Krusei Fungemia Research Articles

Cutaneous presentation of Candida krusei fungemia refractory to amphotericin B

Pediatric Blood & CancerEarly View e30366 LETTER TO THE EDITOR Cutaneous presentation of Candida krusei fungemia refractory to amphotericin B Michelle Toker, Corresponding Author Michelle Toker [email protected] orcid.org/0000-0002-6513-9033 Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA Correspondence Michelle Toker, Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Ave, Bronx, NY, 10461, USA. Email: [email protected]Search for more papers by this authorCarson Kirkpatrick, Carson Kirkpatrick Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USASearch for more papers by this authorPooja Srivastava, Pooja Srivastava Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USASearch for more papers by this authorBijal Amin, Bijal Amin Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USASearch for more papers by this authorBenedict Wu, Benedict Wu Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USASearch for more papers by this author Michelle Toker, Corresponding Author Michelle Toker [email protected] orcid.org/0000-0002-6513-9033 Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA Correspondence Michelle Toker, Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Ave, Bronx, NY, 10461, USA. Email: [email protected]Search for more papers by this authorCarson Kirkpatrick, Carson Kirkpatrick Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USASearch for more papers by this authorPooja Srivastava, Pooja Srivastava Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USASearch for more papers by this authorBijal Amin, Bijal Amin Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USASearch for more papers by this authorBenedict Wu, Benedict Wu Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USASearch for more papers by this author First published: 19 April 2023 https://doi.org/10.1002/pbc.30366Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issuee30366 RelatedInformation

P357 Update on risk factors for Candida krusei-Fungemia

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PMInstitut für Medizinische Mikrobiologie der Universitätsmedizin Essen, Robert Koch Haus, Virchow Straße 179, 45147 Essen, GermanyObjectivesInfection with Candida species have been an increasing threat to hospital patients worldwide. During the last decade research has shown high mortality rates associated with candidemia and progressing drug resistance to NAC (non-albicans Candida) species. This study aims to solidify risk factors for C. krusei fungemia.Patients and MethodsWe retrospectively analyzed patient data with at least one C. krusei or C. albicans positive blood culture at Essen University Hospital between 2008–2020.Relevant categories consisted of age, gender, underlying condition, central venous catheters (CVC), steroids, leukopenia <4000/μl, diabetes, antifungal treatment, hospital ward, and outcome.We used the Chi-Squared test to compare categorical valuables. P-values were considered significant <.05 and highly significant <.01.ResultsFrom 1380 patients who tested positive for Candida spp. between 2008–2020, 40 were positive for C. krusei and 786 for C. albicans. Candida albicans presented as the leading species (57.0%), followed by C. glabrata (23.5%), C. parapsilosis (5.8%), C. tropicals (5.1%), and C. krusei (2.9%). A total of 67.6% of patients were located at ICU. Incidence rates for Candida positive blood cultures increased from 1.0% to 10.0%. Candida krusei was most common in patients 51–60 years of age.In both groups, overall survival was identical (52.2% C. krusei/54.3% C. albicans). For C. krusei correlation between outcome and antifungal treatment was highly significant (P .044). A total of 20% more C. krusei infected hemato-oncology patients died than in the C. albicans group (62.5% C. krusei/46.5% C. albicans). In all, 60.0% of C. krusei patients on ICU died. In the C. krusei group all patients with CVC died and all patients without survived.Conclusion Candida-positive blood cultures increased from 1% in 2008 to 10% in 2020.Three major risk factors for C. krusei fungemia were found: CVC, hemato-oncology malignancies, and leukocytopenia.

Breakthrough Invasive Fungal Infections (bIFI) Are Uncommon in Patients with Newly Diagnosed Acute Leukemia Receiving Primary Antifungal Prophylaxis

Introduction: Mold-active primary antifungal prophylaxis (PAP) is widely recommended in neutropenic patients (pts) with newly diagnosed acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS) who undergo remission-induction chemotherapy (RIC). Posaconazole (PCZ) prophylaxis resulted in fewer invasive fungal infections (IFIs) when compared to fluconazole and was associated with a survival advantage in this population (Cornely et al, 2007). Similarly, pts with acute lymphoblastic leukemia (ALL) undergoing RIC are also at risk of IFI due to prolonged neutropenia. Although PCZ is the preferred agent for PAP, the incorporation of targeted agents into acute leukemia therapy calls for more individualized choices in PAP. Other mold-active agents including voriconazole (VCZ) and isavuconazole (ISA) or the echinocandins are alternatives which may be preferred in individual settings due to variations in toxicity, patient co-morbidities, drug interactions, and cost. Little contemporary data exists to compare the incidence of breakthrough IFI (bIFIs) in pts with AML or ALL receiving PCZ, VCZ, or ISA as prophylaxis during RIC. Methods: We reviewed the medical records of all consecutive pts with newly diagnosed AML/MDS or ALL treated at our institution from 3/2016-7/2019. Included pts received high-intensity chemotherapy, or a lower-intensity venetoclax (VEN)-containing regimen, for RIC. Therapy with high-dose (&amp;gt; 1g/m2/day) cytarabine (HiDAC), continuous cytarabine plus an anthracycline (3+7), or HyperCVAD was considered high-intensity therapy. Patients receiving PCZ, VCZ, or ISA for &amp;gt; 5 days beginning during induction therapy were included. Baseline evidence of prior mold infection and treatment with a concomitant echinocandin were not allowed. Echinocandin use preceding mold-active PAP was allowed, however prior use of an amphotericin B product was not. bIFI were defined according to ECMM criteria (Cornely et al, 2019). Results: We identified 232 pts with AML/MDS (n=186), ALL (n=43), and biphenotypic leukemia (n=3). Among the AML/MDS pts, 31% (n=57) received a lower-intensity VEN-containing regimen, while 69% (n=129) received a high-intensity regimen with or without VEN. Nearly all pts with ALL and biphenotypic leukemia received high-intensity RIC with HyperCVAD or a HiDAC containing regimen. Of the 232 pts, PCZ (n=111), VCZ (n=84), or ISA (n=37) were used as PAP, respectively (Table 1). Most pts (n=157; 68%) received an echinocandin for a median of 6 days (range, 0-38), prior to transitioning to a mold-active triazole. Ten (4.3%) pts had a bIFI (6 proven, 1 probable, 3 possible) during induction therapy while receiving PAP (Table 2) including 9 (4.8%) pts with AML/MDS and 1 (2.3%) patient with ALL. An equal number of pts with bIFI were receiving lower-intensity, VEN-based therapy, or high-intensity therapy. Among the 84 pts receiving VCZ, 4 (4.8%) had a bIFI (4 proven); 3 pts (2.7%) receiving PCZ had a bIFI (2 proven, 1 possible); 3 pts (8.1%) receiving ISA had a bIFI (1 probable, 2 possible). C. glabrata (n=3), and C. krusei, Cryptococcus spp. and Fusarium spp. (one each) accounted for the 6 proven bIFIs. One patient had both C. glabrata and C. krusei fungemia. The probable bIFI was pneumonia with a positive Aspergillus GM from BAL. The 3 possible bIFI were pneumonia (n=2) and sinusitis (n=1). Eight pts (80%) were neutropenic (ANC &amp;lt; 500 cells/mm3) for &amp;gt;14 days at the time of bIFI, 1 pt was neutropenic for &amp;gt;7 days, and 1 pt had ANC &amp;gt; 500 cells/mm3. Seven pts with bIFI received a prior echinocandin for a median of 3 days (range, 0-15) prior to initiation of triazole PAP. Seven pts were neutropenic for &amp;lt; 7 days (n=2), 7-14 days (n=3), or &amp;gt; 14 days (n=2) at the time of azole initiation. bIFI occurred after a median of 20 days (range, 5-72) of azole PAP and a median of 24 days (range, 12-71) from the initiation of RIC. One patient with bIFI deceased within 42 days of starting RIC and did not achieve a response after RIC (bIFI-related mortality: 0.44%). Conclusion: The incidence (&amp;lt;5%) and mortality (&amp;lt; 0.5%) due to bIFI in a contemporary cohort of pts with newly diagnosed acute leukemia receiving PAP is low. bIFI occurred late in induction therapy and most often in pts with &amp;gt; 14 days of neutropenia. Prophylaxis with VCZ, PCZ, or ISA, with or without a prior echinocandin, appear to be comparable options for PAP in pts with newly diagnosed AML or ALL undergoing RIC. Disclosures Bose: CTI BioPharma: Honoraria, Research Funding; Astellas Pharmaceuticals: Research Funding; Celgene Corporation: Honoraria, Research Funding; Constellation Pharmaceuticals: Research Funding; Kartos Therapeutics: Honoraria, Research Funding; Incyte Corporation: Consultancy, Honoraria, Research Funding, Speakers Bureau; Promedior, Inc.: Research Funding; Pfizer, Inc.: Research Funding; NS Pharma: Research Funding; Blueprint Medicines Corporation: Honoraria, Research Funding. Kontoyiannis:Gilead Sciences: Honoraria; United Medical: Honoraria; Astellas Pharma: Consultancy; Cidara Therapeutics: Consultancy; Amplyx Pharmaceuticals: Consultancy; Mayne Pharma: Consultancy; Pharma Pharmaceutical Industries: Consultancy; Merck &amp; Co.: Consultancy, Honoraria. OffLabel Disclosure: Voriconazole and isavuconazole are approved for the treatment of invasive fungal infections rather than the prevention, as discussed in this abstract.

Folliculocentric cutaneous presentation of disseminated Candida krusei infection in a patient with acute myeloid leukemia

Candida krusei (C. krusei) is a multidrug-resistant opportunistic fungal pathogen that may cause disseminated infections in immunocompromised hosts. However, its clinical and histologic features are not well-characterized. We present a unique case to contribute to the growing knowledge base associated with this organism. During hospitalization for neutropenic fever, a 19-year-old man with acute myeloid leukemia, who underwent hematopoietic stem cell transplantation, developed a generalized folliculocentric eruption following initiation of antifungal therapy for newly diagnosed C. krusei fungemia. Despite adequate antifungal coverage and negative blood cultures, the follicular-based erythematous papules persisted. Biopsies demonstrated yeast within ruptured follicles, without angiotropism or involvement of the interfollicular dermis, subcutaneous tissue, or stratum corneum. Concurrent skin tissue cultures confirmed C. krusei. The patient remained febrile despite aggressive antifungal therapy, with relapse of leukemia and subsequent death. Our case is unusual given the development of cutaneous lesions following clearance of fungemia, with yeast limited to ruptured follicular lumina, possibly indicating a primary cutaneous source or early transfollicular/transepidermal elimination. Given the limited available descriptions of cutaneous histopathology for C. krusei, we seek to add to the understanding of its pathophysiology and aid in the diagnosis and treatment of this often fatal infection.

Candida krusei Arthritis in an Adolescent With Acute Myelogenous Leukemia

We report a case of Candida krusei arthritis in an adolescent with secondary acute myelogenous leukemia, who underwent an allogeneic bone marrow transplant complicated by C. krusei fungemia 4 months before her presentation. The infection was successfully treated with voriconazole.

Treatment of fungal myositis with intra-lesional and intravenous itraconazole: a case report

IntroductionFungal myositis is very uncommon, even in patients who are immunocompromised. Because of its rarity and a lack of clinical experience, no consensus has been reached about the best means of treating fungal myositis. To the best of our knowledge this is the first description of the treatment of fungal myositis with simultaneous intravenous and intra-lesional itraconazole.Case presentationA 35-year-old Chinese woman with acute myelomonocytic leukemia developed Candida krusei fungemia and fungal myositis in the right biceps brachii after chemotherapy. A course of intravenous itraconazole and subsequently intravenous voriconazole was initiated and her blood cultures became sterile; however, our patient remained febrile and the myositis did not resolve. Intravenous itraconazole was restarted simultaneously with low-dose intra-lesional itraconazole. The pyrexia settled after 48 hours and within 10 days the lesion could be seen to be resolving. After the course of intravenous and intra-lesional anti-fungals was complete, oral itraconazole was administered as maintenance therapy.ConclusionsTo the best of our knowledge this is the first case in which fungal myositis was successfully treated with intravenous and intra-lesional itraconazole in a patient with acute myelomonocytic leukemia. The efficacy and safety of locally-administered itraconazole to treat intractable soft tissue infections requires further evaluation.

Successful Treatment With Caspofungin of Refractory Candida krusei Candidemia in a Very Low Birth Weight Preterm Infant

To the Editors: Candida krusei is an emerging nonalbicans Candida species recognized as a potentially multidrug resistant fungal pathogen.1 The incidence of C. krusei fungemia is highest in leukemic patients and less frequent in neonates.2 We report the first case of refractory candidemia by C. krusei successfully treated with caspofungin in a premature infant. CASE REPORT A 1160 g male infant was delivered vaginally at 26 weeks of gestational age. His mother had been admitted 5 days earlier to our institution for preterm premature rupture of membrane and had received steroids and antibiotic therapy. The infant did not need respiratory support or supplemental oxygen after delivery. An umbilical venous catheter was placed and empiric ampicillin plus gentamicin therapy instituted. On day 4, fluconazole prophylaxis (3 mg/kg twice a week) was begun. On day 5, a percutaneous inserted central catheter (PICC) was placed, and the umbilical catheter was removed. On day 17, a peripheral blood culture was performed because of the appearance of thrombocytopenia, apnea, hyporeactivity, and fever; the infant required intubation and mechanical ventilation. The PICC was removed and replaced with a new one at another site. Two days later, C. krusei colonies grew from the day 17 blood culture. Based on antifungal susceptibility testing, liposomal amphotericin-B (LAmB, 3 mg/kg/d), already started on day 17, was continued and fluconazole was discontinued. One week later, LAmB was increased to 5 mg/kg/d after a second blood culture was positive for C. krusei. Renal and cerebral ultrasound, echocardiogram, and eye examinations were repeatedly normal. Chest radiograph and liver ultrasound were suggestive of Candida end-organ dissemination. On day 41, after 22 days of LAmB treatment and with a third positive blood culture, caspofungin was added in a dosage of 50 mg/m2/d (7 mg/d), without a loading dose. The infant had a prompt improvement; thrombocytopenia (previously requiring 11 platelet transfusions) resolved, and 5 days later the infant was extubated and resumed enteral nutrition. The PICC was removed. LAmB was discontinued after 5 days of combined therapy. Blood cultures performed on the 6th and 11th days of caspofungin treatment were negative. The infant, already suffering cholestasis [total bilirubin, 4.7 mg/dL, direct bilirubin, 2.5 mg/dL, alanine aminotransferase (ALT), 54 U/L, aspartate aminotransferase (AST), 140 U/L], showed acute liver failure since the 3rd day of caspofungin therapy. The dosage of caspofungin was reduced to 5 mg/d and 3.5 mg/d on 4th and on 11th day of therapy, respectively. Treatment lasted 12 days. Liver enzymes peaked at 346 (ALT) and 744 (AST) 3 days after caspofungin withdrawal to normalize thereafter in 2 months. Elevation of liver enzymes and direct bilirubin values during caspofungin therapy has been previously reported in neonates.3 The infant is now 6 months old, is thriving well and shows normal neurologic development at the ongoing follow-up. Fabio Natale, MD Antonella Castronovo, MD Daniela Regoli, MD Mario De Curtis, MD Department of Pediatrics “La Sapienza” University of Rome Rome, Italy Paolo Manzoni, MD Division of Neonatology and NICU S. Anna Hospital Turin, Italy

Blood Stream Infections by Candida glabrata and Candida krusei: A Single-Center Experience

Background/AimsThe increasing incidence of Candida glabrata and Candida krusei infections is a significant problem because they are generally more resistant to fluconazole. We compared the risk factors associated with C. glabrata and C. krusei fungemia with Candida albicans fungemia and examined the clinical manifestations and prognostic factors associated with candidemia.MethodsWe retrospectively reviewed demographic data, risk factors, clinical manifestations, and outcomes associated with C. glabrata and C. krusei fungemia at a tertiary-care teaching hospital during a 10-years period from 1997 to 2006.ResultsDuring the study period, there were 497 fungemia episodes. C. glabrata fungemia accounted for 23 episodes and C. krusei fungemia accounted for 8. Complete medical records were available for 27 of these episodes and form the basis of this study. Compared to 54 episodes of C. albicans fungemia, renal insufficiency and prior fluconazole prophylaxis were associated with development of C. glabrata or C. krusei fungemia. The overall mortality was 67%. The fungemia-related mortality of C. glabrata and C. krusei was higher than that of C. albicans (52 vs. 26%, p=0.021). Empirical antifungal therapy did not decrease the crude mortality. Multiple logistic regression analysis showed that high APACHE II scores, catheter maintenance, and shock were independently associated with an increased risk of death.ConclusionsRenal insufficiency and prior fluconazole prophylaxis were associated with the development of C. glabrata or C. krusei fungemia. Fungemia-related mortality of C. glabrata or C. krusei was higher than that of C. albicans. Outcomes appeared to be related to catheter removal, APACHE II scores, and shock.

Successful treatment ofCandida kruseifungemia with amphotericin B and caspofungin

We report a leukemic patient with C. krusei fungemia who failed to respond to liposomal amphotericin B therapy alone. The addition of caspofungin eradicated infection and was well tolerated. Our report is the first to describe successful treatment of a patient with invasive C. krusei infection using this combination of antifungals. Combination therapy could be a useful treatment option for invasive candidosis, particularly when caused by more resistant species such as C. krusei.

Candida krusei fungemia in an unrelated allogeneic hematopoietic stem cell transplant patient successfully treated with Caspofungin

Candida krusei fungemia in an unrelated allogeneic hematopoietic stem cell transplant patient successfully treated with Caspofungin

SepticCandida kruseithrombophlebitis of inferior vena cava with persistent fungemia successfully treated by new antifungal agents

Treatment of Candida krusei fungemia can be problematic. We describe a 44-year-old critically ill, non-immunocompromised patient who had persistent Candida krusei fungemia complicated with septic thrombophlebitis of the inferior vena cava. Successful treatment was achieved by parenteral caspofungin followed by prolonged oral voriconazole. Persistent fungemia in the face of ongoing antifungal therapy and prompt removal of central line should alert physicians to the diagnosis of septic thrombophlebitis. Though combined therapy with amphotericin B and surgical intervention probably remains the treatment of choice, prolonged new antifungal agents, which have better efficacy, tolerability and bioavailability, may be a useful alternative where the central veins are relatively inaccessible or the patient is at high operative risk.

Incidence and Management of Proven and Probable Fungal Infections in Patients with Acute Leukemia: A Single Center Experience

The incidence of fungal infections and the role of liposomal amphotericin B (Ambisome) in proven and probable infections were evaluated in acute leukemic patients, intolerant to conventional amphotericin B. During 1999-2002, 307 febrile episodes occurred in 231 patients. Fungi were responsible for 3% of bloodstream infections. Ambisome was employed in 5 fungal sepsis (1 Candida albicans, 1 C. famata, 1 C. tropicalis, 1 C. krusei, 1 Geotrichum capitatum) 2 Aspergillosis, 2 probable fungal pneumonia cases. A favorable response was achieved in 78% of patients (4 fungemia, 2 aspergillosis, 1 probable), an unfavorable response in 1 C. krusei fungemia and in 1 probable pneumonia. Our antimicrobial pattern docu-mented a high resistance rate to azoles. We concluded that Ambisome is an effec-tive and well tolerated agent and its introduction has changed the outcome for many patients, although in some refractory diseases other strategies must be con-sidered.

Candida glabrata and Candida krusei fungemia after high-risk allogeneic marrow transplantation: no adverse effect of low-dose fluconazole prophylaxis on incidence and outcome

Candidemia is a serious complication in patients following allogeneic blood, marrow, and organ transplantation. Fourteen patients developed nosocomial fungemia among 204 allogeneic marrow transplants performed during 1997-1999. Incidence of hematogenous candidiasis was 6.8 per 100 allogeneic BMT. All 14 had an indwelling central venous catheter (CVC) and fluconazole (100-200 mg daily) was given prophylactically. In 11 (78.5%) neutropenic patients, duration between agranulocytosis and diagnosis of fungemia was (median, +/- s.d.) 10 +/- 8 days. Candida glabrata (53.3%) was the most common yeast species, followed by C. krusei (33.3%), and C. parapsilosis (13.3%). Candida albicans was conspicuously absent. Ten patients (71.4%) had primary transplant-related complication (>2 days) including hemolytic uremic syndrome/thrombotic thrombocytopenic purpura (HUS/TTP) (n = 5), severe hemorrhagic cystitis (n = 3), and bacteremia (n = 2). Seven (50.0%) patients expired and in three (21.4%) deaths were attributed to fungemia. The impact of a primary transplant-related complication on short-term survival in this setting was not significant (P = 0.07) (HUS/TTP (P > 0.5); neutropenia (P > 0.5); GVHD (P = 0.35)). Removal of CVC did not alter outcome in our group (P > or = 0.5) although in patients with persistent fungemia (>72 h), and those with preceding bacteremia, mortality was significantly higher (P = 0.002). Conventional prognosticators of poor outcome did not adversely effect short-term survival in our transplant recipients with hematogenous candidiasis. The predominance of C. glabrata and C. krusei breakthrough infections was similar to what is seen with high-dose fluconazole (400 mg) prophylaxis, and no adverse effects of low-dose fluconazole in terms of increased incidence of non-susceptible Candida species was seen.

Candida krusei fungemia. An escalating serious infection in immunocompromised patients.

Candida krusei is inherently resistant to fluconazole and is emerging as a frequent cause of fungemia in patients with hematologic malignant neoplasms. To determine the risk and prognostic factors associated with C krusei fungemia in comparison with Candida albicans fungemia in patients with cancer. Retrospective study of 57 cases of C krusei fungemia occurring at the M. D. Anderson Cancer Center, Houston, Tex, from 1989 to 1996. The C krusei cases were compared with 57 cases of C albicans fungemia with respect to demographics, underlying cancer, Acute Physiology and Chronic Health Evaluation II score, immunosuppression status, chemotherapy, and the use of central venous catheters, as well as fluconazole prophylaxis. At our institution, C krusei accounted for 5% of fungemias during 1989 through 1992 and for 10% during 1993 through 1996. Patients with C krusei fungemia more often had leukemia than patients with C albicans (77% vs 11%; P =.02), whereas catheter-related infections were more common among patients with C albicans fungemia (42% vs 0%; P<.001). Patients with C krusei fungemia had a lower response rate (51% vs 69%; P =.05), largely because they more frequently were neutropenic and had disseminated infection. Mortality related to fungemia was 49% in the cases with C krusei vs 28% in C albicans. Multiple logistic regression analysis showed that persistent neutropenia (P =.02) and septic shock (P =.002) were predictors of poor prognosis. In neutropenic patients, C krusei fungemia is associated with high mortality. It should be suspected in patients with leukemia who are receiving fluconazole prophylaxis and should be treated aggressively with an amphotericin B regimen.

Nosocomial Candida krusei Fungemia in Cancer Patients: Report of 10 Cases and Review

The risk factors, therapy and outcome of ten cases of fungemia due to Candida krusei, appearing during the last 10 years in a single national cancer institution, are analyzed. Univariate analyses did not find any specific risk factors in comparison to 51 Candida albicans fungemias appearing at the same institution and with a similar antibiotic policy. Association with prior fluconazole prophylaxis was not confirmed because only one case appeared in a patient previously treated with fluconazole. Howewer, attributable and crude mortality due to C. krusei fungemias was higher than for C. albicans fungemia. The authors review 172 C. krusei fungemias published within the last 10 years to compare with the incidence, therapy and outcome of C. krusei fungemia from our cancer institute.

Molecular typing for investigating an outbreak of Candida krusei

Invasive infections due to Candida krusei are often observed in immunocompromised patients who have received prior therapy with fluconazole, although infection has also occurred in patients in the absence of this antifungal agent. From August 25 through September 19, 1995, we identified four patients with C. krusei fungemia on our hematology/oncology unit. Molecular typing of all the isolates was performed by restriction endonuclease analysis of genomic DNA using HinfI. A total of 7 patients found to be colonized or infected with C. krusei were matched with 14 controls. There was no difference between the cases and controls with respect to underlying disease, duration of hospitalization, or neutropenia. The numbers of days of hyperalimentation, corticosteroids, and antibiotics were similar between both groups. The mean number of antibiotics was greater in the cases versus controls (5.0 versus 2.5; p = .003). There was no difference with respect to total dose or duration of fluconazole administration. Molecular typing of the isolates revealed that four had identical DNA banding patterns, plus another two that differed by one band and were considered related. Three historical strains were unrelated. In conclusion, this report demonstrates that molecular typing can be used to define clonality and, thereby, support increased infection control practices to eliminate such outbreaks when evidence of clonal spread is present.

Candida krusei Fungemia

Candida krusei has recently been increasingly recognized as a pathogen in immunocompromised patients with malignancies. We report four immunocompromised patients with C. krusei fungemia and review the literature. Including our 4 cases, 62 cases of C. krusei fungemia were identified in the literature. Detailed information was available for only 25 patients. The clinical features of patients with C. krusei fungemia are similar to those reported for Candida tropicalis. Most patients were neutropenic and more than one half of the patients had received antifungal therapy and had evidence of gastrointestinal mucosal breakdown before the development of C. krusei fungemia. The overall mortality was 48%. Patients treated with regimens containing amphotericin B had improved survival over patients who received no therapy. Favorable response rates were higher in patients receiving high-dose amphotericin B or high-dose amphotericin B plus flucytosine when compared to patients treated with low-dose amphotericin B.

Intra-abdominal Abscess and Fungemia Caused by Candida krusei

A 73-year-old man with chronic lymphocytic leukemia experienced an intra-abdominal abscess caused by Candida krusei. Treatment with drainage alone led to dissemination of the infection and resultant C krusei fungemia. The fungemia responded to therapy with amphotericin B, but the patient died of multisystem failure. We stress the rarity of intra-abdominal infection and fungemia with this organism and the necessity for treatment of candidal intra-abdominal infection with antifungal agents. X