Positive Fungal Cultures Research Articles

Assessment of the Clinical Diagnosis of Onychomycosis by Dermoscopy.

BackgroundAs a common clinical superficial fungal infection, the diagnosis of onychomycosis relies on clinical features, traditional KOH direct microscopy and fungal culture. In recent years, dermoscopy has been widely used in the diagnosis and treatment of infectious diseases and has provided new options for the diagnosis of onychomycosis.ObjectiveTo evaluate the value of dermoscopy in the clinical diagnosis of onychomycosis and to explore the relationship between each clinical subtype and the dermoscopic pattern.MethodsA retrospective study of 114 cases of clinically suspected onychomycosis was conducted to compare the differences between dermoscopy and fungal pathogenic examination (microscopy and culture) in the diagnostic sensitivity of onychomycosis and to analyze the relationship between nine common dermoscopic modalities and clinical subtypes of onychomycosis.ResultsAmong the 114 proposed patients, 87 nails with positive fluorescent staining microscopy and/or positive fungal cultures were diagnosed as onychomycosis. The sensitivity and specificity of dermatoscopy, using the mycological findings as a reference, were 86.21 and 33.33%, respectively. The incidence of common dermatoscopic patterns in the 87 nails with confirmed onychomycosis was as follows: white flocculation in 76 cases (87.35%), longitudinal nail pattern in 72 cases (82.76%), jagged changes in the distal nail plate in 69 cases (79.31%) and yellow staining in 46 cases (52.87%), these four patterns were more commonly seen in the distal lateral subungual onychomycosis and total dystrophic onychomycosis, but there was no statistical difference in the positive dermatoscopic pattern between these two types (P > 0.05).ConclusionDermoscopy can be an important aid in the diagnosis of onychomycosis, especially when fungal microscopy or culture is not appropriate, but this method is still not a substitute for fungal microscopy and culture.

Effect of intravaginal gentian violet for acute vaginal candidiasis treated with a single dose oral fluconazole: a randomised controlled trial

The study aims to evaluate the additive effect of intra-vaginal gentian violet (GV) on a single dose oral 200 mg fluconazole for acute vaginal candidiasis (VC). Women aged ≥18 years who had VC were randomly allocated to receive either fluconazole 200 mg (group 1, FLU, N = 90); or the fluconazole with GV (group 2, FLU + GV, N = 93). Outcome measures were 2-week clinical cure rate, conversion of positive fungal culture, time-to-cure, side effects, satisfaction and symptomatic recurrence within 2 months. No significant difference of participants’ characteristics was observed. They were 32.4 ± 8.7 year-old and non-obese. Participants receiving FLU + GV had higher clinical cure rates (81.7% vs. 74.4%, p=.236); lower recurrence rate (19.4% vs. 30.0%, p=.097); shorter time-to-cure (3.1 vs. 4.0 days, p=.013); but lower culture conversion rate (74.2% vs. 80.0%, p=.351). Participants in both groups reported high satisfaction and none had severe adverse events. In conclusion, the addition of GV results in a shorter time-to-cure but not cure rate. Clinical trial registration: TCTR20180917003 (http://thaiclinicaltrials.org/show/TCTR20180917003). Impact Statement What is already known on this subject? The efficacy of fluconazole for acute vaginal candidiasis is limited to 75–90% due to drug resistance and non-albicans Candida. Gentian violet (GV) has long been used for mucosal candidiasis; and is recommended as the second line treatment for women with recurrent vulvovaginal candidiasis (RVVC). What do the results of this study add? Adding GV to a single oral 200 mg fluconazole results in a quicker resolution of symptoms of acute VC but not cure rate. The participants’ satisfaction and acceptance are high. Lifestyle modification, particularly reduction of sugar-rich diet, associates with the higher culture-based cure rate. What are the implications of these findings for clinical practice and/or further research? As GV is widely and easily accessible, and speculum examination with or without microscopy is the main diagnostic tool of VC; the single application of GV seems doable in real-life practice. This simple anti-septic solution can accelerate symptom resolution. However, the proper frequency of GV application should be further explored. As importantly, lifestyle modification should always be included in counselling session to optimise treatment outcome.

Paranasal Sinus Fungus Ball, Anatomical Variations and Dental Pathologies: Is There Any Relation?

Objective:The purpose of this study was to investigate the relationship between anatomical variations and the fungus ball (FB), and the association between odontogenic etiologies and the maxillary sinus FB.Methods:We analyzed the clinical records of 66 patients who underwent endoscopic sinus surgery for FB. The anatomical variations determined were nasal septal deviation (NSD) and direction, presence of Onodi and Haller cell, concha bullosa and lateral recess of the sphenoid sinus. Further, dental X-ray records were reviewed to detect any possible odontogenic etiologies in patients with maxillary sinus FBs.Results:There were 41 female and 25 male patients. Positive fungal culture was found in 60 patients (91%) and the causative fungus was Aspergillus species in all cases. The correlation between NSD and localization of the maxillary sinus FB was statistically significant (p=0.0409). Maxillary sinus FB was more common on the concave side of the NSD. Presence of dental pathologies was significantly associated with maxillary sinus FB compared to the healthy side (p=0.0011). For sphenoid sinus FB, NSD was detected in a similar number for both the affected and unaffected side and there were no significant correlations (p>0.05). However, the relationship between sphenoid sinus FB and presence of lateral recess was significant (p=0.0262).Conclusion:Our study revealed that the maxillary sinus FB was more common on the concave side of the deviated septum. Also, dental pathologies or a presence of dental treatment history were associated with maxillary sinus FB.

Abstract 96: CompLement C5 Antibodies For Decreasing Brain Injury After Aneurysmal Subarachnoid Hemorrhage (CLASH): A Randomized Controlled Phase II Clinical Trial

Introduction: The inflammatory response after aneurysmal subarachnoid hemorrhage (aSAH) has been associated with early brain injury, delayed cerebral ischemia, and poor functional outcome. In experimental SAH studies, complement C5 antibodies administered shortly after SAH reduced brain injury with approximately 40%. We investigated the pharmacodynamic efficacy and safety of eculizumab (a complement C5 antibody) in aSAH patients. Methods: We conducted a randomized, controlled, open-label, phase II clinical trial with blinded outcome assessment in the Netherlands. Patients were randomized (1:1) to receive eculizumab plus standard care or to standard care alone. Eculizumab (1200 mg) was administered intravenously < 12 h, on day 3 and on day 7 after ictus. Patients in the intervention group received prophylactic antibiotics for 4 weeks and prophylactic antifungal therapy if the patient had a central line or an external ventricular shunt and a positive fungal or yeast culture. The primary outcome was C5a concentration in the cerebrospinal fluid (CSF) on day 3 after ictus. Secondary outcomes included the occurrence of adverse events, eculizumab concentration and inflammatory parameters in the blood and CSF, cerebral infarction on magnetic resonance imaging, and clinical and cognitive outcomes. We aimed to evaluate 26 patients with CSF assessments, 13 in the intervention group and 13 in the comparator group. Results: A total of 31 patients have been included, of which 26 with CSF samples. Conclusions: Final results will be presented at the conference. Trial registration: Netherlands Trial Register: NTR6752. European Clinical Trials Database (EudraCT): 2017-004307-51.

Discrepancies Between Clinical and Anatomic Causes of Death in Acute Invasive Fungal Sinusitis: An Institutional Experience at a Tertiary Care Center.

Acute invasive fungal sinusitis (AIFS) can be challenging to diagnose because of its varied clinical presentation. To evaluate the discrepancies between clinical and autopsy diagnoses in patients with histologic evidence of AIFS at a tertiary care center. Autopsy cases with a pathologic autopsy diagnosis of AIFS from the past 20 years at a tertiary hospital were evaluated for clinicopathologic features. Modified Goldman classification was used to classify discrepant cases. Clinical history was also reviewed. Of 7071 institutional autopsy cases during 20 years, 9 met inclusion criteria and demonstrated AIFS at autopsy. Angioinvasive fungal elements were histologically identified in all cases, with multiorgan involvement in most cases (6 of 9; 67%). Major clinicopathologic discrepancies were identified in 6 cases (67%). AIFS is an uncommon diagnosis rendered at autopsy. There is a subset of cases that demonstrate discrepancy between the clinical impression and pathologic autopsy diagnosis. Antemortem diagnosis of AIFS can be challenging, especially in cases without prototypical clinical symptoms and positive fungal cultures. At autopsy, there was multiorgan involvement, supporting extensive tissue sampling to evaluate for AIFS, even in the setting of negative fungal cultures or lack of classic symptoms. These findings highlight the importance of the pathologist's role at autopsy in the definitive diagnosis of AIFS, especially in clinically equivocal cases.

The Routine Use and Cost Analysis of Acid-Fast Bacilli and Fungal Cultures in Foot and Ankle Surgery: A Retrospective Study

Category:Other; DiabetesIntroduction/Purpose:Infections pertaining to orthopaedic surgery play a major role in patient morbidity and increased healthcare-associated expenses. In the setting of foot and ankle surgery for infection, it is common practice to send acid-fast bacilli (AFB) and fungal intraoperative cultures, although there is no standard protocol in place. In this study, the rate of positive AFB and fungal cultures and associated costs in a consecutive series of foot and ankle surgeries was retrospectively assessed.Methods:Under an IRB-approved protocol, CPT codes were used to identify 447 procedures in 320 patients, who underwent foot and ankle surgery for infection by fellowship-trained foot and ankle orthopaedic surgeons at a Level 1, private, academic hospital from 2014 to 2019. A medical records review was performed to collect microbiology and patient demographic data. Materials and labor cost data, which was provided by the institution, was used to quantify a total culture cost.Results:In this series, there were 185 male and 135 female patients with an average age of 57 years (range, 10-105) and average BMI of 31 kg/m2 (range, 13-56). No patients had positive AFB cultures and 20 patients (7.5%) had positive fungal cultures. There were 434 AFB and 525 fungal cultures performed during these procedures. Based on total cultures performed, there were 0% (0/434) AFB and 5% (26/525) fungal culture positivity rates. The total intra-institutional cost (i.e. labor and materials) for AFB cultures was $23,967. The total labor/materials cost for negative and positive fungal cultures was $12,428 and $2,371, respectively. The total labor/materials cost for all the cultures obtained over the time frame of our study was $38,767.Conclusion:This study highlighted low rates of positive AFB and fungal cultures in the orthopaedic foot and ankle surgery service in a 6-year retrospective review, as well as substantial institutional costs of routine use of intraoperative cultures. While this series included cases from three fellowship-trained foot and ankle orthopaedic surgeons, this study will be expanded to analyze AFB and fungal culturing practices and cost in other orthopaedic subspecialties. Creating and implementing a standardized protocol may achieve cost effectiveness of cultures without diminishing patient outcomes.

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.

In Vitro Antifungal Activity of Plain Socks and Zinc Oxide Nanoparticle–Coated Socks

Fungal foot infection is a common superficial fungal infection and is recognized as an important public health problem. Related to the wearing of occlusive footwear, foot infection is usually caused by dermatophytes and nondermatophyte molds. Previous in vitro studies have demonstrated that zinc oxide nanoparticles (ZnO-NPs) have antimicrobial activity against fungi. This study, therefore, evaluated the ability of socks coated with ZnO-NPs to inhibit fungal growth in an in vitro model mimicking real-life situations. Scale from patients with fungal foot infections was equally divided into three groups: control, plain socks, and ZnO-NP socks. The specimens in the control group were routinely fungal cultured, whereas in the plain sock and ZnO-NP sock groups, scale was incubated with plain socks and ZnO-NP socks, respectively, for 24 hours. After incubation, each piece of sock was cultured. The fungal culture results of the three groups were progressively evaluated for 4 weeks. From 31 specimens, the positive fungal culture results of the control, plain sock, and ZnO-NP sock groups were 100%, 64.5%, and 54.8%, respectively. Specimens incubated with plain socks (P = .001) or with ZnO-NP socks (P < .001) had a significant reduction in the number of positive fungal cultures compared with the control. Plain socks and ZnO-NP socks significantly inhibited fungal growth relative to the control. The wearing of either plain socks or ZnO-NP socks can prevent fungal foot infection because these socks act as a barrier to the insoles of shoes.

The epidemiological aspects of fungal keratitis in a population sample from Northern Iran: A cross-sectional study.

ABSTRACTIntroduction:Fungal keratitis can be influenced by different genetic, environmental, and even iatrogenic factors that the impact of such factors can be very different in various populations. Thus, it should be attempted to provide a clear picture of the epidemiological situation of this disease in different areas. The aim of this study was to investigate the epidemiological aspects of fungal keratitis in a population sample from northern Iran.Methods:This cross-sectional study was conducted on all consecutive patients clinically suspected to fungal keratitis that were ultimately diagnosed by positive fungal culture that admitted to Amiralmomenin hospital in Rasht city, Iran, between 2011 and 2019. The sampling method was census. The required information was collected by reviewing the hospital’s recorded files.Results:Forty seven patients were examined in the study that 53.2% of the patients were men. Among the population of women, housewives-farmers with the prevalence rate of 45% and among the population of men, those with farm occupation with the prevalence rate of 52% formed the most common occupational subgroups. Most patients (89.3%) had no history of any ocular surgery or manipulation. Aspergillus was the most frequent pathogen (23.4%) followed by Penicillium (19.1%) and Fusarium (17.0%). History of chronic disorders was also revealed in 44.6%. The results of smear and culture obtained from the study were as follows: in 8.5% of patients as positive smear and positive culture, and in 91.5% as negative smear and positive culture. Only 2.1% used the lens.Conclusion:Fungal keratitis affects our male population slightly higher than females with the highest overall prevalence rate in the sixth and seventh decades of life. The most frequent fungal strains responsible for fungal keratitis include Aspergillus followed by Penicillium and Fusarium.

Fungal and mycobacterial cultures should not be routinely obtained for diagnostic work-up of patients with suspected periprosthetic joint infections.

Fungal and mycobacterial periprosthetic joint infections (PJI) are rare events. Clinicians are wary of missing these diagnoses, often leading to the routine ordering of fungal and mycobacterial cultures on periprosthetic specimens. Our goal was to examine the utility of these cultures and explore a modern bacterial culture technique using bacterial blood culture bottles (BCBs) as an alternative. We performed a retrospective review of patients diagnosed with hip or knee PJI between 1 January 2010 and 31 December 2019, at the Mayo Clinic in Rochester, Minnesota, USA. We included patients aged 18 years or older who had fungal, mycobacterial, or both cultures performed together with bacterial cultures. Cases with positive fungal or mycobacterial cultures were reviewed using the electronic medical record to classify the microbiological findings as representing true infection or not. There were 2,067 episodes of PJI diagnosed within the study period. A total of 3,629 fungal cultures and 2,923 mycobacterial cultures were performed, with at least one of these performed in 56% of episodes (n = 1,157). Test positivity rates of fungal and mycobacterial cultures were 5% (n = 179) and 1.2% (n = 34), respectively. After a comprehensive review, there were 40 true fungal and eight true mycobacterial PJIs. BCB were 90% sensitive in diagnosing true fungal PJI and 100% sensitive in detecting rapidly growing mycobacteria (RGM). Fungal stains were performed in 27 true fungal PJI but were only positive in four episodes (14.8% sensitivity). None of the mycobacterial stains was positive. Routine fungal and mycobacterial stains and cultures should not be performed as they have little clinical utility in the diagnosis of PJI and are associated with significant costs. Candida species and RGM are readily recovered using BCB. More research is needed to predict rare non-Candida fungal and slowly growing mycobacterial PJI that warrant specialized cultures. Cite this article: Bone Joint J2022;104-B(1):53-58.

Clinical and microbiological pattern of intertrigo

Background: Intertrigo is a common disorder affecting many flexural areas of the body with significant morbidity.&#x0D; Objectives: To determine the clinical pattern of intertrigo. To determine bacterial and fungal pathogens associated with intertrigo. To assess the antibacterial and antifungal sensitivity pattern of the responsible organisms.&#x0D; Methods: A total number of 230 patients with intertrigo attending dermatology unit were included in the study after ethical clearance. Laboratory investigations were done to identify the etiologic agent and their sensitivity pattern.&#x0D; Results: Majority of patients (75%) belonged to 20-60 years of age. Male to female ratio was 1.15:1. Remarkable proportion (52%) presented with the involvement of more than one intertriginous area. The most common site involved was toe web space (63%) in particular 4th toe web space. Of all positive bacterial cultures 45% revealed Staphylococcus aureus (MSSA+MRSA) followed by CNSA (Coagulase negative Staphylococcal aureus), diptheroids and pseudomonas. The majority of MSSA (Methicillin sensitive Staphylococcus aureus) isolates (91%) were sensitive to cloxacillin and MRSA (Methicillin resistant Staphylococcus aureus) to teicoplanin (85%). CNSA isolates showed considerable proportion of sensitivity to vancomycin (37%) and majority of diptheroids isolates were sensitive to penicillin(87%). All isolates (100%) of pseudomonas were sensitive to gentamicin. Of all positive fungal cultures, candida species constituted the majority (35%) followed by fusarium species (33%) and dermatophytes (30%). Overall fusarium species shows high value of MIC50 and MIC90 for itraconazole, fluconazole and ketoconazole. Fluconazole showed very high MIC50 and MIC90 (256 ug/ml) for dermatophytes and fusarium species whereas itraconazole and ketoconazole showed lower MIC for these fungi.&#x0D; Conclusion: Intertrigo can affect various intertriginous areas, among which toe web space is the most common region involved. Intertrigo can be caused by a variety of organisms: Staphylococcus aureus and candida species constituted the majority of cases. Majority of MSSA sensitive to cloxacillin and MRSA to teicoplanin. MIC of itraconazole, fluconazole and ketoconazole are high in fusarium species comparing to candida and dermatophytes. However, itraconazole and ketoconazole had lower MIC than dermatophytes and fusarium comparing to fluconazole.

Interventional Effect of Nanosilver Paint on Fungal Load of Indoor Air in a Hospital Ward.

Hospital ward environments contain various types of microorganisms, in which fungal agents are one of the main contaminants that may cause hospital-acquired infections. Regarding this, the aim of the present study was to evaluate the effect of nanosilver paint on reducing fungal contaminants of indoor air in an educational, research, and treatment center. Two rooms in the hematology ward were selected. One room was painted using usual paint (control room) and the other room was painted with paint containing nanosilver particles (experimental room). One hundred and twelve samples were collected using active (Anderson BioSampler) and passive (settle plate or open plate) air sampling techniques. The samples were incubated for 3–7 days at 35°C, and the positive fungal cultures were examined according to morphological and microscopic characteristics. Following active sampling, the mean and standard deviation of the number of colony-forming units (CFU/m3) of fungi colonies in the experimental and control rooms were 29.21 ± 17.99 and 22.50 ± 10.02 before intervention and 13.79 ± 6.20 and 31.07 ± 21.1 after intervention, respectively. Following passive sampling, the number of CFU/plate in the experimental and control rooms was 6 and 0 before and 1and 1 after intervention, respectively. The use of the nanosilver paint was effective in reducing air fungal contamination. Moreover, the active sampling method was more sensitive to measuring the concentration changes for fungal bioaerosols.

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

27. Co-infections and antimicrobial use in patients hospitalized with COVID-19

BackgroundIn-hospital antimicrobial use among COVID-19 patients is widespread due to perceived bacterial and fungal co-infections. We aim to describe the incidence of these co-infections and antimicrobial use in patients hospitalized with COVID-19 to elucidate data for guiding effective antimicrobial use in this population.MethodsThis retrospective study included all patients admitted with COVID-19 from January 1, 2020, to February 1, 2021 at any of the three teaching hospitals of the NYU Langone Health system. Variables of interest were extracted from the health system’s de-identified clinical database. The nadir of hospital admissions between the first and second peaks of hospital admissions in the dataset was used to delineate the First Wave and Late Pandemic periods of observation. A cut-off of 48 hours after admission was used to differentiate Co-infections and Secondary infections respectively among isolates of clinically relevant bacterial or fungal pathogens in blood or sputum samples. Population statistics are presented as median with interquartile range (IQR) or total numbers with percentages. Results663 of 7,213 (9.2%) inpatients were found to have a positive bacterial or fungal culture of the respiratory tract or blood during the entire course of their initial admission at our hospitals for COVID-19. Positive respiratory cultures were found in 437 (6.1%) patients, with 94 (1.3%) being collected within 48 hours of admission. Blood culture positivity occurred in 333 patients (4.6%), with 115 (1.6%) identified within 48 hours of admission. Infection-free survival decreased with duration of hospitalization, with rate of secondary infections steadily rising after the second week of hospitalization as seen in Figure 1. 70.2% of inpatients received antimicrobials for a median duration of 6 antimicrobial days (IQR 3.0 – 12.0) per patient. A higher proportion of patients received antimicrobials in the first wave than in the late pandemic period (82.6% vs. 51.8%). Table 1. Table 2 Figure 1 Infection free survival represented as duration of admission in days on the X-axis, and proportion of admitted patients remaining infection-free in the Y-axis. The blue line represents blood cultures and the orange line represents sputum cultures.ConclusionThere was a very low incidence of co-infection with SARS-CoV-2 infection at admission. A longer duration of hospitalization was associated with an increased risk of secondary infections. Antimicrobial use far exceeded the true incidence and detection of co-infections in these patients.Disclosures All Authors: No reported disclosures

Study of spectrum of fungal isolates in the sputum of newly diagnosed pulmonary tuberculosis patients.

Tuberculosis is a state of immunosupression which exposes the patients to further opportunistic pathogens like fungus. Methods: 102 newly diagnosed sputum positive pulmonary tuberculosis cases were enrolled. Significant fungal isolates were seen in 31/102 (30.4%) patients. Aspergillus spp. were isolated in 13/31(41.9%) of the positive fungal cultures while Candida spp. were isolated in 15/31 (48.4%). Low body mass index, duration of symptoms, haemoptysis, severity of radiological features and IgG Aspergillus antibodies were independent risk factors for positive fungal culture. Significant proportion of patients with PTB have fungal colonisation of their airways which can lead to poor clinical outcomes. Few easily ascertained clinical parameters can help the clinician to determine patients who are at a higher risk of fungal colonisation.

Is It Cost Effective to Obtain Fungal and Acid-Fast Bacillus Cultures during Spine Debridement?

Study DesignRetrospective study.PurposeTo identify the rate of positive acid-fast bacillus (AFB) and fungal cultures during spine debridement, determine whether these infections are more common in certain spine segments, identify comorbidities associated with these infections, and determine whether the universal performance of fungal and AFB cultures during spine debridement is cost effective.Overview of LiteratureSpine infections are associated with significant morbidity and costs. Spine fungal and AFB infections are rare, but their incidence has not been well documented. As such, guidance regarding sample procurement for AFB and fungal cultures is lacking.MethodsA retrospective review of medical record data from patients undergoing spine irrigation and debridement (I&D) at the University of Missouri over a 10-year period was performed.ResultsFor patients undergoing spine I&D, there was a 4% incidence of fungal infection and 0.49% rate of AFB infection. Steroid use was associated with a higher likelihood (odds ratio, 5.62; 95% confidence interval, 1.33–23.75) of positive fungal or AFB cultures. Although not significant, patients undergoing multiple I&D procedures had higher rates of positive fungal cultures during each subsequent I&D. Over a 10-year period, if fungal cultures are obtained for each patient, it would cost our healthcare system $12,151.58. This is compared to an average cost of $177,297.64 per missed fungal infection requiring subsequent treatment.ConclusionsSpine fungal infections occur infrequently at a rate of 4%. Physicians should strongly consider obtaining samples for fungal cultures in patients undergoing spine I&D, especially those using steroids and those undergoing multiple I&Ds. Our AFB culture rates mirror the false positive rates seen in previous orthopedic literature. It is unlikely to be cost effective to send for AFB cultures in areas with low endemic rates of AFB.

Neutralizing Anti-Granulocyte-Macrophage Colony-Stimulating Factor Autoantibodies in Patients With Central Nervous System and Localized Cryptococcosis: Longitudinal Follow-up and Literature Review.

Neutralizing anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) autoantibodies (AAbs) have been increasingly recognized to predispose healthy individuals to disseminated cryptococcosis. However, studies have only considered patients with central nervous system (CNS) infection. No longitudinal study has captured the disease spectrum and clinical course. We prospectively enrolled adults without human immunodeficiency virus infection who had disseminated or unusual cryptococcosis. We compared the demographics, clinical features, kinetics of serum cryptococcal antigen (CrAg) titers, anti-GM-CSF AAb concentrations, and treatment outcomes between patients with (case patients) and without (control patients) anti-GM-CSF AAbs. Additional reports from the literature were also reviewed. Twenty-three patients were enrolled, of whom 6 tested positive for anti-GM-CSF AAbs. All case patients with positive fungal cultures (5/5 [100%]) were infected with Cryptococcus gattii VGII. Among them, 3 had exclusively pulmonary involvement, and 1 had only musculoskeletal lesions. Patients with CNS cryptococcosis exhibited a higher serum concentration of anti-GM-CSF AAbs than those with extraneural cryptococcosis. Case patients had higher initial and peak levels of serum CrAg and longer duration of antigenemia compared with the control patients. All case patients who had completed antifungal therapy had favorable outcomes without recurrence. Testing for anti-GM-CSF AAbs should be considered for not only previously healthy patients with disseminated cryptococcosis but also those with unexplained, localized cryptococcosis. Recurrence after completion of antifungal therapy was rare despite the persistence of anti-GM-CSF AAbs.

Recent Perspectives in the Management of Fungal Keratitis.

Mycotic keratitis is common in warm, humid regions with a varying profile of pathogenic fungi according to geographical origin, socioeconomic status, and climatic condition. Clinical diagnosis can be challenging in difficult cases and those refractory to treatment. Fungal hyphae on microscopic examination and culture isolation have been the gold standard in the laboratory diagnosis of fungal keratitis. A culture isolate of the aetiological fungus is essential to perform antifungal susceptibility testing. As the culture isolation of fungi is time-consuming, causing delays in the initiation of treatment, newer investigative modalities such as in vivo confocal microscopy and molecular diagnostic methods have recently gained popularity. Molecular diagnostic techniques now help to obtain a rapid diagnosis of fungal keratitis. Genomic approaches are based on detecting amplicons of ribosomal RNA genes, with internal transcribed spacers being increasingly adopted. Metagenomic deep sequencing allows for rapid and accurate diagnosis without the need to wait for the fungus to grow. This is also helpful in identifying new emerging strains of fungi causing mycotic keratitis. A custom-tear proteomic approach will probably play an important diagnostic role in future in the management of mycotic keratitis. Positive repeat cultures are being suggested as an important gauge indicative of a poor prognosis. Positive repeat fungal cultures help to modify a treatment regimen by increasing its frequency, providing the addition of another topical and oral antifungal agent along with close follow-up for perforation and identifying need for early therapeutic keratoplasty. The role of collagen crosslinking in the treatment of fungal keratitis is not convincingly established. Rapid detection by multiplex PCR and antifungal susceptibility testing of the pathogenic fungi, adopted into a routine management protocol of fungal keratitis, will help to improve treatment outcome. Early therapy is essential in minimizing damage to the corneal tissue, thereby providing a better outcome. The role of conventional therapy with polyenes, systemic and targeted therapy of antifungal agents, newer azoles and echinocandins in fungal keratitis has been widely studied in recent times. Combination therapy can be more efficacious in comparison to monotherapy. Given the diversity of fungal aetiology, the emergence of new corneal pathogenic fungi with varying drug susceptibilities, increasing the drug resistance to antifungal agents in some genera and species, it is perhaps time to adopt recent molecular methods for precise identification and incorporate antifungal susceptibility testing as a routine.

Dermatophytic onychia: Effectiveness of rapid immunochromatographic diagnostic testing directly on samples compared to culture

BackgroundUntil now, definite diagnosis of dermatophytic onychia has been made by taking a nail sample and placing it in culture. The result is usually obtained only after 2 to 3weeks. More recently, diagnosis within a few minutes after sampling has become possible thanks to an immunochromatography technique developed in Japan and now available in France: the Diafactory Tinea Unguium® test strip (Biosynex, France). MethodsOver a 12-month period, 80nail samples from 80patients giving rise to a positive fungal culture were included in the study. For each patient, part of the removed nail was stored at room temperature and an immunochromatographic test was retrospectively performed according to the supplier's instructions. A small fragment of nail (≥ 1mg) was mixed with a few drops of reagent in a tube for 1min and the test strip was then placed in the tube with the result being visible to the naked eye (control strip, positivity strip) after incubation for a few minutes. ResultsCompared with the culture method used for 51 isolated dermatophytes (42 Trichophyton rubrum, 9 Trichophyton interdigitale), the sensitivity of the rapid test was 96.07% (49/51). For the 29other fungal cultures (10Fusarium sp., 3Scytalidium sp., 3Scopulariopsis brevicaulis,3Aspergillus sp., 1Alternaria sp., 3Candida albicans, 1Candida parapsilosis, 1Trichosporons sp., 1Rhodotorula sp., and 3Corynebacterium sp.), the specificity was 75.86% (22/29). False positives were mainly due to the genera Fusarium and Scopulariopsis (6 of 7false positives), which were the likely cause of onychomycosis. DiscussionThis rapid test could be useful in limiting excessive clinical diagnosis of dermatophyte onychomycosis. The rapid test has several advantages: ease of application, speed of results, and good performance, which, together, could improve diagnostic certainty during the actual consultation, thus limiting prolonged unnecessary prescriptions of antifungal treatments, while waiting for the laboratory culture results (3weeks for a negative result).