Intravenous Antifungal Therapy Research Articles

Endogenous Fungal Endophthalmitis: A Single-Center Retrospective Study and Review of the Literature

To evaluate factors that inform systemic antifungal choices in patients with endogenous fungal endophthalmitis (EFE). Single-institution retrospective case series. Charts of EFE patients from 2010 to 2023 were reviewed. Patients treated systemically for EFE with a minimum of 14 days of follow-up were included. Outcome measures included time to improvement in vitritis or chorioretinitis, systemic therapy modification, and need for surgical intervention. A total of 20 eyes of 16 patients were included. Candida species were most common (43.8%), followed by culture-negative EFE (37.5%) and Aspergillus species (18.8%). In all, 90% of eyes had vitritis and/or macula-involving chorioretinitis. The majority of Candida infections (60%) or culture-negative EFE (75%) were treated initially with oral antifungals. Patients with a history of immune compromise, positive fungal culture, or positive Fungitell assay were more likely to be treated with early intravenous (IV) antifungal therapy. Two patients required systemic antifungal therapy modification because of worsening chorioretinitis, in 1 case due to voriconazole-resistant Aspergillosis that demonstrated chorioretinal lesion growth despite intravitreal amphotericin B injections and systemic voriconazole, and in the second case due to worsening chorioretinitis from Candida dubliniensis infection that regressed upon switch from oral to IV fluconazole. Initial systemic treatment decisions in patients with EFE were driven by systemic culture positivity, systemic symptoms, or comorbidities. Intravitreal antifungal therapy may be insufficient to arrest progression of chorioretinal lesions in some cases. Larger studies are needed to determine whether visible end-organ damage in the form of chorioretinitis may be useful for guiding systemic therapy changes.

Role of Hyperbaric Oxygen in Treatment of Invasive Fungal Sinusitis

Abstract Background Invasive fungal infections are a major cause of morbidity and mortality in immunodeficient individuals (such as AIDS patients) and in transplant recipients or tumor patients undergoing immunosuppressive chemotherapy. The most widely accepted therapy is the multimodal approach of using intravenous (IV) anti-fungal therapy in combination with sinus debridement, and hyperbaric oxygen (HBO) for the management of invasive fungal sinusitis. HBO has an important role in management of those patients; there is a significant survival benefit with adjunctive HBO use, as HBO has a fungistatic effect, decrease growth rate of fungus, and decrease the morbidity. Objective to assess the use of Hyperbaric oxygen in treatment of invasive fungal sinusitis and evaluate its efficacy as HBO has a fungistatic effect, decrease growth rate of fungus, and decrease the morbidity. Patients and Methods The pertinent role of hyperbaric oxygen therapy in treatment of invasive fungal sinusitis has been popularized over the past decade, to approve the important role of HBOT we established our systematic review which include 15 studies and 98 patients. Results We assess the beneficial effect of adding HBOT in the protocol treatment of invasive fungal rhinosinusitis, which illustrate the favorable results supporting adding HBOT, as survival rate among patients treated with HBOT 66% against 42% survival rate among patients treated without HBOT. Conclusion Hyperbaric oxygen therapy is an attractive option in treatment of invasive fungal rhinosiusitis as an adjunctive therapy.

Predictors for Prolonged Hospital Stay Solely to Complete Intravenous Antifungal Treatment in Patients with Candidemia: Results from the ECMM Candida III Multinational European Observational Cohort Study

BackgroundTo date, azoles represent the only viable option for oral treatment of invasive Candida infections, while rates of azole resistance among non-albicans Candida spp. continue to increase. The objective of this sub-analysis of the European multicenter observational cohort study Candida III was to describe demographical and clinical characteristics of the cohort requiring prolonged hospitalization solely to complete intravenous (iv) antifungal treatment (AF Tx).MethodsEach participating hospital (number of eligible hospitals per country determined by population size) included the first ~ 10 blood culture proven adult candidemia cases occurring consecutively after July 1st, 2018, and treating physicians answered the question on whether hospital stay was prolonged only for completion of intravenous antifungal therapy. Descriptive analyses as well as binary logistic regression was used to assess for predictors of prolonged hospitalization solely to complete iv AF Tx.FindingsHospital stay was prolonged solely for the completion of iv AF Tx in 16% (100/621) of candidemia cases by a median of 16 days (IQR 8 – 28). In the multivariable model, initial echinocandin treatment was a positive predictor for prolonged hospitalization to complete iv AF Tx (aOR 2.87, 95% CI 1.55 – 5.32, p < 0.001), while (i) neutropenia, (ii) intensive care unit admission, (iii) catheter related candidemia, (iv) total parenteral nutrition, and (v) C. parapsilosis as causative pathogen were found to be negative predictors (aOR 0.22 – 0.45; p < 0.03).InterpretationHospital stays were prolonged due to need of iv AF Tx in 16% of patients with candidemia. Those patients were more likely to receive echinocandins as initial treatment and were less severely ill and less likely infected with C. parapsilosis.

Short intravenous amphotericin B followed by oral posaconazole using a simple, stratified treatment approach for diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis: a prospective cohort study

ObjectivesTo evaluate the efficacy and safety of short-course intravenous amphotericin B followed by sustained release posaconazole tablets for diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis. MethodsThis prospective, pragmatic study included adults with diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis. Patients received short (7–14 days) or long (15–28 days) intravenous antifungal therapy (short intravenous antifungal treatment [SHIFT] or long intravenous antifungal treatment [LIFT], respectively) depending on the presence or absence of brain involvement. All patients received step-down posaconazole tablets, debridement, and glycemic control. The primary outcome was the treatment success at week 14, which was determined by assessing survival and the absence of disease progression through clinical evaluation and nasal endoscopy. Log-binomial regression analysis (risk ratio and 95% CI) was performed to assess factors associated with the primary outcome. ResultsIntravenous therapy was administered to 251 participants: SHIFT, 205 (median duration, 13 days); LIFT, 46 (median duration, 22 days). Treatment success at 3 months was 88% (217/248; 95% CI, 83–91%): SHIFT group, 93% (189/203; 89–96%); LIFT group, 62% (28/45; 47–76%). All-cause mortality was 12% (30/251): SHIFT group, 6% (13/205); LIFT group, 37% (17/46). Age (aRR [95% CI]: 1.02 [1.00–1.05]; p 0.027), diabetic ketoacidosis at presentation (2.32 [1.20–4.46]; p 0·012), glycated haemoglobin A1c (1.19 [1.03–1.39]; p 0.019), stroke (3.93 [1.94–7.95]; p 0·0001), and brain involvement (5.67 [3.05–10.54]; p < 0.0001) were independently associated with unsuccessful outcomes. Discussion: Short intravenous amphotericin B with step-down posaconazole tablets should be further studied as primary treatment option for diabetes or COVID-19-associated mucormycosis in randomized controlled trials.

Granulomatous panuveitis in disseminated sporotrichosis: case report and review of the literature

PurposeTo report a case of intraocular sporotrichosis presenting with bilateral granulomatous panuveitis.MethodsObservational case report and literature review.Case presentationA 62-year-old woman with a history of polycythemia vera presented with a non-healing ulcer at the left index finger, generalized erythematous papules, and bilateral granulomatous panuveitis. Cultures of skin and amputated finger identified Sporothrix schenckii. The diagnosis of intraocular sporotrichosis secondary to disseminated sporotrichosis was made. Intravenous liposomal Amphotericin B and intravitreal Amphotericin B were used to control systemic and ocular disease resulting in resolution of the skin lesions and intraocular inflammation.ConclusionsIntraocular sporotrichosis can manifest as bilateral granulomatous panuveitis in the setting of disseminated sporotrichosis. Treatment with intravenous and intravitreal antifungal therapy is useful for controlling intraocular infection.

Successful treatment of fungal central thrombophlebitis by surgical thrombectomy in Korea: a case report

Fungal thrombophlebitis of the central vein is a rare, life-threatening disease associated with significant morbidity and mortality. It requires immediate central venous catheter removal and intravenous antifungal therapy, combined in some cases with either anticoagulation or aggressive surgical debridement. A 70-year-old male patient injured by a falling object weighing 1,000 kg was transferred to our hospital. A contained rupture of the abdominal aorta with retroperitoneal hematoma was treated with primary aortic repair, and a small bowel perforation with mesenteric laceration was treated with resection and anastomosis. After a computed tomography scan, the patient was diagnosed with thrombophlebitis of the left internal jugular vein and brachiocephalic vein. Despite antifungal treatment, fever and candidemia persisted. Therefore, emergency debridement and thrombectomy were performed. After the operation, the patient was treated with an oral antifungal agent and direct oral anticoagulants. During a 1-year follow-up, no signs of candidemia relapse were observed. There is no optimal timing guideline yet for relapsed fungal central thrombophlebitis. Surgical treatment should be considered for early recovery.

Management of Acute Invasive Fungal Sinusitis

Acute invasive fungal sinusitis (AIFS) is an uncommon and usually life-threatening clinical condition. Mortality in AIFS is very high. The colonization of the fungi at the sinonasal tract does not indicate the infection. The status of the immune condition of the patient plays an integral part in different manifestations of AIFS. AISF is an aggressive type of fungal infection and often leads to a fatal situation, particularly in patients who are immunocompromised. Diagnostic nasal endoscopy, as well as a computed tomography scan, is warranted in these patients. Magnetic resonance imaging improves diagnostic accuracy and assesses the spread of the disease into orbit and the brain. Histopathological and microbiological examinations confirm the diagnosis. To save lives, early diagnosis and treatment are essential. Therefore, clinicians need to have a high level of suspicion for this illness. Management of AIFS requires a multidisciplinary approach with significant predictors of survival being surgical debridement and antifungal treatment. Patients require urgent hospitalizations with intravenous antifungal therapy and surgical debridement. As soon as AIFS is identified, antifungal medication should begin. Higher survival rates are achieved with complete endoscopic resection of the disease than with incomplete resection. Liposomal amphotericin B has a more favorable outcome and fewer side effects than amphotericin B. The mainstays of AIFS management continue to be early surgical debridement and antifungal treatment. This review article discusses the epidemiology, etiopathogenesis, clinical features, investigations, and current treatment options of AIFS.

Non-surgical local treatment for pulmonary aspergilloma

Pulmonary aspergilloma (PA) is usually secondary to pulmonary cavities. The main purpose of PA treatment is to prevent life-threatening hemoptysis. Many patients cannot tolerate surgical resection, which is considered the preferred treatment. Oral or intravenous antifungal therapy is less effective because PA usually does not invade the blood vessels of the pulmonary cavity. In this case, arterial embolization, local injection with drugs, and radiation therapy can be considered. This article will summarized various non-surgical local treatments for PA (hemoptysis) to refer clinical decision-making.

Renal mucormycosis presenting during the COVID-19 pandemic: A series of 11 cases from a tertiary care center in India.

Introduction:Renal mucormycosis has been documented to occur even in apparently immunocompetent individuals. Owing to the rarity of this disease, literature on its management is small. We present our experience of diagnosing and managing 11 cases of primary renal mucormycosis who presented during the second wave of the COVID-19 pandemic in India.Methods:We reviewed the records of all patients presenting to our institute with a diagnosis of acute pyelonephritis from March 2021 to September 2021. All patients with a radiological, microbiological, or histopathological diagnosis of renal mucormycosis were included in the analysis and all demographic and clinical details, including a history of COVID-19 disease and its treatment, were noted. All patients were treated by a combination of intravenous antifungal therapy and aggressive surgical debridement including nephrectomy and multivisceral resection as required. Predictors of mortality were evaluated by statistical analysis.Results:A total of 93 patients presented to our hospital with features of acute pyelonephritis of which 11 patients were suspected to have primary renal mucormycosis based on characteristic imaging features and confirmed on microbiological and histopathological examination. Of these, four patients had a history of COVID-19 infection. Only one patient had diabetes mellitus. Ten patients underwent nephrectomy and seven needed resections of surrounding organs. The colon was the most commonly involved organ. Five patients (45.5%) died of progressive sepsis. None of the predictors of mortality that were analyzed showed statistical significance.Conclusion:A high index of suspicion, early cross-sectional imaging, prompt institution of antifungal therapy, and aggressive surgical extirpation are very important for achieving good outcomes in patients of primary renal mucormycosis.

Mucormycosis with Ca Breast Cancer

Mucormycosis is an extraordinary fungal contamination because organisms of Mucorales frequently happening in immunologically or diabetics compromised patients. Best case of number one Mucormycosis of breast is mentioned withinside in the English literature. We can explain another patient of Mucormycosis which is located in breast of patient with no fundamental disease and is well treated with intravenous antifungal therapy &amp; mastectomy. Today, Breast cancer is usually diagnosed life-frightening cancer in women and can cause cancer death in women. Since past two decades, breast cancer research had led to remarkable advances in consideration of the disease, arising in less toxic as well as most effective diagnosis. Improved public understanding and better protection had show to early diagnoses at phases likely to complete surgical incision and healing therapy. As a result, cancer of breast survival rates has increased dramatically ,especially among young women. This article discusses the causes, types, clinical symptoms, and various non-pharmacological (such as radiation therapy and surgery) and pharmacological (including gene therapy, chemotherapy, etc.) approaches to breast cancer.

680. Month Long Fungemia due to Candida auris Endocarditis

Background Candida auris (C. auris) is a multidrug resistant Candida species, reported to cause persistent fungemia along with a multitude of invasive fungal infections. We report the first case of C. auris fungemia due to endocarditis.Methods61 year old man with a history of diverticulitis that required sigmoid resection and was complicated by abdominal abscesses due to multi drug resistant organisms warranting heavy antibiosis. Prolonged hospitalisation for that surgery was followed by a stay at a long term acute care hospital. He was readmitted at an outside hospital with sepsis where blood cultures grew C.auris. Upon evaluation, was found to have aortic valve endocarditis. Per patient’s preference, surgery was initially deferred. Despite escalation of therapy with a combination of antifungals, he remained fungemic for five weeks with repeat blood cultures showing changing antifungal susceptibility patterns. Patient eventually underwent surgical intervention at our facility, with valve cultures being positive for C.auris. After the surgery he was treated with 6 weeks of intravenous combination antifungal therapy.Results C.auris’s pathogenicity stems from multiple mechanisms with multi drug resistance being most pertinent. What adds to the complexity of the management is the absence of C.auris specific minimum inhibitory concentration breakpoints. Therefore treatment is based on Center for Disease Control’s (CDC) proposed breakpoints that have been extrapolated from other Candida spp. It is further complicated by lack of C.auris specific data showing essential agreement among different commercially available antifungal susceptibility testing (AFST). Heteroresistance of the microbial population is an issue that must be considered in such protracted fungemia. ConclusionInvasive infections due to Candida auris presents as a diagnostic and therapeutic challenge to clinicians. Disclosures All Authors: No reported disclosures

RADICAL TREATMENT FOR BLASTOMYCOSIS FOLLOWING FAILED LIPOSOMAL AMPHOTERICIN

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary blastomycosis is a respiratory disease that is caused by the fungus Blastomyces, most commonly through inhalation of the fungal spores. Infected individuals typically show symptoms 3 weeks to 3 months after inhalation of these spores. About 50% of patients with pulmonary blastomycosis are asymptomatic. Individuals with severe blastomycosis are initially treated with intravenous antifungal therapy with Amphotericin followed by long-term itraconazole maintenance therapy. CASE PRESENTATION: We present the case of an immunocompetent young male who was diagnosed with pulmonary Blastomyces dermatitidis and had poor clinical response to 10 days of liposomal Amphotericin B (L-AmB). Due to persistent hypoxia and hypoxemia, the patient was endotracheally intubated and extracorporeal membrane oxygenation (ECMO) was initiated. Due to the poor response to L-AmB, L-AmB was discontinued in favor of continuous infusion of amphotericin B deoxycholate (AmB-d). Additionally, the patient was started on a short course of corticosteroids. With the combination of these treatments, the patient had significant clinical improvement. The patient was taken off ECMO on day 9 and extubated on day 12 after the initiation of AmB-d. DISCUSSION: Literature review yielded limited information regarding treating blastomycosis with a continuous AmB-d infusion. To our knowledge, this is the third case reported in the literature of the use of continuous AmB-d infusion for the treatment of severe blastomycosis. ARDS due to blastomycosis has a mortality of up to 80% with the standard of treatment in such severe cases being liposomal amphotericin. Given that ECMO and AmB-d infusion were started concurrently, it is unclear if the significant improvement was due to the decrease in burden on the respiratory system by ECMO or due to AmB-d infusion demonstrating higher effectiveness compared to liposomal amphotericin B, or a combination of both. A case reported by Branick, K et al. discusses a patient on ECMO treated with L-AmB without improvement until AmB-d continuous infusion was started. Even though they attributed the treatment failure to clogging of the ECMO circuit by L-AmB, their belief was that ECMO is not an effective means to treat Blastomycosis and therefore, believed that the patient improvement was solely due to AmB-d infusion. CONCLUSIONS: While L-AmB is considered first line treatment for blastomycosis, the mortality remains high in those with ARDS associated with blastomycosis. This case demonstrates the importance of considering AmB-d in patients with severe blastomycosis who may have poor response to L-AmB. ECMO and steroids were also included in the patient's treatment plan which may have contributed to the patient's improvement. In a disease process with such high mortality rates, the need for continued evaluation of treatment options is crucial given the limited treatment options currently available. REFERENCE #1: Branick K, Taylor MJ, Trump MW, Wall GC. Apparent interference with extracorporeal membrane oxygenation by liposomal amphotericin B in a patient with disseminated blastomycosis receiving continuous renal replacement therapy. Am J Health Syst Pharm. 2019;76(11):810-813. REFERENCE #2: Meyer KC, McManus EJ, Maki DG. Overwhelming pulmonary blastomycosis associated with the adult respiratory distress syndrome. N Engl J Med. 1993;329(17):1231-1236. REFERENCE #3: Lahm T, Neese S, Thornburg AT, Ober MD, Sarosi GA, Hage CA. Corticosteroids for blastomycosis-induced ARDS: a report of two patients and review of the literature. Chest. 2008;133(6):1478-1480. DISCLOSURES: No relevant relationships by Christopher Chew, source=Web Response No relevant relationships by Henry Ogbuagu, source=Web Response No relevant relationships by Dhaval Patel, source=Web Response No relevant relationships by Nikhilesh Thapa, source=Web Response No relevant relationships by Merin Varghese, source=Web Response

Sino Cranial Aspergillosis Mimicking Skull Base Meningioma- A Case Report and Review of Literature

Fungal infections of the nose and paranasal sinuses can be categorised into invasive and noninvasive forms. Central Nervous System (CNS) Aspergillosis is extremely rare in immunocompetent individuals. Invasive fungal sinusitis affecting CNS commonly poses a diagnostic dilemma on imaging, often confused with neoplastic processes. Here, Authors report a case of invasive sino cranial aspergillosis in immunocompetent individual mimicking a meningioma on imaging. A 46-year-old male patient presented with history of seizure like episode and right eye proptosis to Neurology Department. On Magnetic Resonance Imaging (MRI), there was enhancing T2 weighted hypointense extra-axial mass lesion along right frontal convexity with associated osseous erosion, intraorbital extension and associated sinus disease. Based on clinical presentation and imaging features, initial diagnosis of a aggressive neoplastic lesion was made. Patient subsequently underwent biopsy which showed fungal elements of Aspergillus Fumigatus species. Patient underwent endoscopic sinus surgery and along intravenous and oral antifungal therapy with good response to treatment. This case highlights the key role of imaging including MRI and CT in making accurate diagnosis of fungal sinusitis especially in immunocompetent individuals and differentiate from other entities like meningioma.

Orbital mucormycosis in immunocompetent children; review of risk factors, diagnosis, and treatment approach

BackgroundOrbital mucormycosis is a rare but potentially severe and troublesome invasive fungal infection that could be occurred even in healthy individuals. The initial clinical presentation is similar to bacterial pre-septal or septal cellulitis, especially in early stages.Case presentationHerein, we describe the successful management of a series of five cases presenting with orbital mucormycosis in previously healthy children.ConclusionsOrbital mucormycosis is extremely rare in healthy children and maybe life-threatening when diagnosis delayed given a similar clinical presentation with bacterial septal cellulitis. Intravenous antifungal therapy with amphotericin B and timely surgical drainage is live-saving.

Breakthrough of invasive fungal disease with posaconazole as primary prophylaxis after induction chemotherapy for acute myeloid leukemia

Objective: To investigate the breakthrough incidence of invasive fungal disease(IFD) and side effects of posaconazole as primary prophylaxis during induction chemotherapy for acute myeloid leukemia(AML). Methods: A total of 206 newly diagnosed AML patients admitted to our department during January 2016 and December 2018 were enrolled in the study. Exclusive criteria were as followings including patients diagnosed as acute promyelocytic leukemia; those who received intravenous antifungal therapy after admission or had history of IFD one month before induction chemotherapy, or those with functional insufficiency of vital organs and those older than 65. Forty-seven patients received posaconazole (posaconazole group), 61 cases received voriconazole (voriconazole group) and 98 cases did not receive any prophylaxis (control group) during induction chemotherapy. Prophylactic efficacy and safety between posaconazole and voriconazole were compared. Results: During induction chemotherapy, five possible cases of IFD occurred in posaconazole group (10.6%); while 11 cases (18.0%) were in voriconazole group including 7 possible, 3 probable and 1 proven. Thirty-five cases (35.7%) in control group were diagnosed as IFD including 19 possible, 11 probable and 5 proven ones. The incidences of IFD in posaconazole and voriconazole group were significantly lower than that in control group (P<0.05). The difference of posaconazole group and voriconazole group was not significant (P>0.05). The reported adverse events in posaconazole group were significantly lower than those in voriconazole group [12.8%(6/47) vs. 32.8%(20/61), P<0.05]. Conclusions: Posaconazole and voriconazole decrease IFD as primary prophylaxis during induction chemotherapy in patients with AML. The prophylactic effect of IFD with posaconazole is similar as voriconazole, but posaconazole shows better safety.

Pulmonary aspergillosis is a rare finding in diabetic patients: a case report

Background: Aspergillosis is an infection caused by a common mold (type of fungus) named Aspergillus. Its spores are present in air but usually do not cause any disease in immune-competent people. However, it can cause various types of diseases, which most commonly involve the respiratory system. Early recognition and treatment are important for better outcomes. Case Presentation: A middle-aged diabetic male presented with high blood glucose levels leading to hyperosmolar hyperglycemic non-ketotic coma and was treated accordingly. His baseline chest X-ray showed reticulo-nodular shadowing and cavitatory lesion in left middle zone and was being treated on the lines of pneumonia. After 4 days of treatment, the patient did not improve and had had contrast enhanced CT-scan chest showing a reverse halo sign along with a fungal ball in the lung cavity. His white blood cells were increased, erythrocyte sedimentation rate was normal, and sputum for acid-fast bacilli was negative, but positive for Aspergillus species. Conclusion: Diagnosis of pulmonary aspergillosis was made and the patient was managed accordingly with intravenous antifungal therapy. Early diagnosis and treatment is necessary.

P238 Chemotherapy venous access port endocarditis in a patient with breast cancer

Abstract Funding Acknowledgements No funding Background/Introduction Right sided infective endocarditis (IE) accounts for less than 10% of all IE cases. Predisposing factors include portal of entry, implanted foreign material and unrepaired congenital heart disease with conduit. Fungal endocarditis (FE) constitutes the most severe form of IE and is etiologically connected predominantly to Candida and Aspergillus species. Among these two agents, Candida species is a common nosocomial infection with increasing prevalence and mortality rates up to 40% in cases of systemic candidiasis. Individuals with different forms of solid or hematological malignancies, under chemotherapy regimens or bone marrow transplantation comprise a particularly susceptible patient population. Case presentation A 58 year old woman with personal history of triple negative breast adenocarcinoma stage IV under palliative chemotherapy, administered for metastatic mass riknosis in the gastrointestinal tract, was admitted to the Emergency Department of our Hospital due to persistent fever, malaise and dyspnea on effort. Chemotherapy was infused via an implantable venous access port (intraport catheter). Methods/Results: Her heart auscultation revealed a holosystolic ejection type murmur of 3/6 located in the third intercostal space of changing quality. Candida tropicalis was isolated in three separate blood cultures. Transthoracic echocardiography demonstrated a good overall left ventricular systolic function. The right cavities were moderately dilated with moderate tricuspid regurgitation and a pulmonary pressure estimated at 45 mmHg. A large vegetation (approximately 2 cm maximal diameter) at the atrial surface of the posterior and diaphragmatic leaflets of the tricuspid valve with parts of the vegetation periodically apparent in the right ventricle was observed. Transesophageal echocardiography confirmed the findings of the transthoracic study and elucidated in the bicaval view the connection of the vegetation in the tricuspid valve with the edge of the intraport catheter. Moreover computed tomography scan revealed multiple pulmonary emboli in the segmental branches of the bronchial tree and a circumscribed peripheral pulmonary infarct of the left inferior lobe. A multidisciplinary team concluded that the best treatment strategy would require aggressive intravenous combined antifungal therapy until eradication followed by removal of the implantable venous access port, which was uncomplicated. Conclusions The majority of fungal endocarditis episodes represented healthcare-associated infections in vulnerable subsets of patients. Treatment of Candida endocarditis can prove challenging because of the formation of biofilms on prosthetic devices often requiring combination therapy. Septic pulmonary embolism with multiple loci is a frequent complication in right sided infective endocarditis. Removal of the prosthetic device if feasible in addition to antifungal treatment is linked to a more favorable prognosis. Abstract P238 Figure. Chemotherapy intraport endocarditis

Isolated Renal Mucormycosis in Immunocompetent Hosts: Clinical Spectrum and Management Approach.

Isolated renal mucormycosis in immunocompetent hosts is a rare entity. We present the largest case series of isolated renal mucormycosis in immunocompetent hosts. Retrospective data of isolated renal mucormycosis from March 2012 to June 2017 was reviewed. Fifteen patients of isolated renal mucormycosis were identified. Contrast-enhanced computed tomography scan showed enlarged globular kidneys with decreased or patchy enhancement, perinephric stranding and thickened Gerota's fascia in all patients. Ten patients with unilateral involvement underwent nephrectomy and two of four patients with bilateral renal mucormycosis underwent bilateral nephrectomy. Two patients were managed with intravenous antifungal therapy alone. Overall, the mortality rate in our series was 40% (6/15). Isolated renal mucormycosis in healthy immunocompetent hosts is an emerging new entity. Prompt diagnosis based on the characteristic clinical and radiological picture and starting high-dose antifungal therapy at least 24 hours before surgical debridement offer the best chance of survival in these patients.

Can intravenous antifungal therapy be safely used in the outpatient parenteral antimicrobial therapy (OPAT) setting?

Outpatient parenteral antimicrobial therapy (OPAT) is an established treatment option for patients with a variety of infections who require a period of intravenous therapy, are clinically stable, and do not require continuous monitoring. Many patients with fungal infections require prolonged therapy due to resistance or intolerance to oral antifungal agents. Despite the widespread use of OPAT by infection specialists, antifungal agents appear infrequently used in this setting. We suggest that with appropriate patient selection, patients with fungal infections could successfully be treated on OPAT.

Massive Pneumoperitoneum

A 72-year-old man with a past medical history of pancreatic adenocarcinoma status post biliary and duodenal stent placement presented to the emergency department for one week of cramping abdominal pain in the setting of a surveillance abdominal/pelvis computed tomography (CT) scan done two days prior to admission that showed massive pneumoperitoneum (Figure 1). The patient felt bloated but otherwise had no complaints on presentation. His physical exam was significant for marked abdominal distension with mild diffuse tenderness on palpation, normal bowel sounds, and no peritoneal findings of guarding or rebound. Given concern for perforated viscus causing pneumoperitoneum, he was started on intravenous antibiotics and antifungal therapy. Repeat CT scan on admission demonstrated patent biliary and duodenal stents and no definite source of perforation. The patient remained hemodynamically stable throughout his hospitalization; he continued to have regular bowel movements daily and eventually tolerated a diet. His abdominal distension and pain gradually improved without any surgical intervention, and he was discharged home six days after admission to complete 7 days of oral fluconazole, levofloxacin, and metronidazole. It was thought that this patient most likely had a perforated viscus that sealed off. A CT scan two months later showed complete resolution of the pneumoperitoneum.