Abstract
Background Cryptococcus gattii is a fungal pathogen causing an emerging outbreak in the United States Pacific Northwest (PNW). Treatment guidelines for cryptococcosis are primarily based on data from C. neoformans infections; applicability to PNW C. gattii infection is unknown. We evaluated the relationship between initial antifungal treatment and outcomes for PNW C.gattii patients.MethodsCases were defined as culture-confirmed invasive C. gattii infections among residents of Oregon and Washington States during 2004–2011. Clinical data were abstracted from medical records through one year of follow-up. Recommended initial treatment for central nervous system (CNS), bloodstream, and severe pulmonary infections is amphotericin B and 5-flucytosine; for non-severe pulmonary infections, recommended initial treatment is fluconazole. Alternative initial treatment was defined as any other initial antifungal treatment.ResultsSeventy patients survived to diagnosis; 50 (71%) received the recommended initial treatment and 20 (29%) received an alternative. Fewer patients with pulmonary infections [21 (64%)] than CNS infections [25 (83%)] received the recommended initial treatment (p = 0.07). Among patients with pulmonary infections, those with severe infections received the recommended initial treatment less often than those with non-severe infections (11% vs. 83%, p<0.0001). Eight patients with severe pulmonary infections received alternative initial treatments; three died. Four patients with non-severe pulmonary infections received alternative initial treatments; two died. There was a trend towards increased three-month mortality among patients receiving alternative vs. recommended initial treatment (30% vs. 14%, p = 0.12), driven primarily by increased mortality among patients with pulmonary disease receiving alternative vs. recommended initial treatment (42% vs. 10%, p = 0.07).Conclusions C.gattii patients with pulmonary infections – especially severe infections – may be less likely to receive recommended treatment than those with CNS infections; alternative treatment may be associated with increased mortality. Reasons for receipt of alternative treatment among C.gattii patients in this area should be investigated, and clinician awareness of recommended treatment reinforced.
Highlights
Cryptococcus spp. are basidiomycetous yeast, with two species, C. gattii and C. neoformans, causing most human cryptococcal infections [1,2,3]
Since 2004, an outbreak of C. gattii infections has been documented in the United States Pacific Northwest states of Oregon and Washington [16]
Four patients died before diagnosis of C. gattii infection (3, 7, 7, and 12 days before diagnosis); two had bloodstream infections and two had pulmonary infections
Summary
Cryptococcus spp. are basidiomycetous yeast, with two species, C. gattii and C. neoformans, causing most human cryptococcal infections [1,2,3]. Outbreak-strain subtypes are different from those found in historically endemic Australia and Papua New Guinea (and other areas of the world), where infections are most frequently caused by nonclonal strains of C. gattii, most commonly VGI [11,27,28,29]. Clinical differences between C. gattii infections in the United States Pacific Northwest and historically endemic areas have been described. While C. gattii in historically endemic areas has been reported to infect primarily immunocompetent persons, causing meningoencephalitis [11,27,28,30,31,32], C. gattii infections in Oregon and Washington State occur frequently in immunocompromised persons and present most often as respiratory illness [33]. Cryptococcus gattii is a fungal pathogen causing an emerging outbreak in the United States Pacific Northwest (PNW). We evaluated the relationship between initial antifungal treatment and outcomes for PNW C.gattii patients
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
