Positive Fungal Blood Cultures Research Articles

Neonatal Candidiasis: Clinical Spectrum and Epidemiology at a Tertiary Care Centre, Bhopal, India

Introduction: Neonatal candidiasis is one of the leading causes of sepsis amongst newborns admitted to newborn care unit, especially premature and Low Birth Weight (LBW) babies. It is one of the significant contributors to neonatal morbidity and mortality. Aim: To describe the spectrum and epidemiology of fungal sepsis in Neonatal Intensive Care Unit (NICU) at a tertiary care level. Materials and Methods: A longitudinal study was conducted from January 2018- December 2019 in NICU of Chirayu Medical College and Hospital, a tertiary level hospital in Bhopal, Central India. All neonates, who had positive fungal blood culture were included in the study, their demographic data was analysed (age, birth weight, predisposing factors etc.,), maternal history, their response to the antifungal treatment documented and complications. Statistical analysis was done using the Chi- square test with the help of Statistical Package for Social Sciences (SPSS) software version 2.0. Results: A total of 409 neonates admitted in the NICU during the study period, were suspected clinically to have sepsis and their blood culture was done, of which 110 samples were culture positive. Amongst the 110 neonates, 41(37.2%) were positive for fungal infection {29 showed Candida albicans, 12 Non Albicans Candida (NAC)}. Total 25 neonates were preterm (60.97%). The mean age of admission was 3.02 days, 51.2% (21/41) of the neonates had a history of respiratory distress and related symptoms at birth. There was no significant maternal history. Amongst the risk factors, lower birth weight (<2.5 kg), preterm (<34 weeks), and presence of invasive central lines were statistically associated with morbidity. Urine for candidial hyphae was positive in 12 out of 41 cases (29.27%). Incidence of candidal meningitis was seen in four neonates (13.33%). Thrombocytopenia was the most common laboratory finding amongst these cases (32/41). Among the different regimens used the combination regimen of Lipid based amphotericin B and voriconazole was associated with a better survival. Conclusion: Candida sepsis was found to be the most common cause of septicaemia in the NICU. LBW and preterm babies are especially at greater risk of candida sepsis. Candida albicans still continues to be a dominant aetiology for fungal sepsis, as compared to non candida species.

350. Clinical impact of positive fungal blood cultures for diagnosis and treatment of fungal infections.

Abstract Background Fungal blood cultures are usually ordered when sepsis secondary to disseminated fungal infection is suspected. We aimed to analyze whether positive fungal blood cultures had an added clinical impact over other conventional microbiological tests. Methods We performed a retrospective study of all patients for whom fungal blood cultures were performed for any indication at our institution from June 2018 to March 2022. We reviewed informatics database and medical records to assess the microbiological and clinical impact of positive fungal blood cultures during the initial admission. Assessment of clinical impact was analyzed using a list of predefined positive, negative, and no impact scenarios (Table 1) based by the treating team’s decisions. Results In total, 4447 fungal blood cultures were performed in 3648 admissions during our study period. The overall positivity rate of fungal blood cultures was 6.4% (n=284), of which only 130 (2.9%) were positive for fungi. The most common isolated fungi were Candida spp. (71, 55%), followed by Histoplasma spp. (16, 12%), Cryptococcus spp. (12, 9%), and unidentified mold (9, 7%) (Table 1). The median time to positivity was 106 hours (IQR 79-177). Only 21 (16%) fungal blood cultures resulted in a change in management. Positive fungal blood cultures for fungi led to a positive clinical impact in 17 (13%), negative clinical impact in 4 (3%), and no clinical impact in 109 (84%). Most fungal blood cultures confirmed other conventional microbiological diagnosis (71, 55%) or result was not acted upon (26, 20%). Organisms where fungal blood culture had a positive impact included C. albicans (n=4), and C. parapsilosis (n=3), while Cladosporium spp. (n=2) was the most frequent fungi with a negative clinical impact. Isolated fungi that had no clinical impact because of other confirmatory tests included Candida spp. (n=57), Histoplasma spp. (n=13) and Cryptococcus neoformans (n=10). Table 1.Microbiological characteristics and clinical impact of fungal blood cultures.Abbreviations: h hours; IQR, interquartile range.*Time to positivity was defined as the time from the fungal blood culture collection until growth and preliminary identification of a fungal organism on staining by the microbiology laboratory. **Time to identification was defined as the time from the fungal blood culture collection until identification of the fungal organism by the microbiology laboratory. Conclusion Most of positive fungal blood cultures for fungi resulted in no immediate clinical impact due to other microbiological tests available sooner or isolates thought to be non-clinically significant. Further studies should evaluate the long-term impact of fungemia and identify stewardship interventions to optimize clinical utility of fungal blood cultures. Disclosures All Authors: No reported disclosures.

Incidence of Endogenous Fungal Endophthalmitis in Screening Dilated Exams in Patients with Elevated Beta-D-Glucan Levels versus Positive Fungal Blood Cultures.

PurposeEndogenous endophthalmitis is a severe intraocular infectious condition requiring rapid diagnosis and treatment. This study examines the incidence of fungal endophthalmitis in patients with elevated beta-D-glucan (BG) levels and those with positive blood culture and the utility of ophthalmology consultation in these patients.MethodsSingle center retrospective consecutive cohort study was conducted on patients at Beaumont Health from 2016–2021 who either had positive fungal blood cultures or an elevated BG level.ResultsA total of 147 patients were examined by the ophthalmology department where 30 patients had an elevated BG level and 100 patients had a positive fungal blood culture. Incidence of fungal endophthalmitis was 0% in the elevated BG group and 1.5% in the positive fungal culture group, corresponding to a relative risk ratio of 0.0 (p = 0.31).ConclusionBG testing may be useful in diagnosing isolated cases outside the standard screening paradigm, however the data within this study support the conclusion that there is no compelling evidence at this time to add or use BG as a surrogate for endophthalmitis screening. Further studies are required to further elucidate the role of BG in the care of critically ill patients.

Little Utility of Fungal Blood Cultures in Surgical and Burn Intensive Care Units.

ABSTRACTCritically ill patients are at risk for fungal infections, but there is a paucity of data regarding the clinical utility of dedicated fungal blood cultures to detect such infections. A retrospective review was conducted of patients admitted to the surgical and burn intensive care units at Parkland Memorial Hospital between 1 January 2013 and 31 December 2017 for whom blood cultures (aerobic, anaerobic, and/or fungal cultures) were sent. A total of 1,094 aerobic and anaerobic blood culture sets and 523 fungal blood cultures were sent. Of the aerobic and anaerobic culture sets, 42/1,094 (3.8%) were positive for fungal growth. All fungal species cultured were Candida. Of the fungal blood cultures, 4/523 (0.76%) were positive for growth. Fungal species isolated included Candida albicans, Aspergillus fumigatus, and Histoplasma capsulatum. All 4 patients with positive fungal blood cultures were on empirical antifungal therapy prior to results, and the antifungal regimen was changed for 1 patient based on culture data. The average duration to final fungal culture result was 46 days, while the time to preliminary results varied dramatically. Two of the four patients died prior to fungal culture results, thereby rendering the culture data inconsequential in patient care decisions. This study demonstrates that regular aerobic and anaerobic blood cultures sets are sufficient in detecting the most common causes of fungemia and that results from fungal cultures rarely impact treatment management decisions in patients in surgical and burn intensive care units. There is little clinical utility to routine fungal cultures in this patient population.IMPORTANCE This study demonstrates that regular aerobic and anaerobic blood culture sets are sufficient in detecting the most common causes of fungemia, and thus, sending fungal blood cultures for patients in surgical and burn intensive care units is not a good use of resources.

Characteristics and Incidence of Candidemia in Hospitalized Coronavirus 2019 (COVID-19) Patients

Management of Coronavirus 2019 (COVID-19) with high-dose corticosteroids and interleukin-2 inhibitors has potential benefits, but is associated with immunosuppression and risk of secondary infections. This single-center, retrospective, cohort study evaluated the incidence of candidemia and associated risk factors in hospitalized COVID-19 patients. Twenty-three patients developed candidemia and were matched to 77 non-candidemic COVID-19 controls. The primary outcome was incidence of candidemia. Secondary outcomes included time to first positive fungal blood culture and antifungal initiation, antifungal treatment duration, fungal isolate identification, candidemia risk factors, in-hospital mortality, Intensive Care Unit (ICU) and hospital Length of Stay (LOS) and mechanical ventilation duration. Candidemia incidence was 0.7% (23/3101). Mean time from hospital admission to first positive fungal blood culture was 26.2±14.3 days, with systemic antifungal therapy initiated in 19 patients; seven started antifungal therapy the same day cultures were drawn and 12 within 24 h of preliminary culture results positive for yeast. The remaining four patients expired prior to culture results. Mean duration of antifungal therapy was 9.7±6.6 days. Candida albicans was the most frequently identified isolate. Candidemic patients were more likely to be admitted to the ICU, receive high-dose corticosteroid, renal replacement therapy, mechanical ventilation, central line, tocilizumab and broad-spectrum antimicrobials. They also had higher mortality (82% vs. 22%, p<0.0001) and longer ICU LOS (25 vs 0 days, p<0.0001), hospital LOS (39 vs 10 days, p<0.0001) and mechanical ventilation days (19 vs 0 days, p<0.0001). Candidemia occurrence is rare in COVID-19 patients, but can result in worse clinical outcomes such as high mortality and longer hospital stay. Clinicians should attempt to minimize risk factors and perform routine workup for systemic candida infections in COVID-19 patients in the ICU, on mechanical ventilation and with multiple risk factors.

316. Use of (1-3)-β-D-Glucan Assay for Diagnosis of Candidemia in Patients Hospitalized with SARS-CoV-2 Infection

BackgroundCandidemia is a rare but serious complication of SARS-CoV-2 hospitalization. Combining non-culture and culture-based diagnostics allows earlier identification of candidemia. Given higher reported incidence during COVID-19 surges, we investigated the use of (1-3)-β-D-glucan (BDG) assay at our institution in those who did and did not develop candidemia.MethodsRetrospective study of adults admitted to The Mount Sinai Hospital between March 15-June 30 2020 for SARS-CoV-2 infection, with either ≥1 BDG assay or positive fungal blood culture. Data was collected with the electronic medical record and Vigilanz. A BDG value ≥ 80 was used as a positivity cutoff. Differences in mortality were assessed by univariate logistic regression using R (version 4.0.0). Statistical significance was measured by P value < .05.ResultsThere were 75 patients with ≥1 BDG assay resulted and 28 patients with candidemia, with an overlap of 9 between the cohorts. Among the 75 who had BDG assay, 23 resulted positive and 52 negative. Nine of 75 patients developed candidemia. Of the 23 with a positive assay, 5 developed candidemia and 18 did not. Seventeen of the 18 had blood cultures drawn within 7 days +/- of BDG assay. Four patients with candidemia had persistently negative BDG; 2 had cultures collected within 7 days +/- of BDG assay. With a cut-off of >80, the negative predictive value (NPV) was 0.92. When the cut-off increased to >200, NPV was 0.97 and positive predictive value (PPV) was 0.42. Average antifungal days in patients with negative BDG was 2.6 vs. 4.2 in those with a positive. Mortality was 74% in those with ≥1 positive BDG vs. 50% in those with persistently negative BDGs. There was a trend towards higher odds of death in those with positive BDG (OR = 2.83, 95% CI: 1.00-8.90, p < 0.06).ConclusionThere was substantial use of BDG to diagnose candidemia at the peak of the COVID-19 pandemic. Blood cultures were often drawn at time of suspected candidemia but not routinely. When cultures and BDG were drawn together, BDG had a high NPV but low PPV. High NPV of BDG likely contributed to discontinuation of empiric antifungals. The candidemic COVID-19 patients had high mortality, so further investigation of algorithms for the timely diagnosis of candidemia are needed to optimize use of antifungals while improving mortality rates. Disclosures All Authors: No reported disclosures

75. Utility of Fungal Blood Cultures in Portland, Oregon

BackgroundFungal blood cultures (fungal isolators) should be used, if at all, primarily for identification of mold infections. At our institution we noted patients having fungal blood cultures drawn in many other situations, including when the primary team was concerned for candida bloodstream infection. We sought to describe the utility of this practice and of fungal blood cultures in general.MethodsWe retrospectively reviewed the results of fungal blood cultures for 2 years, from 3/1/2019-3/1/2021. We evaluated the number of episodes, culture results, whether there was a had prior bloodstream infection, and risk factors for fungal infection including renal replacement (RRT), ECMO, and immunosuppression (IS). Immunosuppression was defined as chronic systemic steroid use, recent receipt of high dose steroids within 2 weeks, history of organ transplantation, history of stem cell transplantation, hematologic malignancies, or receipt of a biologic agent.Results187 fungal blood cultures were drawn in 143 patients - 80 cultures in 70 patients from 3/2019-3/2020 and 107 cultures in 73 patients from 3/2020-3/2021. Only 3 patients had positive fungal blood cultures:1 (Candida krusei) from 3/2019-3/2020 and 2 (Candida albicans and Cyrptococcus neoformans) from 3/2020-3/2021; in all 3 cases the organism also grew from standard blood culture isolators. From 3/2019-3/2020, 1/80 cultures were drawn from an individual on ECMO while 15/80 were drawn from individuals on RRT, and 32/80 were in a IS individuals. From 3/2020-3/2021, 45/107 cultures were drawn from an individual on ECMO, 24/107 were drawn in an individual on RRT, and 73/107 were drawn in a IS individuals. The majority of individuals in whom a fungal blood culture was drawn during 3/2020-3/2021 were individuals with COVID-19. Upon chart review most of the cultures were drawn due to concern for candidemia. Results of fungal blood cultures drawn from 3/2019-3/2021 at OHSUConclusionFungal blood cultures have an extremely low yield at our institution, with a 1.6% positivity rate over a 2 year period, and all of those cultures were detected by standard blood culture isolators. Most of these cultures were drawn in situations where this test has no utility. Furthermore, the test has limited utility to detect dimorphic and mold bloodstream infections. Restriction of this test may limit inappropriate use.Disclosures All Authors: No reported disclosures

Incidence of chorioretinitis and endophthalmitis in hospitalized patients with fungemia.

Bloodstream candida infections can seed the eye via hematogenous spread and result in chorioretinitis or endophthalmitis. If undetected and untreated, this can result in permanent vision loss. Past studies evaluating incidence of ocular candidiasis among hospitalized patients with positive fungal blood cultures have demonstrated variable rates of occurrence, but recent studies have generally shown a lower incidence than was reported several decades ago. Given low rates of occurrence, the utility of screening patients with dilated fundus exams has been called into question. The primary aim of this investigation is to identify the rate of chorioretinitis and endophthalmitis based on dilated fundoscopy for patients with fungemia at a tertiary care hospital. This study was a retrospective chart review of adult patients admitted to the medical centre of the University of Arkansas for Medical Sciences (UAMS) between May 1, 2014 and December 31, 2017, who had positive fungal blood cultures during their hospitalization. There were 324 positive fungal cultures in 290 patients. Of this initial group, there were 161 eye exams. Ocular examination identified 7 of 161 patients (4.3%) with chorioretinitis or endophthalmitis. These outcomes along with previous studies support the current guidelines that screening with dilated fundus examination for these patients is appropriate and necessary.

1167. Got Micafungin? The Incidence of Fungemia in Patients with Septic Shock

BackgroundTimely administration of antibiotics in patients presenting with sepsis decreases mortality, however evidence evaluating empiric antifungal coverage has been inconclusive. Recent data have shown no mortality benefit of empiric antifungal therapy in patients with ICU-acquired sepsis. Despite the lack of data, the Surviving Sepsis Campaign recommends empiric coverage for all suspected pathogens, including fungi. The purpose of this study is to determine the frequency of concomitant septic shock and fungemia at UMass Memorial Medical Center, a large tertiary care center.MethodsThis was a retrospective cohort study that included adult patients with a discharge diagnosis of severe sepsis or septic shock and/or fungemia admitted to UMMMC between October 2017 and October 2019. Patients with positive fungal blood cultures were further reviewed to identify if septic shock was present within 24 hours of blood culture collection. Additionally, risk factors for fungemia and 30-day mortality were assessed. Exclusion criteria included pregnancy, cultures from outside hospitals, incarceration, and hospice care.ResultsIn the analysis period, 4,253 patients had a discharge diagnosis of severe sepsis or septic shock. There were 68 cases of fungemia. In total, 54 patients with fungemia were included after applying exclusion criteria. Of the 54 patients with fungemia, 8 patients (15.1%) met criteria for septic shock at the time of positive blood culture, while 81% met SIRS criteria. Of the 4,253 total patients, 0.19% had coexisting fungemia and septic shock. At 30 days, four patients (7.4%) with both septic shock and fungemia had expired out of 12 total deaths. Three of the four deaths had multiple risk factors for fungemia including central line in place for greater than 48 hours, parenteral nutrition, and prolonged antibiotic therapy.ConclusionSeptic shock is a rare presentation of fungemia. Most patients with septic shock and fungemia have known risk factors. Despite recommendations by the Surviving Sepsis Campaign to initiate therapy for all likely pathogens, including fungal species, the incidence of fungemia presenting as septic shock at our academic medical center was very low and does not appear to warrant empiric coverage.Disclosures All Authors: No reported disclosures

653. Comparison of Yeasts identification by Biofire, Culture and ePlex for Quality Assurance purpose

BackgroundAt the University of Kentucky Medical center (UKMC), positive fungal blood cultures are concurrently run through the Biofire Blood Culture Identification (BCID) panel which detects 5 Candida species. The newer platform, the GenMarkDx ePlex BCID-FP (fungal panel) is designed to detect 16 fungal targets. Our study compares the performance of the Biofire BCID panel’s with culture as the gold standard method. We examine the percentage of agreement by both testing methods and predict the performance of the GenMarkDx ePlex BCID-FP panel based on culture results. We also look at the number of other yeasts not included in Biofire BCID panel that could be picked up by the GenMarkDx ePlex BCID-FP panel.MethodsPositive fungal blood cultures from July 1, 2018 to June 30, 2019 were run through the Biofire BCID panel. Culture results were used to extrapolate whether the GenMarkDx ePlex FP would provide any additional diagnostic benefit. Results were categorized as true or false positives and negatives as compared to culture as the gold standard.ResultsA total of 141 blood cultures were tested via the Biofire BCID panel for the identification of yeasts. Of these, 123 (87%) yielded Biofire results in concordance with culture results. We would expect these also to be positive on the GenMarkDx ePlex BCID-FP panel. In addition, 18 specimens (13%) would have tested positive on the GenMarkDx ePlex BCID-FP panel and not the Biofire BCID panel. These organisms were noted to be Candida lusitaniae (n=6), Cryptococcus neoformans (n=3), Candida dublinensis (n=2), and Candida keyfr (n=1). Organisms that were found on culture that were not detected by both GenMarkDx ePlex BCID-FP panel and Biofire BCID panel were Candida nivariensis (n=2), Pichia ohmeri (n=1), Trichospon species (n=2).ConclusionBased on these data, we expect that the ePlex would have correctly identified 95.9% of the yeasts in this patient population. This represents an additional 18 (13%) of specimens that could be detected rapidly from the positive blood culture if the GenMarkDx ePlex BCID-FP panel were used instead of the Biofire BCID panel. Early identification can influence the choice of antifungal agent. Less than 5 % of the yeasts would have remained unidentified by ePLex compared to 13% for Biofire.Disclosures All Authors: No reported disclosures

Ophthalmology Consultation to Detect Endogenous Endophthalmitis: Clinical Characteristics in Consulted Versus Diagnosed Cases Among At-Risk Inpatients.

Predisposing factors for ophthalmology consultations and endogenous endophthalmitis were compared among inpatients with systemic infection. This was a retrospective cohort study in a tertiary care hospital between January 1, 2010, and December 31, 2014. Multivariable logistic regression was utilized. There were 9,527 encounters identified with systemic infection. The 5-year incidence rate was 8.4% (803/9,527) for consultations and 0.3% (25/9,527) for endophthalmitis. Factors most associated with consultations included positive fungal blood cultures and HIV. Factors most associated with endophthalmitis included positive blood fungal cultures and endocarditis. Four of 25 endophthalmitis patients lacked positive blood cultures; six of 20 endophthalmitis patients with adequate mentation were asymptomatic. Positive blood fungal cultures were strongly associated with both endophthalmitis and consultations. Endocarditis was strongly associated with endophthalmitis but less associated with consultation and may warrant increased attention. Neither presence of symptoms nor positive cultures may be sufficiently accurate to determine need for consultation. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:159-169.].

249. Limited Diagnostic Utility of Extended Aerobic Blood Culture Incubation for Fungal Pathogen Detection

BackgroundBlood cultures are an important diagnostic tool for the detection of fungemia. At our institution, fungal blood cultures consist of aerobic blood culture with incubation extended from the standard 5 days to 14 days. Orders for fungal blood cultures exist in multiple electronic order sets for selected populations, including oncology and bone marrow transplant services.MethodsTo determine the yield of fungal blood cultures at our institution, a 570-bed tertiary-care referral center, we extracted all fungal blood culture results over a 4.5-year period (January 1, 2014–May 15, 2018) from a Laboratory Information System.ResultsOf the 21,657 fungal blood cultures performed, only 202 (0.9%) demonstrated growth and 189 (0.9%) grew fungal organisms. The majority (90%, n = 182/202) of positive fungal blood cultures grew a Candida or other yeast species. 96% (n = 174/182) of the fungal cultures that grew yeast would have been detected with standard bacterial blood culture. Eight of these cultures became positive during the extended hold period and grew a Candida species. All 8 cultures were collected from patients who had previous positive cultures for the same Candida species detected by standard incubation. Five fungal blood cultures from 4 patients turned positive after 5 days of incubation. Among these, two additional fungal pathogens were identified including 2 cases of Lomentospora prolificans and 2 cases of Fusarium. In both cases of L. prolificans and one case of Fusarium, the patients had previous positive blood cultures that detected the same organism with standard incubation. One patient with Fusarium had no previous positive blood cultures, but had multiple tissue cultures positive for Fusarium. The remaining cultures that turned positive after 5 days of incubation contained bacterial organisms, a number of which were considered clinically insignificant (e.g., Cutibacterium species).ConclusionThese data suggest that extended incubation of aerobic blood culture bottles has limited diagnostic utility beyond standard bacterial blood culture for detection of fungemia. Fungal blood cultures represent an opportunity for improved diagnostic test stewardship, and use should be restricted to selected situations in consultation with Infectious Diseases or Laboratory Medicine.Disclosures All authors: No reported disclosures.

256. Optimizing the Clinical Utilization of T2 Rapid Candida Panel at a Large Community Hospital

BackgroundCandidemia is the fourth leading hospital-acquired bloodstream infection with an estimated mortality rate of 35%. Fungal blood cultures result in at least five days and fail to identify 40% of Candida infections. The T2 Candida Panel is a diagnostic test which utilizes whole blood to provide rapid detection of five Candida varieties. It has a 91% sensitivity and 99% specificity rate and enables physicians to initiate or de-escalate therapy rapidly, possibly decreasing mortality. However, practical utilization clinically has not been studied. Our aim is to evaluate the appropriate utilization of the T2 Candida Panel in a large community hospital.MethodsA retrospective chart review of hospitalized with a T2 Candida Panel result from December 2015 to June 2018 was performed. The panel was restricted and could only be ordered by two specialties, Infectious Disease and Oncology. Baseline demographics and patient characteristics were collected. Endpoints assessed included patient outcomes, antifungal medication use, T2 Candida panel results, corresponding blood culture results, time to appropriate therapy and duration of therapy.ResultsA total of 628 T2 Candida panels resulted during the study period with 56.6% involving the intensive care setting. The average age was 59.5 years with 52.5% of the population being male. Of the total, 8.1% (n = 60) were positive. Only three patients had a positive fungal blood culture result with a negative T2 panel collected at the same time (sensitivity 94.3%, 95% CI 80.8–99.3; specificity 94.2%, 95% CI 91.4–96.3). 264 (42%) were ordered with concomitant antifungal therapy and 48.1% underwent de-escalation of therapy based on T2 result. The average time to de-escalation was 137 hours. Of the positive results, 40 (66.7%) had an antifungal ordered when the T2 panel was ordered and 30 (50%) were switched to appropriate therapy after T2 resulted in an average time of 11 hours.ConclusionOur data shows that while the T2 Candida Panel demonstrated faster and more sensitive results, there was still a considerable delay in achieving appropriate therapy. The variation in utilization of the T2 Candida Panel indicates that further intervention regarding appropriate use of the panel is required. Disclosures All authors: No reported disclosures.

Prevalence and factors predictive of intraocular fungal infection in patients with fungemia at an academic urban tertiary care center.

ObjectiveTo report the prevalence and to identify factors predictive of intraocular infection in patients with fungemia receiving prophylactic antifungal therapy.MethodsA retrospective review of patients who received prophylactic antifungal therapy and a dilated fundus examination at an academic urban tertiary care center from 2000 to 2007. Basic demographic information, fungal species grown, antifungal agent(s) used, number of positive blood culture specimens, visual acuity, visual symptoms, and known risks of disseminated candidiasis were noted. Logistic regression analysis was used to determine the factors significantly associated with intraocular fungal infection.ResultsA total of 132 patients with positive fungemia culture were requested to have ophthalmology consults. The prevalence of ocular infection was 6.9% (N=9). All nine patients were infected with Candida species. Undergoing gastrointestinal (GI) surgery within the prior 6 months was significantly related to developing intraocular infection, with an odds ratio of 18.5 (95% confidence interval, 15.1–24.3; P=0.002). Having ≥3 positive fungal blood cultures was also a significant risk factor, with an odds ratio of 2.6 (95% confidence interval, 1.8–3.7; P=0.03). Among 40 patients having GI surgery, eight (20.0%) had intraocular fungal disease, compared with one of 92 patients (1.1%) not having GI surgery. Among 125 patients with a negative baseline examination result, two of 32 patients (6.3%), who had recent GI surgery, subsequently developed fungal ocular disease, compared with 0 of 93 patients (0%), who did not have recent GI surgery.ConclusionRecent GI surgery and higher numbers of positive fungal blood culture specimens may be predictive of candida ocular infections. Normal baseline fundoscopy examination results in patients with such risks may require repeat evaluations to detect delayed manifestations.

Inpatient Ophthalmology Consultation for Fungemia: Prevalence of Ocular Involvement and Necessity of Funduscopic Screening.

To determine the generalizability of recent data assessing the necessity of ophthalmic consultation for fungemic patients, we examined the prevalence, microbial profile, and treatment of fungal chorioretinitis and endophthalmitis among patients with positive fungal cultures referred for ophthalmologic consultation at a tertiary care medical center. Retrospective cross-sectional study. All inpatient ophthalmology consultations from Wills Eye Hospital at Thomas Jefferson University between January 1, 2006 and December 31, 2012 were retrospectively reviewed and cross-referenced to a microbiologic database of positive fungal blood cultures. This included 227 adult consecutive inpatients with positive fungal blood cultures (n= 215) or suspected fungemia (n= 12). Clinical data were extracted from records held by the microbiology laboratory and inpatient records. Patients were deemed to have ocular fungal involvement if dilated fundus examination demonstrated evidence of chorioretinitis or endophthalmitis. Two hundred and twenty-seven consultations were requested to evaluate patients for ocular manifestations of fungemia. Eleven patients (4.8%, 95% CI 2.4%-8.5%) were diagnosed with fungal chorioretinitis or endophthalmitis. Of these 11 patients, 5 had visual symptoms, 2 were asymptomatic, and 4 were unable to communicate. A total of 5 patients (2.2%) received intravitreal injections following funduscopic screening. An additional 11 patients (4.8%) had nonspecific fundus lesions considered to be inconsistent with ocular fungal involvement. The most common fungal species identified were Candida albicans (n= 85), Candida glabrata (n=63), and Candida parapsilosis (n= 44). The current study found a low rate of disseminated ocular involvement in patients with positive fungal cultures referred for ophthalmologic consultation. However, 2 patients with ocular fungal involvement denied visual symptoms and over half of affected patients were asymptomatic or unable to communicate. As the presence and severity of ocular involvement in fungemic patients may dictate the mode and duration of antifungal treatment, funduscopic screenings may still have an important role.

PO-0559 Candida Bloodstream Infections In A Nicu (2001–2012)

<h3>Background and aims</h3> Recent reports indicate that the incidence of Candida ssp. bloodstream infection (BSI) is decreasing among NICU patients, and is associated with antifungal prophylaxis and the dwell time of peripherally inserted central catheters (PICCs). This study describes the epidemiology of invasive fungal infections in a single NICU. <h3>Methods</h3> We conducted a retrospective study of invasive candidiasis occurring in 6730 infants admitted to our NICU. Positive fungal blood cultures were identified through searching our microbiology database. <h3>Results</h3> From a total of 2637 blood cultures performed during the study period, there were 6 (&lt;0.1%) Candida spp. (Candida albicans n = 5, Candida lusitaniae n = 1) BSIs reported. In 3 cases premature rupture of membranes was observed, and in 2 cases maternal vaginal smears were positive for Candida ssp. All Patients with Candida albicans BSI (Gestational age 24.3 to 27.0 weeks) had PICCs, while blood cultures became positive between day 1 to 10. 1 patient died on day 13. Treatment consisted in Fluconazole (67%), Amphotericin B (33%), and Caspofungin (17%), partially combined. Persistent positive Candida BSIs were not reported. Systemic antifungal prophylaxis is not implemented at our NICU. During the same period 402 positive fungal cultures in 198 patients were documented from other sources. <h3>Conclusions</h3> Even without prophylactic systemic antifungal therapy at our NICU the observed rate of Candida BSIs is low but in line with other studies. Prenatal vaginal smears might help to detect ELBW infants being at high risk for candidemia.

Outcomes, Impact on Management, and Costs of Fungal Eye Disease Consults in a Tertiary Care Setting

To determine the frequency of clinical management changes resulting from inpatient ophthalmic consultations for fungemia and the associated costs. Retrospective case series. Three hundred forty-eight inpatients at a tertiary care center between 2008 and 2012 with positive fungal blood culture results, 238 of whom underwent an ophthalmologic consultation. Inpatient charts of all fungemic patients were reviewed. Costs were standardized to the year 2014. The Student t test was used for all continuous variables and the Pearson chi-square test was used for categorical variables. Prevalence of ocular involvement, rate of change in clinical management, mortality rate of fungemic patients, and costs of ophthalmic consultation. Twenty-two (9.2%) of 238 consulted patients with fungemia had ocular involvement. Twenty patients had chorioretinitis and 2 had endophthalmitis. Only 9 patients (3.7%) had a change in management because of the ophthalmic consultation. One patient underwent bilateral intravitreal injections. Thirty percent of consulted patients died before discharge or were discharged to hospice. The total cost of new consults was $36 927.54 ($204.19/initial level 5 visit and $138.63/initial level 4). The cost of follow-up visits was $13 655.44 ($104.24/visit). On average, 26.4 patients were evaluated to find 1 patient needing change in management, with an average cost of $5620.33 per change in 1 patient's management. Clinical management changes resulting from ophthalmic consultation in fungemic patients were uncommon. Associated costs were high for these consults in a patient population with a high mortality rate. Together, these data suggest that the usefulness of routine ophthalmic consultations for all fungemic patients is likely to be low.

Clinical and laboratory characteristics of penicilliosis marneffei among patients with and without HIV infection in Northern Thailand: a retrospective study

BackgroundPenicilliosis marneffei is increasingly observed in individuals without HIV infection. This study aimed to compare the clinical and laboratory features among HIV infected and uninfected individuals with penicilliosis marneffei.MethodsA retrospective cohort study was conducted between January 1, 2007 and December 31, 2011 at Chiang Mai University Hospital. We included individuals who were ≥15 years of age and presented with culture-proven P. marneffei infection.Results116 HIV-infected and 34 HIV-uninfected patients were enrolled. Comparing to HIV-infected patients, HIV-uninfected patients were older; less likely to have fever, splenomegaly, and umbilicated skin lesions; more likely to have Sweet’s syndrome and bone and joint infections; had higher white blood cell count, platelet count, and CD4 cell count; had lower alanine transaminase (ALT); and less likely to have positive fungal blood cultures. The mortality rates were 20.7% and 29.4% among HIV infected and uninfected patients, respectively.ConclusionsClinical manifestations of penicilliosis marneffei are different between patients with and without HIV infection. Physician’s awareness of this disease in HIV-uninfected patients may prompt the diagnosis and timely treatment, and can lead to a better outcome.

Fungal Infections in Cholangitis: Implementation of Diagnostic and Therapeutic Algorithm

Purpose: Infections of the biliary tract with Candida and other fungal species have frequently been reported in the recent years. The aim of this multicenter study was to establish an algorithm for clinical diagnostics and treatment of biliary candidiasis. Methods: Ninety-four patients were included in the study (ClinicalTrials.gov Identifier: NCT01109550). Bile samples for microbiological analysis were obtained by endoscopic retrograde cholangiography (ERC). If appropriate, endoscopic bile duct biopsies were taken for evaluation of invasive fungal infection. Buccal smears and stool samples were collected to identify the individual transient flora. The obtained information was integrated into a diagnostic algorithm (Figure 1).Figure 1: Suggested diagnostic and therapeutic algorithm for biliary candidiasis.Results: In 26 of the 94 patients, we found Candida species in the bile (27.7%). Risk factors for biliary candidiasis were recent long-term antibiotic therapy (>7 days) and age (p<0.05). Forty-two percent of the Candida subspecies were differentiated as complicated with assumed resistance against azole antifungals (C. glabrata, tropicalis, dubliensis). One invasive mycosis was identified histologically without mycological proof in the in bile. Eight patients were treated with antimycotic drugs according to our suggested treatment algorithm; two patients with progressive cancer, two with biliary cast syndrome after cardiopulmonary resuscitation, one with M. Ormond, and three with sepsis of unknown focus. Positive oral (buccal) and enteral (stool) fungal cultures did not correlate with biliary candidiasis (p=0.066 and p=0.158). Furthermore, no significant association of prior endoscopic sphincterotomy (p=0.360) or prior ERCP (p=0.341) and biliary candidiasis were found. No positive fungal blood culture samples were obtained. Conclusion: Candida and its subspecies are frequently seen in the bile of patients with biliary obstruction. Our data indicate that the suggested diagnostic algorithm for biliary candidiasis is feasible in daily clinical routine. The question whether transpapillary biopsies are necessary to diagnose biliary candidiasis is not answered yet. This research was supported by an industry grant from Merck Investigator-initiated Studies Program.

Nosocomial candidemia in an Italian tertiary care hospital

In a retrospective ongoing study, the incidence of nosocomial candidemia among patients (pts) admitted to a tertiary-care teaching hospital (bed capacity 2400; 78 beds for intensive care units, ICUs) was evaluated together with causative pathogens, potential risk factors, antifungal treatment, and crude mortality. During the primary study period (November 1991—October 1994) there were 136 episodes of candidemia occurring in 136 pts (median age 62 years, range 4–96). The overall incidence of candidemia was 11.3 episodes per 10 000 hospital admissions. The underlying diseases were the following: solid or hematological malignancies (43 pts), major abdominal surgery (30 pts), cardiovascular diseases (18 pts), trauma (17 pts), other diseases (28 pts). At the onset of candidemia 67 pts (49%) were located in ICUs, 48 and 21 pts respectively in surgical and medical wards. C. albicans (83 strains) accounted for 53% of all blood culture Candida isolates. Fifty-three pts (39%) received adequate antifungal treatment: 16 pts amphotericin-B and 37 pts fluconazole. The overall crude mortality was 54%. The number of positive fungal blood cultures (1 culture versus >1 culture) did not influence crude mortality (54% versus 63%). In addition, the mortality of pts infected by C. albicans (55%) was similar to that of pts infected by C. non-albicans species (45%). The mortality of pts located in ICUs (79%) was significantly higher (P < 0.001) than that of pts in surgical (29%) and medical wards (33%). Finally, the mortality of pts who did not receive adequate antifungal therapy (70%) was significantly higher (P < 0.001) than that of treated pts (30%). In conclusion, the incidence of nosocomial candidemia was high during the primary phase of the study; most of our pts with candidemia had severe underlying diseases and were hospitalized in ICUs. The number of fungal positive blood cultures did not influence the crude mortality, confirming that a single bood culture shuld not be dismissed as benign transient candidemia. On the contrary, about two-third of our pts did not receive an adequate antifungal treatment and the majority of them died.