Catheter-related infections by Hansenula anomala in children

Fungemia With Wickerhamomyces anomalus: A Case Report and Literature Review

We report the case of an 84-year-old man with a history of IgG4-related sclerosing cholangitis who was diagnosed with advanced esophageal cancer and underwent radiation and chemotherapy. An implantable central venous access port was placed for chemotherapy and total parenteral nutrition. The patient presented with a fever and received antimicrobial therapy for acute cholangitis but remained febrile, and subsequently, yeast was detected in the aerobic bottle of blood culture obtained from the central venous line. The yeast was identified as Wickerhamomyces anomalus. Liposomal amphotericin B was administered, and the central line access port was removed. After confirmation of negative blood cultures and 14 days post treatment, he underwent reinsertion of the central line access port. Due to persistent pain at the insertion site, fluconazole was added for an additional 14 days, and the patient was discharged and transferred to another hospital. Wickerhamomyces anomalus is a rare fungal infection with other synonyms including Pichia anomala, Hansenula anomala, and Candida pelliculosa. A literature review of 53 case reports of Wickerhamomyces anomalus, Pichia anomala, Hansenula anomala, and Candida pelliculosa was conducted, with a total of 211 cases reviewed. Fungemia was reported in 94% of cases, with central venous catheterization, parental feeding, low birth weight, and immunocompromised status identified as major risk factors. The majority of cases were pediatric, particularly neonatal, and there were reports of nosocomial infections causing outbreaks, with some cases involving the eye such as endophthalmitis or keratitis.

In vitro activity of seven systemically active antifungal agents against a large global collection of rare Candida species as determined by CLSI broth microdilution methods

Five Candida species (C. albicans, C. glabrata, C. tropicalis, C. parapsilosis, and C. krusei) account for over 95% of invasive candidiasis cases. Some less common Candida species have emerged as causes of nosocomial candidiasis, but there is little information about their in vitro susceptibilities to antifungals. We determined the in vitro activities of fluconazole, voriconazole, posaconazole, amphotericin B, anidulafungin, caspofungin, and micafungin against invasive, unique patient isolates of Candida collected from 100 centers worldwide between January 2001 and December 2007. Antifungal susceptibility testing was performed by the CLSI M27-A3 method. CLSI breakpoints for susceptibility were used for fluconazole, voriconazole, anidulafungin, caspofungin, and micafungin, while a provisional susceptibility breakpoint of < or = 1 microg/ml was used for amphotericin and posaconazole. Of 14,007 Candida isolates tested, 658 (4.7%) were among the less common species. Against all 658 isolates combined, the activity of each agent, expressed as the MIC50/MIC90 ratio (and the percentage of susceptible isolates) was as follows: fluconazole, 1/4 (94.8%); voriconazole, 0.03/0.12 (98.6%); posaconazole, 0.12/0.5 (95.9%); amphotericin, 0.5/2 (88.3%); anidulafungin, 0.5/2 (97.4%); caspofungin, 0.12/0.5 (98.0%); and micafungin, 0.25/1 (99.2%). Among the isolates not susceptible to one or more of the echinocandins, most (68%) were C. guilliermondii. All isolates of the less common species within the C. parapsilosis complex (C. orthopsilosis and C. metapsilosis) were susceptible to voriconazole, posaconazole, anidulafungin, caspofungin, and micafungin. Over 95% of clinical isolates of the rare Candida species were susceptible to the available antifungals. However, activity did vary by drug-species combination, with some species (e.g., C. rugosa and C. guilliermondii) demonstrating reduced susceptibilities to commonly used agents such as fluconazole and echinocandins.

Pichia anomala fungaemia in immunocompromised children. Fallbericht. Pichia anomala-Fungamie bei immunkompromittierten Kindern

Pichia anomala is an emerging yeast causing serious nosocomial infections in newborn and immunocompromised children. We describe nosocomial port catheter infection due to P. anomala in three children who were receiving cancer chemotherapy, bloodstream infection in a preterm infant and in an infant with severe combined immunodeficiency. All patients were treated with amphotericin B. All isolates were susceptible to amphotericin B and fluconazole. No recurrence was observed during follow-up in four of five patients. The common clinical feature in all of our patients was the presence of prior antimicrobial therapy.

Antifungal therapy--state of the art at the beginning of the 21st century

The most relevant information on the present state of the art of antifungal chemotherapy is reviewed in this chapter. For dermatomycoses a variety of topical antifungals are available, and safe and efficacious systemic treatment, especially with the fungicidal drug terbinafine, is possible. The duration of treatment can be drastically reduced. Substantial progress in the armamentarium of drugs for invasive fungal infections has been made, and a new class of antifungals, echinocandins, is now in clinical use. The following drugs in oral and/or intravenous formulations are available: the broad spectrum polyene amphotericin B with its new "clothes"; the sterol biosynthesis inhibitors fluconazole, itraconazole, and voriconazole; the glucan synthase inhibitor caspofungin; and the combination partner flucytosine. New therapy schedules have been studied; combination therapy has found a significant place in the treatment of severely compromised patients, and the field of prevention and empiric therapy is fast moving. Guidelines exist nowadays for the treatment of various fungal diseases and maintenance therapy. New approaches interfering with host defenses or pathogenicity of fungal cells are being investigated, and molecular biologists are looking for new targets studying the genomics of pathogenic fungi.

Hansenula anomala outbreak at a surgical intensive care unit: a search for risk factors

During a 5-month period, Hansenula anomala (H. anomala), an opportunistic fungus, caused an outbreak of infections in eight adult patients treated at a surgical intensive care unit (ICU). The source of the infections and route of transmission could not be identified. A case-control study included 32 patients treated simultaneously at the surgical ICU. Univariate analysis pointed to the following significant risk factors: blood alkalosis, reduced urea, duration of hospitalization, bacteremia and colonization with Pseudomonas aeruginosa, and an APACHE II score >17 (during bacteremia or fungemia). The stepwise logistic regression multivariate analysis showed only the duration of blood alkalosis to be significant in case patients.

Pichia anomala outbreak in a nursery: exogenous source?

BACKGROUND

Pichia anomala is a rare cause of fungemia. From February to April, 1998, eight cases of fungemia occurred in the intensive care and high risk units of the Nursery. There were four infants with P. anomala infection, one of whom also had Candida parapsilosis infection, two cases with C. parapsilosis infection and two with Candida albicans infection.

OBJECTIVE

To determine factors associated with fungemia in the intensive care and high risk units of the Nursery, especially P. anomala.

METHODS

A cohort study with 59 newborns.

RESULTS

Factors associated with fungemia were: central venous catheter (CVC) (P = 0.0006); total parenteral nutrition (TPN) (P = 0.0005); lipid emulsion (P = 0.002); previous antimicrobial use (P = 0.002); and other invasive procedures (P = 0.002). Factors associated with P. anomala fungemia were: CVC (P = 0.004); TPN (P = 0.018); previous antibiotic use (P = 0.037); and other invasive procedures (P = 0.037). Evaluation of the units demonstrated that there were several technical problems involving administration of TPN that was manipulated in the Nursery without precautions. Changes in TPN formulation and education as to adequate technique were implemented. During follow-up (1998 to 1999) only two fungemias occurred that were caused by C. albicans. Cultures of hands of personnel were negative for P. anomala. Electrophoretic karyotyping of P. anomala showed three profiles.

CONCLUSIONS

Factors associated with fungemia were catheter use, invasive procedures and total parenteral nutrition, suggesting that the acquisition of P. anomala was exogenous.

Pathogenicity of Hansenula anomala in model of immunocompromised mice

Systemic infections caused by opportunistic fungi have shown an increased frequency in the past 10 years, particularly in immunocompromised patients. Hansenula anomala is an ascosporogenous yeast of the Ascomycetes class found in the skin, throat, and digestive tract transient normal flora. This study was conducted to compare the pathogenicity of H. anomala and Candida albicans in a model of immunocompromised mice. Thirty-eight Swiss mice were divided into two groups as follows: 30 animals received an intraperitoneal (i.p.) injection of cyclophosphamide (200 mg/kg) four days before the induction of infection with H. anomala (1 x 10(6) yeasts/mL), and 8 animals received 100 mg/kg of cyclophosphamide at 3-day intervals during 3 weeks before inoculation of 1 x 10(7) yeasts/mL. All animals were treated with amoxicillin/clavulanic acid (40 mg/kg) four days before induction of infection. A group of mice inoculated with C. albicans (ATCC 64548) served as control. Tissue samples from the lung, spleen, liver, and kidney for histological and mycologic studies were obtained at necropsy. In each animal, the number of viable yeasts per gram of kidney was determined. The organs most frequently infected by H. anomala were the kidneys and the liver (20%), and the lung (10%). However, in conditions of sustained immunosuppression, H. anomala was found in 65.5% of the organs examined. It is concluded that in an experimental model of immunocompromised mice, the pathogenicity of H. anomala was low.

Yeast killer systems

The killer phenomenon in yeasts has been revealed to be a multicentric model for molecular biologists, virologists, phytopathologists, epidemiologists, industrial and medical microbiologists, mycologists, and pharmacologists. The surprisingly widespread occurrence of the killer phenomenon among taxonomically unrelated microorganisms, including prokaryotic and eukaryotic pathogens, has engendered a new interest in its biological significance as well as its theoretical and practical applications. The search for therapeutic opportunities by using yeast killer systems has conceptually opened new avenues for the prevention and control of life-threatening fungal diseases through the idiotypic network that is apparently exploited by the immune system in the course of natural infections. In this review, the biology, ecology, epidemiology, therapeutics, serology, and idiotypy of yeast killer systems are discussed.