Incidence Of Candidosis Research Articles

Primary prophylaxis of cryptococcal disease with fluconazole in HIV-positive Ugandan adults: a double-blind, randomised, placebo-controlled trial

Cryptococcal disease remains an important cause of morbidity and mortality in HIV-infected individuals in sub-Saharan Africa, despite the introduction of antiretroviral therapy. We studied fluconazole as primary prophylaxis against cryptococcal disease in patients awaiting or starting antiretroviral therapy in Uganda. In this prospective, double-blind randomised controlled trial, we enrolled HIV-positive adults with CD4 counts less than 200 cells per μL, cryptococcal antigen (CrAg)-negative, naive for antiretroviral therapy, and coming from five local AIDS organisations in Masaka district, Uganda. Enrolment took place between Sept 14, 2004, and Feb 1, 2008. Participants were randomly allocated to placebo or 200 mg fluconazole three times per week (1:1) in blocks of 40. Randomisation was done with ralloc procedure in Stata. Participants were reviewed after 4 weeks and referred for antiretroviral therapy, then seen every 8 weeks. Participants discontinued trial treatment when CD4 counts reached 200 cells per μL (median 197 days). Primary endpoints were invasive cryptococcal disease and all-cause mortality. Secondary endpoints were time to first episode and incidence of oesophageal candidosis, time to first episode and incidence of oropharyngeal or vaginal candidosis, and time to first hospital admission or death. The primary safety endpoint was cessation of trial drug because of transaminase concentrations higher than five times the upper limit of normal (ULN), or other major adverse events. Analyses were done by intention to treat and included all participants enrolled in the trial. Participants and researchers were masked to group assignment. This trial is registered with controlled-trials.com, number ISRCTN 76481529. Of 1519 individuals enrolled, 760 participants received fluconazole and 759 received placebo. 19 developed cryptococcal disease, one in the fluconazole group and 18 in the placebo group (p=0·0001); adjusted HR (aHR) 18·7 (95% CI 2·5-140·7). One case of cryptococcal disease could be prevented by treating 44·6 patients with baseline CD4 counts lower than 200 cells per μL. Fluconazole was effective against cryptococcal disease both before (aHR=11·0 [1·4-85·3]) and after start of antiretroviral therapy (no cases in fluconazole vs seven cases on placebo). Seven participants died from cryptococcal disease, none in the fluconazole group. All-cause mortality (n=189) did not differ between the two groups (p=0·46). Fluconazole reduced the time to first episode of oesophageal, and oropharyngeal and vaginal candidosis, as well as the incidence of all candidosis (p<0·0001), but had no effect on hospital admission or death. The frequency of elevated transaminases (>5×ULN) was similar between groups (aHR=0·94 [0·65-1·35]). Fluconazole was safe and effective as primary prophylaxis against cryptococcal disease, both before and during early antiretroviral treatment. Cryptococcal infection was less common than anticipated because of the rapid commencement of antiretroviral therapy and exclusion of those with positive CrAg. In patients with negative CrAg on screening, fluconazole prophylaxis can prevent cryptococcal disease while waiting for and in the early weeks of antiretroviral therapy, particularly in those with CD4 counts of less than 100 cells per μL. Medical Research Council, UK, and Rockefeller Foundation.

Presente y futuro de la micología médica

During the second part of XX century, the prevalence of fungal infections has raised inexorably. The main cause has been the increase of number of immunosupressed patients and the new aggressive therapeutic approaches. Since 1970, the annual incidence of candidosis and aspergilosis has increased 40 and 6.5 times, respectively. Additional studies reported in USA and Europe indicated that Candida produce between 5-10% of all episodes of nosocomial sepsis. In this revision, we analyse the present situation of Medical Mycology including the most relevant aspects as: a) the increase of incidence in fungal infections; b) the problems of the diagnosis including classical and new methodologies and antifungal susceptibility testing, and c) the uncertainties of the treatment due to the arrival of new formulations and new antifungals The future of Medical Mycology depends in many factors but molecular biology will play the central role although this discipline will develop slower than other microbiology areas as virology or bacteriology. Although the increase of incidence in invasive fungal infections has been enormous, we must not forget that any group in solitary could not answer the many unresolved questions. Thus, the call for research executed by Instituto de Salud Carlos III for financing Thematic Research Networks could be the starting point for a new time in invasive fungal infections.

Deep-seated mycosis as a complication in bone marrow transplantation patients.

Achieving control of opportunistic fungal infections which occur during the course of immunosuppressive therapy is one of the key factors deciding the success or failure of bone marrow transplantation (BMT). A review was conducted of autopsied patients who had undergone BMT at the University of California at Los Angeles Medical Center in the USA between 1985 and 1994. The incidence of complication by deep-seated mycoses was determined, and the causative fungal species and invaded organs were elucidated. Deep fungal infections were found to have occurred in 31.5% (47/149 cases) of the BMT patients, and disseminated disease was found in approximately one-quarter of the infected cases. The findings suggest that BMT patients, who require the use of potent immunosuppressive agents, show increased susceptibility to the development of more serious, and widespread diffuse fungal infections. The most commonly detected causative fungi were Aspergillus species and Candida species. In addition, it was found that the incidence of candidosis had decreased markedly in recent years; conversely, aspergillosis had increased. It was surmised that these findings reflect the development of antifungal agents which are effective against candidosis and have enabled a reduction in the incidence of this disease even in BMT patients, whereas aspergillosis remains difficult to treat. In consideration of these findings regarding the manifestation of deep-seated mycosis in BMT patients, we conclude that in order to increase the success rate of BMT it will be essential to establish safe and effective methods for the prevention and treatment of aspergillosis.