The purpose of this study was to determine among patients with candidemia the real rate of ophthalmoscopy and the impact of performing ocular assessment on the outcome of the disease. We performed a ...post hoc analysis of a prospective, multicenter, population-based candidemia surveillance program implemented in Spain during 2010-2011 (CANDIPOP). Ophthalmoscopy was performed in only 168 of the 365 patients with candidemia (46%). Ocular lesions related to candidemia were found in only 13/168 patients (7.7%), of whom 1 reported ocular symptoms (incidence of symptomatic disease in the whole population, 0.27% 1/365). Ophthalmological findings led to a change in antifungal therapy in only 5.9% of cases (10/168), and performance of the test was not related to a better outcome. Ocular candidiasis was not associated with a worse outcome and progressed favorably in all but 1 evaluable patient, who did not experience vision loss. The low frequency of ophthalmoscopy and ocular involvement and the asymptomatic nature of ocular candidiasis, with a favorable outcome in almost all cases, lead us to reconsider the need for systematic ophthalmoscopy in all candidemic patients.
BackgroundClinical characteristics, risks, and outcomes in solid organ transplant (SOT) recipients with zygomycosis in the era of modern immunosuppressive and newer antifungal agent use have not been ...defined MethodsIn a matched case-controlled study, SOT recipients with zygomycosis were prospectively studied. The primary outcome measure was success (complete or partial response) at 90 days ResultsRenal failure (odds ratio OR, 3.17; P=.010), diabetes mellitus (OR, 8.11; P<.001), and prior voriconazole and/or caspofungin use (OR, 4.41; P=.033) were associated with a higher risk of zygomycosis, whereas tacrolimus (OR, 0.23; P=.002) was associated with a lower risk of zygomycosis. Liver transplant recipients were more likely to have disseminated disease (OR, 5.48; P=.021) and developed zygomycosis earlier after transplantation than did other SOT recipients (median, 0.8 vs 5.7 months; P<.001). Overall the treatment success rate was 60%. Renal failure (OR, 11.3; P=.023) and disseminated disease (OR, 14.6; P=.027) were independently predictive of treatment failure, whereas surgical resection was associated with treatment success (OR, 33.3; P=.003). The success rate with liposomal amphotericin B was 4-fold higher even when controlling for the aforementioned variables ConclusionsThe risks identified for zygomycosis and for disseminated disease, including those that were previously unrecognized, have implications for further elucidating the biologic basis and for optimizing outcomes in SOT recipients with zygomycosis
Recent advances in the treatment of hematologic malignancies have improved the overall survival rate, but the number of patients at risk of developing an invasive fungal infection (IFI) has ...increased. Invasive infections caused by non-
species, non-
molds, and azole-resistant
have been increasingly reported in recent years. We developed a cross-sectional multicenter survey which involved a total of 55 hematologists and infectious disease specialists from a total of 31 Spanish hospitals, to determine the most frequent strategies used for the management of IFIs. Data collection was undertaken through an online survey which took place in 2022. Regarding key strategies, experts usually prefer early treatment for persistent febrile neutropenia, switching to another broad-spectrum antifungal family if azole-resistant
is suspected, broad-spectrum azoles and echinocandins as prophylactic treatment in patients receiving midostaurin or venetoclax, and liposomal amphotericin B for breakthrough IFIs after prophylaxis with echinocandins in patients receiving new targeted therapies. For antifungals failing to reach adequate levels during the first days and suspected invasive aspergillosis, the most appropriate strategy would be to associate an antifungal from another family.
Background. Current advances in transplantation practices may influence the development of cytomegalovirus (CMV) disease after renal transplantation. Methods. From September 2003 through February ...2005, 1470 renal transplant recipients (55 of whom were kidney-pancreas transplant recipients) were prospectively studied in the 16 transplant centers affiliated with the Spanish Network of Infection in Transplantation, with use of an ad hoc–designed online database. Univariate and multivariate analyses with logistic regression were performed to detect risk factors for CMV disease. Results. A total of 105 episodes of CMV disease (37 with visceral involvement) developed in 99 (6.7%) of 1470 patients. Attributable mortality appeared in 1 (1.0%) of 105 cases. Multivariate analysis showed that, apart from CMV serological mismatch, presence of rejection episodes, and the use of antilymphocitic drugs, a simultaneous pancreas transplantation (odds ratio OR, 3.7; 95% confidence interval CI, 1.5–9), use of cyclosporine (OR, 1.7; 95% CI, 1.18–2.9), a donor >60 years of age (OR, 2.3; 95% CI, 1.5–3.7), and chronic graft malfunction (OR, 1.8; 95% CI, 1.14–2.9) were independently associated with CMV disease, whereas use of sirolimus had a protective effect (OR, 0.27; 95% CI, 0.1–0.78). Conclusions. Additional risk factors related to current transplantation practices influence the epidemiology of CMV after renal transplantation and should be taken into account in the design of prophylactic strategies in this population of kidney or kidney-pancreas recipients.
T2 magnetic resonance imaging (T2MR) is a new method for the diagnosis of invasive candidiasis, although most studies have analyzed its role in patients with candidemia or not infection.
We present ...the case of a patient with arteritis and thrombosis of the hepatic graft resulted from an undocumented fungal infection in the explanted liver.T2MR in serum was a suitable diagnostic tool for the diagnosis of the deep-seated invasive candidiasis in the absence of candidemia or the isolation of the yeast in culture.
T2MR allowed the diagnosis of deep-seated invasive candidiasis in an immunodepressed patient without candidemia, even before the onset of symptoms.
Background. Influenza vaccine effectiveness is not optimal in solid organ transplant recipients (SOTR). We hypothesized that a booster dose might increase it. Methods. TRANSGRIPE 1–2 is a phase 3, ...randomized, controlled, multicenter, open-label clinical trial. Patients were randomly assigned (1:1 stratified by study site, type of organ, and time since transplantation) to receive 1 dose (control group) or 2 doses (booster group) of the influenza vaccine 5 weeks apart. Results. A total of 499 SOTR were enrolled. Although seroconversion at 10 weeks did not meet significance in the modified intention-to-treat population, seroconversion rates were significantly higher in the booster arm for the per-protocol population (53.8% vs 37.6% for influenza A(H1N1)pdm; 48.1% vs 32.3% for influenza A(H3N2); and 90.7% vs 75% for influenza B; P < .05). Furthermore, seroprotection at 10 weeks was higher in the booster group: 54% vs 43.2% for A(H1N1)pdm; 56.9% vs 45.5% for A(H3N2); and 83.4% vs 71.8% for influenza B (P < .05). The number needed to treat to seroprotect 1 patient was <10. The clinical efficacy (99.2% vs 98.8%) and serious adverse events (6.4% vs 7.5%) were similar for both groups. Conclusions. In SOTR, a booster strategy 5 weeks after standard influenza vaccination is safe and effective and induces an increased antibody response compared with standard influenza vaccination consisting of a single dose. Clinical Trials Registration. EudraCT (2011-003243-21).
•Peritoneal and serum concentrations of echinocandins were analysed in surgical patients with suspected candida peritonitis.•The peritoneal concentrations obtained for the three candins in the ...present study ranged 0.21–0.46 μg/mL for caspofungin, 0.68–0.88 μg/mL for micafungin and 0.66–1.82 μg/mL for anidulafungin, and most concentrations were <1 μg/mL.•The levels of echinocandins that were found in the peritoneum were below the concentrations of resistant mutant selection published by other authors.•These data warn about mutant selection in patients on prolonged treatment with echinocandins and suboptimal control of abdominal infection.
A possible increase in Candida resistance, especially in Candida glabrata, has been speculated according to poor diffusion of echinocandins to peritoneal fluid.
Peritoneal and serum concentrations of caspofungin, micafungin and anidulafungin were analysed in surgical patients with suspected candida peritonitis. After 4 days of starting therapy, serum and peritoneal samples (through peritoneal drainage) were obtained at baseline, 1, 6, 12 and 24 h of drug administration. Micafungin and anidulafungin concentrations were determined using high-performance liquid chromatography (HPLC/F), whereas caspofungin concentrations were established by bioassay.
Twenty-three critically ill patients with suspected abdominal fungal infection who were receiving an echinocandin were prospectively recruited. No specific criteria were applied to prescribe one specific echinocandin. No special clinical differences were observed among the three groups of patients. All were receiving antibiotic therapy, 80% required inotropic drugs, and fungal peritonitis was confirmed in 74% of them. The AUC0_24h (mg × h/L) obtained in serum and peritoneal fluid were: 126.84 and 34.38, 98.52 and 18.83, and 66.9 and 8.78 for anidulafungin, micafungin and caspofungin, respectively. The median concentration in peritoneal fluid ranged from 0.66 to 1.82 μg/mL for anidulafungin, 0.68–0.88 μg/mL for micafungin and 0.21–0.46 μg/mL for caspofungin.
The results showed moderate penetration of echinocandins into the peritoneal fluid of these patients. These levels are below the threshold of resistance mutant selection published by other authors. This could justify a potential risk of resistance in patients with prolonged treatment with echinocandins and suboptimal control of abdominal infection.
Aspergillus galactomannan (GM) antigenemia is an early marker of invasive aspergillosis (IA), but may yield false-positive results. A prospective study, testing GM periodically in serum samples of ...liver transplant recipients, was performed.
An index more than or equal to 0.5 were considered positive. Positive GM in samples from patients without any other criteria of proven or probable IA was considered as false-positive. The test was performed weekly during the first month after transplantation.
Three patients developed IA. In total, 414 serum samples from 85 liver transplant recipients were analyzed. Mean number of samples per patient (out of those who could be assessed) was 4.8. The number of false-positive GM samples was 40 (9.6%), corresponding to 28 patients. The frequency of false-positive results in samples obtained during the first week posttransplantation was 36% (27 of 75), significantly higher than the number of false-positive samples obtained after the first week (3.8%; 13 of 339; P<0.001). Multivariate analysis showed that antibacterial prophylaxis with ampicillin was the only independent factor associated with a false-positive result. Different vials of beta-lactam antibiotics were tested for GM. We obtained a positive GM value (>0.5) in four of the six vials of ampicillin, in three of the six vials of piperacillin-tazobactam, in none of the six vials of cefotaxime, and in none of the six controls.
The present study suggests that the administration of ampicillin as antibacterial prophylaxis during the first days after transplantation could be a possible cause of false-positive GM results.
Background. It is necessary to clarify the incidence of and risk factors for tuberculosis (TB) among solid-organ transplant (SOT) recipients as well as changes in the chronology, clinical ...presentation, and prognosis of the disease. Methods. A total of 4388 SOT recipients were monitored prospectively at 16 transplant centers included in the Spanish Network for Research in Infectious Diseases (REIPI). TB episodes were studied, and the incidence rate was calculated. Certain variables were analyzed, by Cox regression analysis, as potential risk factors for TB. Results. Among the 4388 SOT recipients, 21 cases of TB were reported (0.48%). The median duration of follow-up was 360 days (range, 0–720 days). The global incidence of TB was 512 cases per 105 patients per year (95% confidence interval CI, 317–783), which was higher than that in the general population in Spain (18.9 cases per 105 inhabitants per year; relative risk RR, 26.6). The highest incidence (2072 cases per 105 patients per year; 95% CI, 565–5306) was observed among lung transplant recipients (RR, 73.3). Of the TB cases, 95% occurred within the first year after transplant, and 76% were pulmonary forms. Crude mortality was 19.0%, and attributable mortality was 9.5%. Multivariate analysis identified recipient age (RR, 1.05; 95% CI, 1.0–1.1) and receipt of a lung transplant (RR, 5.6; 95%, 1.9–16.9) as independent risk factors. Conclusions. TB incidence is increased among SOT recipients. The risk factors identified were age and receipt of a lung transplant. TB-attributable mortality (9.5%) is still high.
PDF
