), PCR combined with T2 Magnetic Resonance (T2Candida and T2Bacteria panel, T2Biosystem), and metagenomics-based assays (including SepsiTest, Molzym; iDTECT Dx Blood, PathoQuest; Karius NGS plasma Test, Karius). Performance characteristics, advantages and pitfalls of each method are described, and available data about their impact on patients' clinical outcomes are discussed. IMPLICATIONS The potential of rapid diagnostic tests applied on whole blood in improving the management of patients with bloodstream infection and sepsis is high, both in terms of reducing turnaround times and improving the sensitivity of pathogen and antimicrobial resistance detection. However, overall, there is still a scarcity of data about the real-life performance of such tests, and well-designed studies are awaited for assessing the impact of these emerging technologies on patients' outcomes.
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8
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Mind the gaps: challenges in the clinical management of invasive candidiasis in critically ill patients. Curr Opin Infect Dis 2021; 33:441-448. [PMID: 33044240 DOI: 10.1097/qco.0000000000000684] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Strict adherence to clinical practice guidelines is recognized to improve outcomes but the inconvenient truth is that only a small subset of what is done in medicine has been tested in appropriate, well designed studies. In this article, we aim to review controversial aspects of the clinical management of invasive candidiasis recommended by guidelines. RECENT FINDINGS Despite still being recommended by guidelines, we fail to identify a single randomized clinical trial documenting that the use of antifungal drugs in high-risk critically ill patients without microbiologic documentation of Candida infection decreases mortality. Regarding deep-seated Candida infections, most cohort studies of patients with candidemia found less than 5% of patients developed endophthalmitis and endocarditis. In this scenario, it is reasonable to reconsider routine universal screening of both complications in candidemic patients. Finally, a large number of studies have shown that critically ill patients usually have lower echinocandin exposure when compared with other populations. We need more data on the clinical relevance of this finding. SUMMARY We need robust studies to validate new strategies for the clinical management of candidemia in ICU, including: the use of fungal biomarkers in the early initiation or interruption of antifungal therapy in high-risk patients to replace the conventional empirical antifungal therapy driven by predictive rules; validation of targeted screening of eye infection and endocarditis with the aid of fungal biomarkers only in high-risk patients; we should clarify if higher doses of candins are necessary to treat invasive candidiasis in critically ill patients, especially in the case of intra-abdominal infections where drug penetration is suboptimal.
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9
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Cendejas-Bueno E, Peinado H, Baquero-Artigao F, Falces-Romero I, Calvo-Rey C, Banda-Montalvo LL, García-Rodríguez J. Off-label use of T2Candida ® test in vitreous humor for diagnosing invasive candidiasis: a clinical report. Future Microbiol 2021; 16:619-621. [PMID: 34082566 DOI: 10.2217/fmb-2020-0188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Here, we present a case of off-label successful use of the T2 MR (T2Candida® test) for the diagnosis of invasive candidiasis (Candida albicans endolphthalmitis). This case demonstrates that T2Candida could be performed in sterile body fluids to improve microbiological diagnosis of invasive candidiasis.
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Affiliation(s)
- Emilio Cendejas-Bueno
- Department of Clinical Microbiology, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Helena Peinado
- Department of Neonatology, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Fernando Baquero-Artigao
- Department of Pediatric Infectious & Tropical Diseases, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Iker Falces-Romero
- Department of Clinical Microbiology, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Cristina Calvo-Rey
- Department of Pediatric Infectious & Tropical Diseases, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Leticia La Banda-Montalvo
- Department of Neonatology, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Julio García-Rodríguez
- Department of Clinical Microbiology, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain
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10
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Fortún J, Buitrago MJ, Gioia F, Gómez-Gª de la Pedrosa E, Alvarez ME, Martín-Dávila P, Pintado V, Cobeta P, Martinez-Castro N, Soriano C, Moreno I, Corral S, Muñoz P, Moreno-Jimenez G, Cuenca-Estrella M, Moreno-Guillen S. Roles of the multiplex real-time PCR assay and β-D-glucan in a high-risk population for intra-abdominal candidiasis (IAC). Med Mycol 2021; 58:789-796. [PMID: 31811285 DOI: 10.1093/mmy/myz123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/14/2019] [Accepted: 11/23/2019] [Indexed: 01/05/2023] Open
Abstract
Multiplex quantitative real-time PCR (MRT-PCR) using blood can improve the diagnosis of intra-abdominal candidiasis (IAC). We prospectively studied 39 patients with suspected IAC in the absence of previous antifungal therapy. Blood cultures, MRT-PCR, and β-D-glucan (BDG) in serum were performed in all patients. IAC was defined according to the 2013 European Consensus criteria. For MRT-PCR, the probes targeted the ITS1 or ITS2 regions of ribosomal DNA. Candidaemia was confirmed only in four patients (10%), and IAC criteria were present in 17 patients (43.6%). The sensitivity of MRT-PCR was 25% but increased to 63.6% (P = .06) in plasma obtained prior to volume overload and transfusion; specificity was above 85% in all cases. BDG performance was improved using a cutoff > 260 pg/ml, and improvement was not observed in samples obtained before transfusion. In this cohort of high risk of IAC and low rate of bloodstream infection, the performance of non-culture-based methods (MRT-PCR or BDG) was moderate but may be a complementary tool given the limitations of diagnostic methods available in clinical practice. Volume overload requirements, in combination with other factors, decrease the accuracy of MRT-PCR in patients with IAC.
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Affiliation(s)
- J Fortún
- Infectious Diseases Department; Hospital Ramón y Cajal, Madrid
| | - M J Buitrago
- Reference Laboratory in Mycology; Centro Nacional Microbiología, Majadahonda
| | - F Gioia
- Infectious Diseases Department; Hospital Ramón y Cajal, Madrid
| | | | - M E Alvarez
- Infectious Diseases Department; Hospital Ramón y Cajal, Madrid
| | - P Martín-Dávila
- Infectious Diseases Department; Hospital Ramón y Cajal, Madrid
| | - V Pintado
- Infectious Diseases Department; Hospital Ramón y Cajal, Madrid
| | - P Cobeta
- Anaesthetic Department and Surgical Intensive Care Unit; Hospital Ramón y Cajal, Madrid
| | - N Martinez-Castro
- Anaesthetic Department and Surgical Intensive Care Unit; Hospital Ramón y Cajal, Madrid
| | - C Soriano
- Intensive Medicine Department and Medical Intensive Care Unit; Hospital Ramón y Cajal, Madrid
| | - I Moreno
- Surgey Department; Hospital Ramón y Cajal, Madrid
| | - S Corral
- Surgey Department; Hospital Ramón y Cajal, Madrid
| | - P Muñoz
- Clinical Microbiology and Infectious Diseases Department; Hospital Gregorio Marañon, Madrid
| | - G Moreno-Jimenez
- Hematology Department; Blood Bank Unit. Hospital Ramón y Cajal, Madrid
| | - M Cuenca-Estrella
- Reference Laboratory in Mycology; Centro Nacional Microbiología, Majadahonda
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11
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Monday LM, Parraga Acosta T, Alangaden G. T2Candida for the Diagnosis and Management of Invasive Candida Infections. J Fungi (Basel) 2021; 7:jof7030178. [PMID: 33802391 PMCID: PMC7999352 DOI: 10.3390/jof7030178] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/27/2021] [Accepted: 02/28/2021] [Indexed: 02/07/2023] Open
Abstract
Invasive candidiasis is a common healthcare-associated infection with high mortality and is difficult to diagnose due to nonspecific symptoms and limitations of culture based diagnostic methods. T2Candida, based on T2 magnetic resonance technology, is FDA approved for the diagnosis of candidemia and can rapidly detect the five most commonly isolated Candida sp. in approximately 5 h directly from whole blood. We discuss the preclinical and clinical studies of T2Candida for the diagnosis of candidemia and review the current literature on its use in deep-seated candidiasis, its role in patient management and prognosis, clinical utility in unique populations and non-blood specimens, and as an antifungal stewardship tool. Lastly, we summarize the strengths and limitations of this promising nonculture-based diagnostic test.
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Affiliation(s)
- Lea M Monday
- Division of Infectious Diseases, Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (L.MM.); (T.P.A.)
| | - Tommy Parraga Acosta
- Division of Infectious Diseases, Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (L.MM.); (T.P.A.)
| | - George Alangaden
- Division of Infectious Diseases, Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (L.MM.); (T.P.A.)
- School of Medicine, Wayne State University, Detroit, MI 48202, USA
- Correspondence: ; Tel.: 313-916-2556
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12
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Zurl C, Prattes J, Zollner-Schwetz I, Valentin T, Rabensteiner J, Wunsch S, Hoenigl M, Krause R. T2Candida magnetic resonance in patients with invasive candidiasis: Strengths and limitations. Med Mycol 2021; 58:632-638. [PMID: 31613367 DOI: 10.1093/mmy/myz101] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/02/2019] [Indexed: 12/12/2022] Open
Abstract
T2Candida enables detection of five Candida species in whole blood within approximately 5 hours. Routinely drawn EDTA blood samples were prospectively stored and tested with T2Candida in patients with invasive candidiasis identified by routine index blood or sterile site cultures. T2Candida was compared to diagnostic blood and sterile site cultures and also performed with samples obtained prior and after collection of index cultures. T2Candida was evaluated with 133 samples of 32 patients with candidemia and 22 patients with deep-seated invasive candidiasis. In the candidemic group 28/32 (87.5%) patients had at least one positive T2Candida result at any time point. A total of 17/25 (68%) candidemic patients had a positive T2Candida sample that was drawn concurrently to the index blood culture. In the per patient analysis 17/18 (94.4%) candidemic patients with matched T2Candida samples and peripheral blood cultures at any timepoint had a positive T2Candida test. T2Candida revealed discordant Candida species identification in two candidemic patients. Six of 22 (27.3%) deep-seated IC patients had a positive T2Candida result. Despite advanced time-to-results the clinical value of T2Candida in diagnosing candidemia seems to be limited by missing blood culture positive cases. Positivity rates of T2Candida increased when serial T2Candida samples were tested. In patients with suspected deep-seated invasive candidiasis T2Candida might act as a blood based adjunct to sterile site cultures.
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Affiliation(s)
- Christoph Zurl
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,Division of General Paediatrics, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,BioTechMed-Graz, Graz, Austria
| | - Juergen Prattes
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,BioTechMed-Graz, Graz, Austria
| | - Ines Zollner-Schwetz
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Valentin
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Austria
| | - Stefanie Wunsch
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,BioTechMed-Graz, Graz, Austria
| | - Martin Hoenigl
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,Division of Infectious Diseases, Department of Medicine, University of California San Diego, San Diego, California, United States
| | - Robert Krause
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,BioTechMed-Graz, Graz, Austria
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13
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Adequate duration of therapy in severe fungal infections. Curr Opin Crit Care 2021; 26:466-472. [PMID: 32773617 DOI: 10.1097/mcc.0000000000000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To highlight recent findings on the adequate duration of antifungal therapy in patients with invasive fungal disease (IFD). RECENT FINDINGS Plenty of published data available suggest that there is no additional clinical benefit at a certain point after initiation of antifungal treatment in patients with confirmed IFD. Moreover, the prolonged antifungal exposure can be associated with an increased risk of side effects and toxicity as well as striking risk for developing antifungal resistance or rising unnecessary healthcare costs. Recent data suggest that, in the presence of an adequate initial antifungal therapy and adequate source control of the infection, new stratified approaches integrating clinical judgment, biomarkers and microbiological eradication, should be considered as an alternative to the 'one-size-fits-all' treatment duration currently used worldwide. SUMMARY The optimal duration of antifungal therapy is still an unresolved issue that depends by many key elements including the host; the pathogen and its microbiological eradication, the adequateness of initial antifungal therapy and the promptness of source control of the infection. In general, many patients with invasive candidiasis can be treated with a 2 weeks course of antifungal therapy. Longer antifungal course (6 weeks or more) is generally required for patients with invasive aspergilosis.
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14
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D'Onofrio V, Salimans L, Bedenić B, Cartuyvels R, Barišić I, Gyssens IC. The Clinical Impact of Rapid Molecular Microbiological Diagnostics for Pathogen and Resistance Gene Identification in Patients With Sepsis: A Systematic Review. Open Forum Infect Dis 2020; 7:ofaa352. [PMID: 33033730 PMCID: PMC7528559 DOI: 10.1093/ofid/ofaa352] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022] Open
Abstract
Fast microbiological diagnostics (MDx) are needed to ensure early targeted antimicrobial treatment in sepsis. This systematic review focuses on the impact on antimicrobial management and patient outcomes of MDx for pathogen and resistance gene identification compared with blood cultures. PubMed was searched for clinical studies using either whole blood directly or after short-term incubation. Twenty-five articles were retrieved describing the outcomes of 8 different MDx. Three interventional studies showed a significant increase in appropriateness of antimicrobial therapy and a nonsignificant change in time to appropriate therapy. Impact on mortality was conflicting. Length of stay was significantly lower in 2 studies. A significant decrease in antimicrobial cost was demonstrated in 6 studies. The limitations of this systematic review include the low number and observed heterogeneity of clinical studies. In conclusion, potential benefits of MDx regarding antimicrobial management and some patient outcomes were reported. More rigorous intervention studies are needed focusing on the direct benefits for patients.
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Affiliation(s)
- Valentino D'Onofrio
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Department of Infectious Diseases and Immunity, Jessa Hospital, Hasselt, Belgium.,Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lene Salimans
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Branka Bedenić
- Department of Microbiology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | | | - Ivan Barišić
- Molecular diagnostics, Austrian Institute of Technology, Vienna, Austria
| | - Inge C Gyssens
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
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15
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Abstract
PURPOSE OF REVIEW We review the performance of culture-independent diagnostic tests (CIDTs), including β-D-glucan (BDG), polymerase chain reaction (PCR) and T2Candida, in diagnosing invasive candidiasis, their potential roles in patient management, and unintended consequences of testing. RECENT FINDINGS In a recent multicenter trial, T2Candida was 90% sensitive and 98% specific for diagnosing candidemia. A new study provided the first data for T2Candida in diagnosing deep-seated candidiasis, demonstrating sensitivity/specificity of 45%/96%. Two studies showed that ongoing T2Candida-positivity is associated with poor prognosis. In several studies, serum BDG and T2Candida, targeted to patients at-risk for invasive candidiasis, were useful in guiding treatment decisions and antifungal stewardship. A randomized, multicenter trial of BDG-guided empiric antifungal treatment is underway among critically ill patients. PCR performance was highly variable for candidemia and deep-seated candidiasis in recent studies. CIDT results may overstate bloodstream infections, according to current National Healthcare Safety Network (NHSN) definitions. SUMMARY BDG and T2Candida are nearing prime-time status in the clinic. To be useful, testing must be directed to carefully chosen patients and specific clinical questions. Candida PCR is limited by a need for standardized methodologies and commercial assays. NHSN definitions of bloodstream infections must be revised in the era of CIDTs.
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16
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Shariati A, Moradabadi A, Chegini Z, Khoshbayan A, Didehdar M. An Overview of the Management of the Most Important Invasive Fungal Infections in Patients with Blood Malignancies. Infect Drug Resist 2020; 13:2329-2354. [PMID: 32765009 PMCID: PMC7369308 DOI: 10.2147/idr.s254478] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 06/26/2020] [Indexed: 12/12/2022] Open
Abstract
In patients with hematologic malignancies due to immune system disorders, especially persistent febrile neutropenia, invasive fungal infections (IFI) occur with high mortality. Aspergillosis, candidiasis, fusariosis, mucormycosis, cryptococcosis and trichosporonosis are the most important infections reported in patients with hematologic malignancies that undergo hematopoietic stem cell transplantation. These infections are caused by opportunistic fungal pathogens that do not cause severe issues in healthy individuals, but in patients with hematologic malignancies lead to disseminated infection with different clinical manifestations. Prophylaxis and creating a safe environment with proper filters and air pressure for patients to avoid contact with the pathogens in the surrounding environment can prevent IFI. Furthermore, due to the absence of specific symptoms in IFI, rapid and accurate diagnosis reduces the mortality rate of these infections and using molecular techniques along with standard mycological methods will improve the diagnosis of disseminated fungal infection in patients with hematologic disorders. Amphotericin B products, extended-spectrum azoles, and echinocandins are the essential drugs to control invasive fungal infections in patients with hematologic malignancies, and according to various conditions of patients, different results of treatment with these drugs have been reported in different studies. On the other hand, drug resistance in recent years has led to therapeutic failures and deaths in patients with blood malignancies, which indicates the need for antifungal susceptibility tests to use appropriate therapies. Life-threatening fungal infections have become more prevalent in patients with hematologic malignancies in recent years due to the emergence of new risk factors, new species, and increased drug resistance. Therefore, in this review, we discuss the different dimensions of the most critical invasive fungal infections in patients with hematologic malignancies and present a list of these infections with different clinical manifestations, treatment, and outcomes.
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Affiliation(s)
- Aref Shariati
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Moradabadi
- Department of Medical Parasitology and Mycology, Arak University of Medical Sciences, Arak, Iran
| | - Zahra Chegini
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Amin Khoshbayan
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Didehdar
- Department of Medical Parasitology and Mycology, Arak University of Medical Sciences, Arak, Iran
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17
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Camp I, Spettel K, Willinger B. Molecular Methods for the Diagnosis of Invasive Candidiasis. J Fungi (Basel) 2020; 6:jof6030101. [PMID: 32640656 PMCID: PMC7558065 DOI: 10.3390/jof6030101] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/03/2020] [Accepted: 07/04/2020] [Indexed: 12/19/2022] Open
Abstract
Invasive infections caused by members of the genus Candida are on the rise. Especially patients in intensive care units, immunocompromised patients, and those recovering from abdominal surgery are at risk for the development of candidemia or deep-seated candidiasis. Rapid initiation of appropriate antifungal therapy can increase survival rates significantly. In the past, most of these infections were caused by C. albicans, a species that typically is very susceptible to antifungals. However, in recent years a shift towards infections caused by non-albicans species displaying various susceptibly patterns has been observed and the prompt diagnosis of the underlying species has become an essential factor determining the therapeutic outcome. The gold standard for diagnosing invasive candidiasis is blood culture, even though its sensitivity is low and the time required for species identification usually exceeds 48 h. To overcome these issues, blood culture can be combined with other methods, and a large number of tests have been developed for this purpose. The aim of this review was to give an overview on strengths and limitations of currently available molecular methods for the diagnosis of invasive candidiasis.
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18
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What Is New in Candida Infections? T2Candida, Antifungal Stewardship, and Candida auris. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00209-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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19
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20
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Satyanarayana G. Work-up for Fever During Neutropenia for Both the Stem Cell Transplant Recipient and the Hematologic Malignancy Patient. Infect Dis Clin North Am 2019; 33:381-397. [PMID: 31005134 DOI: 10.1016/j.idc.2019.02.003] [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: 01/03/2023]
Abstract
Fever is a common complication in patients with underlying neutropenia and is associated with significant mortality in neutropenic patients with acute myelogenous leukemia or hematopoietic cell transplant. Fever may be the only sign of infection and requires further clinical assessment, including a history, a physical examination, and additional laboratory and radiographic testing. National and international guidelines recommend initiation of empiric antimicrobial therapy in patients with fever during neutropenia. Stepwise escalation of antibacterial therapy, followed by antifungal therapy for patients with persistent fever, generally is recommended. Consideration should also be given to de-escalation of antimicrobial therapy in the appropriate clinical settings.
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Affiliation(s)
- Gowri Satyanarayana
- Division of Infectious Diseases, Vanderbilt University Medical Center, A2200 MCN, 1161 21st Avenue South, Nashville, TN 37232-2605, USA.
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21
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Young BA, Hanson KE, Gomez CA. Molecular Diagnostic Advances in Transplant Infectious Diseases. Curr Infect Dis Rep 2019; 21:52. [PMID: 31773290 DOI: 10.1007/s11908-019-0704-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The infectious complications of transplantation can have devastating consequences for patients. Early and accurate diagnosis is essential to good outcomes. This review describes recent advances in pathogen-directed diagnostic testing and discusses the role of new methods for transplant infectious diseases. RECENT FINDINGS Several molecular assays have been introduced into clinical practice in recent years. When the results of rapid testing are linked to patient-specific interventions, improved outcomes can be realized. Syndromic testing along with metagenomic next-generation sequencing (mNGS) represents novel approaches to infection diagnosis. However, the optimal use of these tests for transplant patients along with an overall assessment of cost-effectiveness demands further study. Molecular diagnostics are revolutionizing transplant care. Clinicians need to be aware of the current diagnostic landscape and have a working knowledge of the nuances related to test performance, result interpretation, and cost.
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Affiliation(s)
- Brittany A Young
- Department of Pathology, University of Utah, Salt Lake City, UT, USA.,Associated Regional and University Pathologists Laboratories (ARUP), Salt Lake City, UT, USA
| | - Kimberly E Hanson
- Department of Pathology, University of Utah, Salt Lake City, UT, USA.,Associated Regional and University Pathologists Laboratories (ARUP), Salt Lake City, UT, USA.,Department of Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA
| | - Carlos A Gomez
- Department of Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA. .,University of Utah School of Medicine, 30 North 1900 East, Room 4B319, Salt Lake City, UT, 84132, USA.
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22
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Lagunes L, Rey-Pérez A. What´s new in intraabdominal candidiasis in critically ill patients, a review. Hosp Pract (1995) 2019; 47:171-176. [PMID: 31585520 DOI: 10.1080/21548331.2019.1677032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A high prevalence of invasive candidiasis has been reported in recent years. Patients admitted to an intensive care unit are at the highest risk for invasive candidiasis, mostly due to the severity of their disease, immune-suppressive states, prolonged length of stay, broad-spectrum antibiotics, septic shock, and Candida colonization. Intraabdominal candidiasis comprises a range of clinical manifestations, from just the suspicion based on clinical scenario to fever, leukocytosis, increase in biomarkers to the isolation of the responsible microorganism. In critically ill patients with IAC prompt treatment and adequate source control remains the ultimate goal.
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Affiliation(s)
- L Lagunes
- Critical Care Department, Hospital Especialidades Medicas, San Luis Potosí, Mexico.,CRIPS, Vall d´Hebron Institut de Recerca, Vall d´Hebron, Barcelona, Spain
| | - A Rey-Pérez
- Burns and Neurotrauma Critical Care Department, Vall d´Hebron, Campus Hospitalari, Barcelona, Spain
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23
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Clancy CJ, Nguyen MH. T2 magnetic resonance for the diagnosis of bloodstream infections: charting a path forward. J Antimicrob Chemother 2019; 73:iv2-iv5. [PMID: 29608754 DOI: 10.1093/jac/dky050] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
We discuss four studies in this issue of the Journal of Antimicrobial Chemotherapy that describe experience with T2 magnetic resonance (T2MR) nanodiagnostics for Candida and bacterial bloodstream infections, in the context of the T2MR literature. T2Candida and T2Bacteria panels use a dedicated instrument to detect amplified DNA from microbial cells directly in whole blood. T2Candida gives positive or negative results for C. albicans/C. tropicalis, C. glabrata/C. krusei, and C. parapsilosis. T2Bacteria detects Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Escherichia coli. In recent trials, T2Candida sensitivity and specificity for candidaemia were ∼90% and ∼98%, respectively. Two studies from Spanish hospitals now provide the first data on T2Candida as a prognostic tool. T2Candida was superior to cultures or serum β-d-glucan in identifying patients with complicated candidaemia, and in predicting the outcomes of empirical antifungal therapy for suspected candidiasis. In a retrospective study from US community hospitals, use of T2Candida was reported to reduce times to appropriate antifungal therapy, shorten courses of empirical therapy, and save an average of US$280 in antifungal costs per patient tested. Finally, a study from a hospital in Rome provides the first clinical data for T2Bacteria: sensitivity and specificity were 89% and 98%, respectively, among patients with positive blood cultures for bacteria detected by the panel, or fulfilling criteria for infection. We conclude that T2MR diagnostics are promising both for detecting bloodstream infections due to Candida and bacteria, and for providing prognostic information. More studies that present real-world performance data are needed.
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Affiliation(s)
- Cornelius J Clancy
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Hong Nguyen
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
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24
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Beganovic M, McCreary EK, Mahoney MV, Dionne B, Green DA, Timbrook TT. Interplay between Rapid Diagnostic Tests and Antimicrobial Stewardship Programs among Patients with Bloodstream and Other Severe Infections. J Appl Lab Med 2018; 3:601-616. [PMID: 31639729 DOI: 10.1373/jalm.2018.026450] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/04/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) aim to provide optimal antimicrobial therapy to patients quickly to improve the likelihood of overcoming infection while reducing the risk of adverse effects. Rapid diagnostic tests (RDTs) for infectious diseases have become an integral tool for ASPs to achieve these aims. CONTENT This review explored the demonstrated clinical value of longer-standing technologies and implications of newer RDTs from an antimicrobial stewardship perspective. Based on available literature, the focus was on the use of RDTs in bloodstream infections (BSIs), particularly those that perform organism identification and genotypic resistance detection, phenotypic susceptibility testing, and direct specimen testing. Clinical implications of rapid testing among respiratory, central nervous system, and gastrointestinal infections are also reviewed. SUMMARY Coupling RDTs with ASPs facilitates the appropriate and timely use of test results, translating into improved patient outcomes through optimization of antimicrobial use. These benefits are best demonstrated in the use of RDT in BSIs. Rapid phenotypic susceptibility testing offers the potential for early pharmacokinetic/pharmacodynamic optimization, and direct specimen testing on blood may allow ASPs to initiate appropriate therapy and/or tailor empiric therapy even sooner than other RDTs. RDTs for respiratory, central nervous system, and gastrointestinal illnesses have also shown significant promise, although more outcome studies are needed to evaluate their full impact.
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Affiliation(s)
- Maya Beganovic
- Advocate Lutheran General Hospital, Department of Pharmacy, Park Ridge, IL
| | - Erin K McCreary
- University of Pittsburgh Medical Center, Department of Pharmacy, Pittsburgh, PA
| | - Monica V Mahoney
- Beth Israel Deaconess Medical Center, Department of Pharmacy, Boston, MA
| | - Brandon Dionne
- Northeastern University, School of Pharmacy, Bouvé College of Health Sciences, Boston, MA.,Brigham and Women's Hospital, Department of Pharmacy, Boston, MA
| | - Daniel A Green
- Columbia University College of Physicians and Surgeons, New York, NY
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25
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Bassetti M, Vena A, Russo A. Management of patients with septic shock due to Candida infection. Hosp Pract (1995) 2018; 46:258-265. [PMID: 30170000 DOI: 10.1080/21548331.2018.1518104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Septic shock represents a serious complication occurring between 6% and 30% of all hospitalized patients; Candida septic shock represents a challenge for clinicians due to the absence of specific risk factors, diagnostic tests, and management. Identification of specific risk factors and use of biomarkers are useful tools considering that differentiation of Candida from bacterial septic shock is demanding. Early effective antifungal treatment, preferably with echinocandins with an adequate source control, represents the best approach for improving survival of patients with septic shock due to Candida. Given the importance of adequate therapy and source control in septic shock attributable to Candida clinical strategies and pathways are needed. This review will focus on epidemiology of septic shock in patients with invasive candidiasis with special attention to diagnostic pathways and treatment strategies.
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Affiliation(s)
- Matteo Bassetti
- a Dipartimento di Area Medica , Università degli studi di Udine , Udine , Italy
| | - Antonio Vena
- a Dipartimento di Area Medica , Università degli studi di Udine , Udine , Italy
| | - Alessandro Russo
- a Dipartimento di Area Medica , Università degli studi di Udine , Udine , Italy
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