Fungal Infections In Patients Research Articles

Recurrent vulvovaginal candidiasis during COVID-19 pandemic: medical algorithm

The review article presents data on the prevalence of candidiasis of various localization against the history of coronavirus infection (COVID-19). The predisposing factors for the development and recurrence of candidiasis in patients after therapy for coronavirus infection have been analysed. Candida is one of the most common pathogens in intensive care units (ICUs), affecting 6 to 10% of patients, and some studies have reported an increasing trend in the prevalence of candidemia. The literature data that we analysed showed that the most common types of fungal infection among patients with a severe course of COVID-19 were C. albicans, then C. auris, C. glabrata, C. parapsilosis, C. tropicalis, S. cerevisiae, C. krusei and Rhodotorula spp. Candida non-albicans species, in particular C. glabrata, C. auris, were the most common causes of death. The previous treatment regimens for patients with COVID-19 included antibiotics, but at present time corticosteroids are more often used, which have an immunosuppressive effect and, accordingly, predispose to the development of candidiasis. The epithelial injury caused by SARS-CoV-2 also enables Candida to attach to the basement membrane, subsequently triggering the development of mucosal candidiasis. As the systemic and local candidiasis are conditioned by common immune mechanisms that are affected by coronavirus infection, vulvovaginal candidiasis (VVC) may recur during COVID-19 therapy. The timely diagnosis and treatment of fungal infections in patients who underwent COVID-19 are crucial for achieving a positive clinical outcome. The article provides an algorithm for the management of patients with recurrent VVC, the principles of action of antifungal drugs, their acceptability and efficacy.

Prevalence and Clinical Risk Factors for Invasive Aspergillosis in Patients with Acute Leukemia at Srinagarind Hospital, Khon Kaen University

Objective: Invasive aspergillosis (IA) is the most common fungal infection in patients with acute leukemia and associated with high mortality rate. We aimed to report the prevalence and clinical risk factors of IA in patients with acute leukemia at Srinagarind Hospital, Khon Kaen University. Materials and Methods: A retrospectively study was performed in adult acute leukemia patients who were diagnosed with IA from January 2006 to December 2015 at Srinagarind Hospital, Khon Kaen University. IA was defined by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group. Clinical characteristics and laboratory data were analyzed. Multivariate logistic regression analysis was used to determine the associations. Results: A total of 355 patients with acute leukemia, invasive aspergillosis was found in 39 patients (11%). The median age was 46 years (IQR of 33 to 59 years). Gender distribution was equal between males and females. Most common type of leukemias in the study are acute myeloid leukemia non-M3 (50.7%), followed by acute myeloid leukemia M3 (24.8%), and acute lymphoblastic leukemia (24.8%) respectively. Using logistic regression analysis, patients who had neutropenia at the time of IA diagnosed (adjusted OR 3.54; p=0.014), hepatitis B viral infection (adjusted OR 3.13; p=0.03), and working as construction worker (adjusted OR 23.08; p<0.001) remained the risk factor of IA. Conclusion: The prevalence of IA in Thai patients with acute leukemia is modest. Neutropenia, hepatitis B viral infection and construction worker were significant clinical risk factors for IA in patients with acute leukemia. Keywords: Invasive aspergillosis; Acute leukemia; Srinagarind Hospital

S3109 Gastric Mucosal Necrosis Due to Mucormycosis in COVID-19 Patient

Introduction: COVID-19 patients, especially severely ill have a higher probability of suffering from invasive mycoses. That was noticed in our practice, and reported in literature.1 Our review of the literature found only one case of COVID-19 related gastric mucormycosis. Here we present a second one. Case Description/Methods: 71-year-old male with Hx of T2DM who presented with shortness of breath, dry cough and fever of 5 days and tested positive for COVID-19. He was admitted for AHRF, given remdesivir and dexamethasone for 2 days and discharged home to continue 10 days course of dexamethasone. Over the course of 1-week, patient's symptoms continued to progress, and he was brought again for shortness of breath and altered mental status. In ED, patient was febrile, hypoxic and was admitted for AHRF due to SARS-Cov-2 pneumonia with possible superimposed bacterial pneumonia. He was intubated and started on pressors, empirical antibiotics, dexamethasone and remdesivir to finish another 10-day course of the latter 2. He remained intubated with multiple failed weaning attempts, and after 2 weeks, tracheostomy tube was placed, and decision was made to proceed with PEG tube placement. Endoscopic mucosal examination was suggestive of diffuse proximal gastric mucosal necrosis sparing the antrum and distal body. PEG placement was cancelled and gastric biopsies histopathology showed invasive fungal disease consistent with Mucormycosis. The patient was started on liposomal amphotericin B and isavuconazonium. After a multidisciplinary discussion, the patient was deemed as a very high risk for gastrectomy and hence surgical intervention was deferred. MRI brain and sinuses showed no signs of invasive fungal disease. 3 weeks after the diagnosis of gastric Mucormycosis he was discharged on antifungals but unfortunately, he expired a few days after discharge. Discussion: In a recent systemic review, they found that 101 cases of mucormycosis in patients with COVID-19 have been reported, of which one of them was gastrointestinal. Pre-existing DM was present in 80% of cases and corticosteroid intake was recorded in 76.3% of cases. Mucormycosis involving nose and sinuses 88.9% was most common followed by rhino-orbital 56.7%. Only one case with gastric Mucormycosis was purported, the patient presented with melena during his stay and unfortunately died in seven days. Clinicians should have a high level of suspicion for concomitant fungal infections in patients with COVID-19 to allow for prompt diagnosis and early intervention.Figure 1.: a. Axial CT image of the upper abdomen. The two open (blue) arrows indicate visualized portions of the distended stomach. The solid (yellow) arrow shows severe hydronephrosis. b. Upper GI image. The solid yellow arrow shows the obstructed proximal duodenum. Note that contrast flows freely from the stomach into the anastomosed limb (solid white arrow) status post diverting jejunostomy c. Microscopic examination of the right ureter biopsy reveals invasive urothelial carcinoma with high grade nuclei.

MUCORMYCOSI (BLACK FUNGUS): A REVIEW

Mucormycosis is a new angioinvasive infection caused by the ubiquitous filamentous fungus of the Mucorales order of the Zygomycete class. Mucormycosis has emerged as the third most prevalent invasive mycosis in patients undergoing hematological and allogeneic stem cell transplantation, following candidiasis and aspergillosis. Sporangiospores must be inhaled on a daily basis. Members of the Mucorales are very infrequent in nasal mucus, indicating that spores in airway mucus are removed via mucociliary transport or that there is a minimal degree of airborne contamination.

Mucormycosis-a Fungal Infection in Patient Recovered from COVID-19

Recently, a fungal disease, “Mucormycosis,” has created a huge fury in everybody’s mind. It is prevalent in immunocompromised individuals, such as people suffering from Covid 19, cancer, HIV, prolonged use of steroids, immunomodulators, and diabetes. It is caused by a group of molds called mucoromycetes found in damp soil, bread, decaying fruits and vegetables, compost piles, animal waste, and moist, dusty construction sites. It can invade the human body through several routes, such as inhalation, injury site, or food/water intake. The ICMR recommends wearing a mask while visiting dusty construction sites, wearing shoes, long trousers, a full sleeve shirt, and gloves when handling soils, moss, or manure, and maintaining personal hygiene, including a good scrub bath. This article further covers the history, pathogenesis, role of Iron, GRP78, and CotH, pathophysiology, geographical spread, and treatment of this rare but fatal disease. Overall, the mortality rates account for 54%, which is further varied depending upon the patient condition, type of fungus & body site infected, speaking of which, as reported, 96% mortality rate alone accounts for the disseminated Mucormycosis.

Idarubicin and Ara-C Treatment Associated with Fungal Infection in Acute Leukemia Patients with Febrile Neutropenia

Background: Pateints with acute leukemia along with febrile neutropenia is at risk for fungal as well as bacterial infections. Fungal infection is a more serious and common infection in this setting, leading to a high mortality rate. There is limited data on clinical factors predictive of fungal infection in acute leukemia with febrile neutropenia. Objective: This study aimed to evaluate clinical predictive factors of fungal infection in acute leukemia patients with FN. Methods: This was a retrospective analytical study and included adult patients diagnosed with acute leukemia, who developed FN, and had positive culture with either bacterial or fungal infection. Predictors for fungal infection were calculated by using logistic regression analysis. A subgroup analysis in patients with acute myeloid leukemia (AML) was also performed. Results: There were 94 patients who met the study criteria. Of those, 29 patients had positive culture for fungus (30.82%), categorized as Aspergillus (19 patients; 65.51%) and Candida (10 patients; 34.49%). The mortality rate was significantly higher in the fungal infection group than the bacterial infection group (24.14% vs. 6.15%; p 0.031). There were six factors in the final model predictive of fungal infection with one independent predictor: treatment regimen of Idarubicin plus Ara-C with an adjusted odds ratio of 5.188 (95% CI of 1.386, 19.419). A subgroup analysis for fungal infection in patients with AML showed that only the treatment regimen of Idarubicin plus Ara- C was a significant factor. Its adjusted odds ratio was 5.138 (95% CI of 1.156, 24.467). Conclusion: Treatment with idarubicin and Ara-C may increase the risk of fungal infection in acute leukemia patients with FN.

Establishment of heparin-binding protein time-resolved immunoassay and some potential clinical applications

AimTo establish a highly sensitive time-resolved fluorescence immunoassay of heparin-binding protein (HBP-TRFIA) and evaluate its application value for bacterial or fungal infections in tumor patients. MethodsTwo types of HBP monoclonal specific antibodies against different epitopes of the antigen molecule were used as coating antibodies and Eu3+-labeled antibodies, respectively. The double-antibody sandwich method was used in establishing HBP-TRFIA, and the methodology was evaluated. The established HBP-TRFIA was used in detecting HBP concentration in the plasma samples of healthy individuals, patients with bacterial or fungal infections, and infected or uninfected patients with various types of tumors. ResultsThe linear range of HBP-TRFIA was (0.11–530 ng/mL). Plasma HBP concentrations detected through HBP-TRFIA were consistent with the results of fluorescence quantitative immunochromatography (ρ = 0.964). The plasma HBP concentrations of infected tumor patients were significantly higher than those of uninfected tumor patients (P < 0.01). ConclusionThis study successfully established a highly sensitive HBP-TRFIA, which was highly comparable to commercially available fluorescent quantitative immunochromatographic kits and was able to facilitate the timely diagnosis of bacterial or fungal infections in patients with tumor.

Candida glabrata Infection: A Rare Complication of Chest Trauma

Candida species are fungi, which are ubiquitous organisms. It is a normal flora of the oral cavity, genitourinary and gastrointestinal tract. An increasing incidence of fungal infections with Candida species has been noted in immunocompromised patients such as intensive care, postsurgical, and neutropenic patients. Candida species are detected in approximately 31 to 55% of healthy individuals. They are more common in immunocompromised individuals. Colonization rates increase with severity of illness and duration of hospitalization. We present a 32-year-old male who presented at our institution with a thoracoabdominal penetrating injury following assault. He had injury to the stomach and left hemi diaphragm, with moderate hemothorax. He had surgery done with repair of the stomach and diaphragm. He however developed chest infection with empyma thoracis thereafter. Culture of the pleural effluent revealed growth of Canddida glabrata which was sensitive to Ketoconazole. He was treated for two weeks and subsequently discharged from the ward and followed up in the clinic. Though C. glabrata infection of the chest is rare, it is however useful to exclude fungal infection in patients with empyema thoracic, as early diagnosis and treatment provides good outcome.

COVID 19 ASSOCIATED INVASIVE FUNGAL INFECTIONS IN CHURU REGION OF RAJASTHAN

Background: COVID 19 or severe acute respiratory syndrome (SARS-CoV-2) evolved as global pandemic since December 2019 when it was first reported in Wuhan, China. Coinfection in patients with COVID-19 has been reported in multiple studies, being bacterial in origin the most frequent; and fungal infection being reported only in severe cases.&#x0D; Methods: This study was conducted at the department of E.N.T. at PanditDeenDayalUpadhyay Medical College, Churu. Cases presented to E.N.T. OPD with clinical features of invasive rhino-orbital fungal infection for the period of two month from 1st June 2021 were included in the study. Patients were clinically evaluated, HRCT, MRI scans and with KOH mount and culture of involved tissue ere done. Patient’s COVID-19 status was ascertained. The clinicopathological association of occurrence of invasive fungal infections in post covid and non-covid patients along with other risk factors like diabetes mellitus, immune compromised state and long-term steroid use was done using statistical methods&#x0D; Results: We studied 21 patients who attended our OPD with features of invasive fungal infection. Most common presentation was swelling and pain in the cheek region and red eye and swelling around the eye, three patients presented with maxillary swelling with blackish discoloration of teeth. Radiological findings were suggestive of fungal etiology in all patients. KOH mount showed fungal hyphae in 20 cases. Total 20 cases were post COVID status. Old DM was there in 12 patients whereas 9 patients showed new onset hyperglycemia.&#x0D; Conclusions: COVID-19 is associated with a significant incidence of secondary infections, both bacterial and fungal probably due to immune dysregulation. The widespread use of steroids/monoclonal antibodies/broad-spectrum antibiotics as part of the management protocols against COVID-19 may lead to the exacerbation of preexisting fungal diseases or development of new infection. Treating Physicians should make themselves aware and prepare for the possibility of invasive secondary fungal infections in patients with COVID-19 infection especially in patients with preexisting risk factors and should enable early diagnosis and treatment with the subsequent reduction of mortality and morbidity.&#x0D; Keywords: Coronavirus, COVID-19, mucormycosis, invasive fungal infections

Suboptimal plasma concentrations with posaconazole suspension as prophylaxis in critically ill COVID-19 patients at risk of Covid-associated pulmonary aspergillosis.

What is known and objectiveThe safety and efficacy of different antifungal agents in the prophylaxis of invasive fungal infection in patients with haematological disorders are known. We comment on the poor bioavailability of posaconazole suspension to suggest that it is not useful in critically ill COVID patients.CommentThe increased mortality and high incidence of COVID‐associated pulmonary aspergillosis (CAPA) might justify administration of off‐label posaconazole for preventing CAPA, being the only drug officially registered for prophylaxis of fungal infections. We decided to initiate off‐label posaconazole prophylaxis in COVID‐19 patients, who were mechanically ventilated and exposed to high‐dose steroids for progressive pulmonary disease or ARDS. We found that posaconazole suspension was inadequate. Very low trough levels were observed after administration, and the dose adjustments necessary for the therapeutic drug monitoring (TDM) of the drug in our critically ill ICU patients were not useful.What is new and conclusionPosaconazole suspension should not be used to prevent CAPA in COVID‐19 patients on high‐dose steroid therapy.

Microbiota of Bronchoalveolar Lavage Samples from Patients of Lower Respiratory Tract Infection – A Changing Trend

Bronchoalveolar lavage (BAL) is the saline wash of the bronchial tree, which aids in diagnosing various pulmonary pathologies. The present study was contemplated with an aim to know the clinical, microbiological profile of BAL samples along with its sensitivity pattern and to assess its utility as a diagnostic tool. This was a prospective observational study, carried over 90 patients presenting with lower respiratory tract infections. The total microbial recovery rate from BAL was 39 (43.3%). The sensitivity, specificity and positive predictive value of BAL were found to be 76.4%, 89.7% and 90.6% respectively. Maximum isolates were bacteria (25.5%) followed by Mycobacterium tuberculosis (MTB) (16.6%) and fungi (1.1%). Predominant bacterial isolates were Gram-negative (81.5%) compared to Gram-positive (18.5%). Multidrug resistance (MDR) in bacteria was seen in 59.2% of isolates. BAL is a valuable diagnostic tool to find not only bacterial but mycobacterial and fungal infections in patients with lower respiratory tract infection (LRTI). A trend towards LRTI with Gram-negative infections is on the rise and they tend to be multidrug-resistant. Hence checking susceptibility patterns is crucial to start evidence-based treatment.

Poor outcome and high prevalence of invasive fungal infections in patients with adult T-cell leukemia/lymphoma exposed to zidovudine and interferon alfa.

Patients treated for adult T-Cell leukemia/lymphoma (ATL) have a poor prognosis and are prone to infectious complications which are poorly described. As the French reference center for ATL, we retrospectively analyzed 47 consecutive ATL (acute, n = 23; lymphoma, n = 14; chronic, n = 8; smoldering, n = 2) patients between 2006 and 2016 (median age 51years, 96% Afro-Caribbean origin). The 3-year overall survival (OS) was 15.8%, 11.3%, and 85.7% for acute, lymphoma, and indolent (chronic and smoldering) forms respectively. Among aggressive subtypes, 20 patients received, as frontline therapy, high dose of zidovudine and interferon alfa (AZT-IFN⍺) resulting in an overall response rate (ORR) of 39% (complete response [CR] 33%) and 17 chemotherapy resulting of an ORR of 59% (CR 50%). Ninety-five infections occurred in 38 patients, most of whom had an acute subtype (n = 73/95; 77%). During their follow-up, patients receiving frontline chemotherapy or frontline AZT-IFNα developed infections in 74% (n = 14/19) and 89% (n = 24/27) of the cases respectively. Sixty-four (67%) of infections were microbiologically documented. Among them, invasive fungal infections (IFI, n = 11) included 2 Pneumocystis jirovecii pneumonia, 5 invasive aspergillosis, and 4 yeast fungemia. IFI exclusively occurred in patients with acute subtype mostly exposed to AZT-IFNα (n = 10/11) and experiencing prolonged (> 10days) grade 4 neutropenia. Patients with aggressive subtype experiencing IFI had a lower OS than those who did not (median OS 5.4months versus 18.4months, p = 0.0048). ATL patients have a poor prognosis even in the modern era. Moreover, the high rate of infections impacts their management especially those exposed to AZT-IFNα.

25554 An integrated safety analysis of treatment-emergent fungal infections in patients with psoriasis treated with ixekizumab from 16 clinical studies

Introduction: Interleukin (IL)-17A is a central cytokine in psoriasis pathogenesis and is important in mucocutaneous immunity against yeast. Blockade of/deficiencies in IL-17A are associated with an increased frequency of Candida infections. This study analyzed treatment-emergent fungal infections in psoriasis patients receiving ixekizumab (IXE), an IL-17A inhibitor, in clinical studies.

Prevalence and predictors of pulmonary fungal infections in patients with acute leukemia and aggressive lymphomas: Implications for cancer care in developing countries

Objectives: Among patients receiving cancer therapy, pulmonary fungal infections (PFIs) are an important cause of morbidity and mortality. Identifying predictors of PFI can direct targeted prophylaxis to improve outcomes, especially in low- and middle-income countries (LMIC) with limited resources. The objectives of the study were to evaluate the predictors of PFI in hospitalized patients with hematological malignancies in the United States and implications for prioritizing anti-fungal care in LMIC. Materials and Methods: Using the 2018 National Inpatient Sample, we conducted a retrospective study of patients ≥18 years, with acute leukemia or aggressive lymphoma. Demographics and outcomes were compared between patients with and without PFI. Predictors of PFI were evaluated by regression analysis. Results: PFI was diagnosed in 1635 (0.8%) of 205,525 eligible hospitalizations and aspergillosis was noted in 1315 (80.4%) of PFI cases. Patients with acute myeloid leukemia (AML) accounted for 64.2% of cases of PFI. Patients with PFI, when compared with those without PFI, were younger, had higher Charlson comorbidity index, were more likely to be non-Caucasian, and to have AML. Patients with PFI had higher odds of respiratory failure, sepsis, and in-hospital mortality. Variables associated with PFI were Hispanic or native American origin (OR = 1.71; 95% CI: 1.21–2.42), Charlson comorbidity index ≥3 (OR = 1.52; 95% CI: 1.16–2.00), neutropenia (OR = 1.97; 95% CI: 1.58–2.46), malnutrition (OR = 2.30; 95% CI: 1.75–3.01), bone marrow transplant status (OR = 2.28, 95% CI: 1.53–3.39), and AML diagnosis (OR = 3.12; 95% CI: 2.40–4.05). Conclusions: This study identified variables associated with PFI in patients diagnosed with acute leukemia and aggressive lymphomas. In LMIC, where resources are scarce, patients with cancer who have the identified high-risk characteristics should be given priority for antifungal prophylaxis.

Risk Factors of Invasive Pulmonary Fungal Infections in Patients with Hepatitis B Virus Related Acute-on-Chronic Liver Failure

To analyze the risk factors of invasive pulmonary fungal infections in patients with HBV-ACL, the clinical data and risk factors of 60 patients with HBV-ACLF complicated IPFI were analyzed retrospectively including clinical parameters, broad-spectrum antibiotics usage, neutropenia, invasive medical manipulations, serum total bilirubin, international normalized ratio (INR), and MELD scores were compared with non-IPFI. Risk factors were analyzed using mathematical tools. Candida species and Aspergillus were detected as the most prominent fungal strains (61.11% and 33.33%, respectively). The risk factors included prolong broad-spectrum antibiotic usage OR = 4.362 , P = 0.008 , neutropenia OR = 3.288 , P = 0.007 , invasive procedures OR = 3.263 , P = 0.010 , serum total bilirubin OR = 1.006 , P = 0.011 , INR OR = 2.101 , P = 0.007 , and MELD scores OR = 1.074 , P = 0.008 . Candida is the main IPFI strains in patients with HBV-ACLF. Broad-spectrum antibiotics usage, neutropenia, invasive manipulations, and the severity of ACLF might be risk factors for IPFI in patients with HBV-ACLF.

Conventional Amphotericin B Associated Nephrotoxicity in Patients With Hematologic Malignancies.

Introduction: Amphotericin B (AmB-d) is one of the most effective therapeutic options against frequently life-threatening systemic fungal infections in patients with hematologic malignancies. However, significant adverse effects including nephrotoxicity associated with its use limit its more widespread use. The objectives of our study were to determine the incidence of AmB-d associated nephrotoxicity, to evaluate clinical and epidemiological characteristics of patients, and to support the notion that conventional amphotericin B remains a valid therapeutic option among hematologic patients with proper patient selection.Materials and methods: A total of 110 patients with hematologic malignancies were admitted to our Hematology Unit between January 2014 and November 2017 who required anti-fungal therapy during intensive systemic chemotherapy. The incidence of AmB-d associated nephrotoxicity, side effect profile, time to nephrotoxicity, and clinical and epidemiological characteristics associated with treatment success were assessed retrospectively.Results: Of the 110 patients receiving AmB-d, 70 (63.6%) were male and 40 (36.4%) were female. The mean age of participants was 44 years. The most common diagnosis was acute myeloid leukemia (n=53, 48.2%), and the most common chemotherapy protocol was 7 + 3 remission-induction (cytarabine 100 mg/m² days 1-7, Idarubicin 12 mg/m² days 1-3; n=24, 21.8%). In 56.4% of the patients, antifungal therapy was given empirically. In 40 patients (36.4%), nephrotoxicity was observed following antifungal treatment, and only four patients had stage 3 renal failure. The mean duration of time to nephrotoxicity from initiation of amphotericin B was four days (min: 2, max: 31). All patients were found to receive at least one additional potential nephrotoxic treatment during the antifungal treatment process. Conclusion: AmB-d is associated with a significant risk of nephrotoxicity. In most hematological patients, antifungal treatment is initiated empirically, and patients received prolonged courses of treatment. Therefore, it is plausible to initiate such treatment with AmB-d, when one considers the already high treatment costs in this patient group as well as the fact that AmB-d offers similar efficacy to antifungal agents at a lower cost. AmB-d may be recommended as a first-line agent in this patient group with the introduction of newer and more costly antifungal agents when needed, on the basis of the fact that these patients can be closely monitored in a hospital setting, reversible nature of nephrotoxicity upon discontinuation, and rare occurrence of severe renal failure requiring dialysis.

Mucormycosis: A Rare Fungal Infection in Patients Affected With Covid 19

Mucormycosis (also known as zygomycosis) is a severe but uncommon fungal infection caused by a fungus known as mucormycetes. Molds can be found all over the place. Mucormycosis is a fungal infection that mostly affects people who have health issues or who take medications that reduce the body's ability to combat germs and illness. Rhizopus species and Mucor species are the most common forms that cause mucormycosis. Rhizomucor species, Syncephalastrum species, Cunninghamella bertholletiae, Apophysomyces, Lichtheimia (formerly Absidia), Saksenaea, and Rhizomucor are some other examples. The COVID19, the disease rapidly spreading across the world, resulting in a worldwide pandemic, which vary from moderate to life-threatening pneumonia with bacterial and fungal coinfections.

Prospective Study of an Antifungal Program to Reduce Invasive Fungal Infections in Patients with Acute Myeloid Leukemia Receiving Induction and Re-Induction Chemotherapy

Background: Invasive fungal infections (IFI) can occur up to 40% of patients with hematologic malignancies and are most common in patients with acute myeloid leukemia (AML). National averages within the United States, per Infectious Diseases Society of America (IDSA), range approximately from 8-10% in this high risk population. IFIs are not only problematic for individual patient care, potentially resulting in increased antimicrobial usage and delay of future chemotherapy treatments or stem cell transplant, but IFI also negatively impact hospital resource utilization including increased days in hospital and the intensive care unit (ICU).Methods: In attempt to decrease IFIs in hematologic malignancy patients at the University of Virginia Health System (UVAHS), a multidisciplinary team of oncology and infectious diseases physicians, nurses, and pharmacists was formed to develop an Antifungal Program. Retrospective chart review was done of 79 patient encounters from 7/2011 to 9/2014 to establish our baseline cohort. For each of these encounters, extensive patient demographics, clinical, and inpatient event data were collected. Analysis of our baseline data showed a 19.7% proven or probable IFI rate in patients with acute myeloid leukemia undergoing induction chemotherapy. In concordance with IFI rates published by IDSA, we aimed to decrease the IFI in this patient population at UVAHS to less than 10%. With guidance from the American Society of Clinical Oncology's Quality Training Program, our team utilized multiple qualitative and quantitative tools to further understand factors contributing to an increased rate of IFIs. These tools included a process map and Ishikawa cause-and-effect diagram to depict all the steps from leukemia diagnosis to end of treatment and hospital discharge, a Pareto chart to quantify delays of individual steps, and a priority matrix categorizing potential interventions based on impact and ease of implementation. A statistical process control chart (p-chart) depicted rates of IFI in the baseline cohort and intervention groups.Results: Our baseline proven or probable IFI rate in patients with acute myeloid leukemia was 19.7%. Antifungal prophylaxis was not administered to baseline cohort patients. Per Pareto chart analysis, the team identified the most common problems contributing to IFI: inconsistent definition of IFI, no routine antifungal prophylaxis, and lack of education for the health care team. Two Plan-Do-Study-Act (PDSA) cycles of interventions were implemented; post-intervention data were collected and analyzed. From 9/2014 to 8/2016, the first PDSA cycle consisted of individual attending physicians ordering antifungal prophylaxis on an ad hoc basis; the first PDSA cycle resulted in a decreased IFI rate of 11.7% (n = 77). Though close to project aim of less than 10%, this process was burdensome and not sustainable, as it required individual physicians to remember to add antifungal prophylaxis and did not standardize which antifungal agent was used. During the second PDSA cycle from 8/2016 to 4/2017, a clinical practice guideline standardized the definition of IFI and recommended posaconazole as the prophylactic antifungal of choice. Team champions educated physicians, nurses, and pharmacists on the new standard work. This second PDSA cycle resulted in zero IFIs (n = 18), surpassing the team's goal of improving IFI to less than 10%. P-chart depicting IFI reduction is shown in Figure 1. Additionally, median ICU length of stay improved from 2.5 days to 1.5 days. Overall hospital length of stay decreased from 32.3 days to 29.9 days. As no proven or probable IFI were diagnosed during PDSA Cycle 2, no resistant fungal organisms were noted.Conclusions: This project illustrates the importance of forming a multidisciplinary team, whose collaborative effort developed an Antifungal Program that reduced IFI rates in a statistical significant method. When compared to historical controls, the Antifungal Program decreased both IFI rates and ICU length of stay. To ensure sustainability of the quality improvement study, monthly electronic medical record reports will capture guideline compliance, specifically the use of antifungal agents, and track future IFI. The Antifungal Program is an effective clinical tool to not only improve patient care, but likely represents increased patient quality of life, cost-savings, and decreased length of stay. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Post-COVID rhinocerebral mucormycosis: an otolaryngologists nightmare

&lt;p class="abstract"&gt;&lt;strong&gt;Background: &lt;/strong&gt;Rhinocerebral mucormycosis which was considered to be a rare occurrence in the pre-COVID era is currently emerging as a life-threatening disease with seemingly poor prognosis in post COVID recovered patients. Prompt diagnosis with urgent surgical and medical management is vital to a positive outcome.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods: &lt;/strong&gt;A retrospective observational study and analysis was done among patients of biopsy proven mucormycosis with preceding history of COVID 19 disease between March 2021 to April 2021 in a tertiary care state run hospital at Pune coinciding with the sudden surge and second COVID 19 wave.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; 20 0ut of 23 patients were having a history of type 2 diabetes mellitus for a mean duration of 4±3.5 years. The most common presenting complaint was unilateral facial swelling, periorbital pain, swelling and oedema in 18 out of 23 patients. All patients had COVID infection within the last one month of presentation with mean duration of 18±8.4 days. Out of 23 patients 16 survived while 19 patients had permanent vision loss and ophthalmoplegia.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Establishing the possibility of invasive secondary fungal infections in patients with history of COVID-19 infection especially in patients with pre-existing risk factors should raise high index of suspicion. Prompt early diagnosis and treatment should be started to reduce morbidity and mortality.&lt;/p&gt;

Infeksi Jamur Dermatofita Pada Penderita Mikosis Kuku

Dermatophytes are a group of fungi that cause nail abnormalities. This study aims to determine dermatophyte fungal infections in patients with nail mycoses. The method used in this study is descriptive and the sample was taken by purposive sampling with the criteria of damaged toenails, with characteristics: nails are not shiny, brownish to black from the base to the tip then the nails are examined directly with 10% KOH and cultured using media Sabouraud Dextrose Agar (SDA). The fungi isolated on slanted agar containing SDA and each fungal species were then identified using preparations for microscopic examination. The results showed that from 30 samples, 8 (eight) nail samples were positive for dermatophytes, namely: 5 (five) people infected with the fungus Tricophyton mentagrophytes species, 2 (two) people infected with the Trichophyton rubrum fungus, and 1 (one) person infected with Epidermophyton floccosum..