Risk Factors For Fungal Infection Research Articles

New Onset Diabetes after Transplant – Risk Factors, Clinical Profile and Outcome

Background: New onset diabetes after transplant (NODAT) remains one among the significant threats to both renal allograft and patient survival. The aim of this study was to analyse the clinical profile and risk factors for NODAT.Methods: This prospective observational study involved patients who underwent renal transplantation in our centre between 2010 and 2015.Results: During the mean follow up period of 18 ± 6 months, incidence of NODAT was 26.6% and the cumulativeincidence was highest in the first year after transplant. Recipient age, pre transplant impaired fasting glucose, Hepatitis C virus (HCV) infection, family history of diabetes, tacrolimus, post transplant hypertriglyceridemia and metabolic syndrome were found to be statistically significant risk factors for NODAT. In Cox multivariate regression analysis, age and family history of diabetes were found to be independent risk factors for NODAT. Fasting C-peptide level underlines insulin resistance as predominant mechanism for NODAT in two third of patients. There were higher incidence of urinary tract infection in the NODAT patients. NODAT was found to be an independent risk factor for fungal infection and 10 year cardiovascular risk in the renal recipients. There was no significant impact of NODAT on short term graft and patient survival.Conclusion: Age, pre-transplant fasting blood glucose, family history of diabetes, HCV infection and tacrolimus were found to be the important risk factors, with insulin resistance as the predominant mechanism for NODAT.

First report of sporadic cases of Candida auris in Colombia

BackgroundCandida auris is a recently reported Candida species that is phenotypically similar to Candida haemulonii and related to hospital outbreaks. This organism can be misidentified as Candida haemulonii, Candida famata, Candida catenulata, or Rhodotorula glutinis by phenotypic approaches. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and DNA sequence analysis using internal transcribed spacer rDNA bar-coding provide an accurate identification. Case reportsThree cases of C. auris infection in patients with risk factors for fungal infection (one admitted to the intensive care unit, one with lymphoma, and one with HIV; all three with previous antibiotic use) are reported; these infections were not epidemiologically related. Yeast isolates were recovered from blood, ocular secretion, and bronchoalveolar lavage and were misidentified as C. catenulata and Candida albicans by the phenotypic MicroScan method. The isolates were confirmed to be C. auris by means of MALDI-TOF MS and DNA sequence analysis. Antifungal susceptibility testing was performed on these C. auris isolates, which exhibited high minimum inhibitory concentrations to triazoles and amphotericin B. One patient survived and the other two died. Only one of these deaths was related to fungemia. ConclusionsC. auris is an emerging and opportunistic multidrug-resistant human pathogen. It is necessary to strengthen measures to achieve an accurate and quick identification and also to avoid its dissemination. This will require improvements in health and infection control measures, as well as the promotion of antifungal stewardship in healthcare facilities.

Fungal Infections in Patients With Infected Pancreatic Necrosis and Pseudocysts: Risk Factors and Outcome.

Fungal infections in patients with acute pancreatitis are common and potentially life threatening. Data on fungal pancreatic infections are inconsistent. Therefore, the aim of this study was to identify risk factors for fungal infection and to determine their impact on survival. This was a retrospective analysis of pathogen spectrum and outcome of infected pancreatic necrosis or pseudocysts from 3 German hospitals from 2002 to 2016. A total of 187 fine-needle aspirations were performed in 113 patients. Fungal pancreatic infections, predominantly caused by Candida species, were identified in 52 patients (46%). Antibiotic treatment before fine-needle aspiration (84.6% vs 49.2%, P = 0.003) and the duration of therapy (9 vs 2 days, P = 0.024) identified patients at an increased risk of fungal infection. Patients with fungal pancreatic infections had a longer hospital stay (34 vs 14 days, P < 0.001), received intensive care treatment more often (55.8% vs 27.9%, P = 0.002), and had a lower 365-day survival (78.4 [SE, 6.6%] vs 95.0 [SE, 2.0%], P = 0.035) than patients with bacterial pancreatic infections only. Fungal infections are common in patients with infected pancreatic necrosis and pseudocysts and indicate patients with a higher risk of mortality in the long term.

Characteristics of Sinus Fungus Ball: A Unique Form of Rhinosinusitis.

Objective:The purpose of this study was to investigate the characteristics of this unique form of rhinosinusitis.Methods:Ninety-one patients with sinus fungus balls were evaluated for clinical characteristics. Nasal tissues obtained from 38 patients with sinus fungus ball, along with 26 controls were used for histopathological, cytokines/chemokines, western blotting, and genetic analyses.Results:Patients with fungus balls had significantly more females and their age was older. The presentation of fungus ball was predominantly unilateral (97.8%). Thirty-three patients (36.3%) had risk factors for fungal infection. Macrophage and neutrophil dominated cellular infiltration was found in nasal tissues of fungus ball patients. A tendency of reduced tight junction staining (e-cadherin) and protein expression was found. Interleukin 8 (IL8) and granulocyte colony stimulating factor (G-CSF) significantly increased in sinus fungus ball tissue homogenates when compared with those from controls. Higher prevalence of a single single nucleotide polymorphism (SNP) with E-cadherin was found in the patients with fungus ball.Conclusions:We found that patients with sinus fungus ball had robust immune responses, allowing recruitment and activation of macrophages and neutrophils. However, patients with sinus fungus ball could have genetic or acquired weakness in immunity. The fungal hyphae were localized and accumulated within single sinus instead of being eradicated by host.

Prevalence, Risk Factors, and Prognosis of Systemic Fungal Infections in the Hospitalized Children in the Northwest of Iran

Introduction: The present study aimed to investigate the prevalence, inductive agents, potential risk factors, and prognosis pertaining to the specific risk factors of fungal infections in the hospitalized children in the northwest of Iran. Materials and Methods: This descriptive-analytical, retrospective study was conducted on all the children who were hospitalized in the Pediatric Hospital of Tabriz, Iran due to positive fungal culture during 23 August 2010-23 September 2013. The culture samples were collected from various positive fungal body fluids, secretions, and/or catheters. Results:In total, 40,638 patients were hospitalized during the study period, 191 of whom had fungal cultures and were enrolled in the study. Among the studied patients, 58% were male, and 42% were female. The prevalence of fungal infections in the pediatric healthcare center was 0.47% (approximately four infections per 1,000 cases). The most common comorbidities in the hospitalized children with positive fungal culture were aspiration pneumonia (15%), urinary tract infections (9%), and septicemia (7%). In addition, the most frequently infected area was the urinary system (37%). Candida albicans and mycelial fungi accounted for the most common varieties of the fungal isolates obtained from the patients. The mortality rate among the studied children with fungal infections was estimated at 27%. Conclusion: According to the results, the main risk factors for fungal infections included the use of intravenous catheters, urinary catheters, intubation, and history of surgery. Therefore, it is recommended that the potential risk factors of these infections be screened and investigated in the patients admitted to the Pediatric Teaching Hospital of Tabriz.

Prevalence of onychomycosis among patients with nail psoriasis who are not receiving immunosuppressive agents: Results of a pilot study.

Nail psoriasis and onychomycosis can often be hard to differentiate clinically and may coexist, complicating each other's course. The aim of this study was to determine the prevalence of onychomycosis among patients with nail psoriasis not being treated with immunosuppressive agents, which constitute an independent risk factor for fungal infections. A cross-sectional study was performed. All adult patients with nail psoriasis who were not receiving antifungal and/or immunosuppressive treatment were recruited at the 2nd University Dermatology Department of Aristotle University of Thessaloniki from 10/2016 till 02/2017. If onychomycosis was clinically suspected, nail samples were collected and direct microscopy with 15% KOH solution and culture were performed. Target-NAPSI and DLQI score were also calculated. Of the 23 patients recruited, 20 were men and 3 were women, with a mean age of 53.43years (48.25, 58.62), a mean target-NAPSI score of 10.72 (9.62, 11.77) and a mean DLQI score of 10.17 (7.46, 12.89). A total of 34.78% of patients tested positive for onychomycosis. Yeast were isolated in 37.50% of cases, non-dermatophyte filamentous fungi in 37.50% and T.rubrum in 12.50%. The prevalence of onychomycosis among nail psoriasis patients is higher than that among the general population of Greece (15%-20%). Yeast and moulds predominate in infection cases of nail psoriasis patients.

Profil mycologique des onychomycoses des mains chez les vendeurs de « Garba » à Abidjan (Côte d’Ivoire)

The aim of this study is to determine the prevalence and the fungi involved in onychomycosis located on fingers in Abidjan. This study includes the sellers of cooked cassava semolina served with fried tuna fish called "garba". Fines squames specimen was processed with 30% KOH for a direct microscope examination. Serous collection were done in physiological serum. Part of the original sample was cultured on Sabouraud medium with antibiotics (chloramphénicol, actidione). Species distribution and antifungal susceptibility by the technique on agar were noted. A total of 205 male sellers were involved. The Onychomycosis prevalence was 6.3%; (95% CI: 3.6-10.3). Five species of yeasts were identified. Candida spp were the most frequent (84.6%) and Candida albicans represented 30.8% of isolated yeasts. Trichosporon cutaneum were isolated in two case (15.4%). Susceptibility for amphotericin-B was 92.3% contrary to 5-fluorocytosine 30.8%. The subjects aged between 15 to 24 (69.2%), with a higher seniority (84.6%) and illiterate (69.2%) were the most affected. The main risk factors of fungal infections were the presence of previous fingernail onychomycosis (P<0.0001) and the frequent fingernail cutting (P=0.0009). Onychomycosis caused by yeast is infrequent among "garba" sellers in Abidjan. The main fungi involved in fingernail onychomycosis were Candida species. It is nevertheless necessary to implement sensitization for them on contributing factors.

Swimming pools and fungi: An epidemiology survey in Polish indoor swimming facilities

Environmental conditions for swimming facilities may support fungal growth and also may represent a biological risk for users. However, since previously published studies both cleaning procedures and sanitary regulations are likely to have been improved. The aim of the study was to examine whether attendance to public swimming pools was still a risk factor for fungal infection of the skin in Poland. We investigated the occurrence of mycotic species, in a sample from Polish swimming pools. Detection and identification of isolated species were achieved by cultural and morphological methods. Study revealed high incidence of yeast and yeast-like fungi. Candida spp. and Rhodotorula rubra were commonly detected, followed by Aspergillus spp. and Trichophyton mentagrophytes. Surprisingly, the prevalence of clinically important species isolated from swimming pool environments did not reflect prevalence of those species in Polish population. The present results are in agreement with previous research and support that swimming pools remain an important reservoir of clinically important fungi, yet the exposure associated with swimming pools may not be a major source of dermatophytic infection in Poland.

Delayed enteral nutrition and antibiotic use are risk factors for fungal infection in neonatal ward sanglah hospital

Delayed enteral nutrition and antibiotic use are risk factors for fungal infection in neonatal ward sanglah hospital

Fungal Gastroduodenitis.

Candida infection of the gastrointestinal (GI) tract is rare in the immunocompetent individual. In immunocompromised patients, it frequently involves the oesophagus, but extra-oesophageal involvement is uncommon. We report a case of primary and isolated gastroduodenal candidiasis. Upper GI endoscopy with biopsy of gastric mucosa was crucial for making the diagnosis. The patient showed transient improvement after therapy with fluconazole.LEARNING POINTSGastroduodenal candidiasis is rarely documented in the literature.Old age is an independent risk factor for fungal infection of the gastrointestinal tract.In this case, fungal gastroduodenitis was associated with gastroparesis.

Risk Factors for Invasive Fungal Infection among Thai Oncologic Patients with Febrile Neutropenia and Cutaneous Presentation: A 5-Year Retrospective Study in Southern Thailand

Background:Febrile neutropenia (FNP) is a condition defined by fever and neutropenia. There are current only limited data on related cutaneous manifestations. This study aimed to assess cutaneous lesions and their etiologies in a Thai group of FNP patients.Methods:A retrospective analysis was conducted on 43 non-transplant febrile neutropenic patients with concurrent cutaneous lesions, as determined by dermatopathologic studies at Songklanagarind Hospital in Thailand over a five-year period.Results:The mean age was 39 years (SD: 18.8). Approximately 60% were male. The most common underlying disease was a hematologic neoplasm. Twenty-one of the participants had developed FNP within 7.5±8.7 days after presenting with skin lesions. Twenty-two participants had skin lesions 9.0±11.1 days after FNP diagnosis. Cutaneous manifestations were mostly in the form of multiple lesions (67.4%), of which the most common were nodular skin lesions (37.2%) presenting on the lower extremities of the body (58.1%). The dermatopathologic diagnoses included infections which were almost all fungal and leukemia cutis. The development of skin lesions after FNP proved to be a statistically significant risk factor for fungal infection (OR 8.13, P = 0.009), whereas age (over 40 years) proved to be a statistically significant protective factor (OR 0.20, P = 0.04).Conclusions:There are a variety of cutaneous manifestations in FNP, of which the most common were cutaneous nodular skin lesions in the lower extremities. The most frequent infection was fungal in patients under 40 who had developed skin lesions after FNP.

Book Review: ICU infection in an era of multi-resistance: Selected proceedings from the 8th Summer Conference in Intensive Care Medicine

[Image omitted: See PDF.]The Society of Critical Care Medicine hosted their Summer Conference in Intensive Care Medicine and compiled the selected proceedings into a 2009 book: ICU Infection in an Era of Multi-Resistance .The [World Health Organization (WHO) sees a rising global threat (2015)] from multiresistance that enables bacteria, viruses, fungi, and parasites. resistance of antimicrobial agents and hospital or healthcare-acquired infections, including infections found in the Intensive Care Unit (ICU), has raised concerns from health caregivers, researchers, and architects devoted to design better and safer healthcare settings. ICU Infection in an Era of Multi-Resistance makes an invaluable and timely addition to the knowledge in such fields. It provides an overview of risks and treatment methods for antibiotic-resistant infections in today's world. It discusses risk factors, medication and treatment trends, and current research evidence.The book is good for both new learners and professionals. It can be an aid for physicians and healthcare providers or a textbook for medical students. It can be beneficial as an introduction to the topic or continuing education for readers from all fields, for example, architects, researchers, health policy makers, and disease control departments. It can be helpful for people in the healthcare furnishing or furniture industry. book is suited for thorough reading and studying or for a quick glance at a certain chapter relevant to your work or study.There is a page of information about continuing education opportunities for critical care providers and practitioners, and an information page identifying the 10 contributors. ICU Infection in an Era of Multi-Resistance discusses how to efficiently reduce risks and to improve treatment outcomes in 15 chapters. chapter titles include Who is at risk for The right drug for the right infection and the importance of early appropriate therapy, and Pandemics: lessons learned and preparing for the future. Each chapter is followed by a summary, a reference list, and two self-assessment questions to help the readers grasp the points. Answers to the questions are not provided. chapters discuss the diagnosis, transmission dynamics, treatment, and prevention measures for most common types of infections such as fungal infection, methicillin-resistant Staphylococcus aureus , vancomycin-resistant enterococci, extended spectrum β-lactamase, and Acinetobacter baumannii . chapters also discuss pandemic infections such as the outbreaks of 1918 influenza, SARS, and H1N1.ICU Infection in an Era of Multi-Resistance uses patient cases as examples both in the chapter content and in the self-assessment questions. Medication usage in the United States as well as in European and Asian countries are discussed. Research evidence is cited while discussing possible solutions for controversial treatment debates. For example, the study of [Murray et al. (2008)] is introduced when discussing risk factors for fungal infections in burn patients in which a 12-year review on patients with severe burns at the U.S. Army Institute of Surgical Research Burn Center was conducted. …

Epidemiology and fungal infection risk factors in patients hospitalized in neonatal and paediatric intensive care units – a multicentre pilot study

Invasive fungal infections are associated with very high mortality and morbidity. Candida sp. is a leading etiological cause of invasive fungal infections (IFI). The aim of this study was to investigate the epidemiol-ogy of FI in patients admitted to neonatal and paediatric ICU (NICU and PICU) to investigate risk factors that may contrib-ute to FI development. In this retrospec-tive epidemiologic multicentre pilot study five neonatal and five paediatric intensive care units were included. The data about epidemiology, patient significant clinical data, chronic metabolic disease, surgery, mechanical ventilation, dialysis, central venous catheter, urinary catheter, arterial catheter, total parenteral nutrition, leuco-penia, neutropenia, previous antimicrobial therapy or prophylaxis were collected. In this study 25 NICU and 40 PICU patients treated with antifungal drugs during 2014 were enrolled. Among patients with fungal infection from the NICU the most often diagnosis and reason for NICU hospitali-zation was prematurity. In four NICUs C. albicans was the most common clinically significant fungal isolate. In one NICU C. parapsilosis was the most frequently iso-lated yeast. From the urine of one NICU patient with urogenital disease C. krusei was isolated. In four of five PICUs C. al-bicans was the most common cause of fungal infections. C. glabrata and C. krusei were also recorded in PICUs. In one PICU patients with clinically important moulds were recorded – patients with haematolog-ical malignancy (Fusarium sp.) and solid&nbsp;organ transplantation (Aspergillus spp). Thus, surveillance of epidemiology, fungal susceptibility and risk factors associated with fungal infection in a prospective mul-ticentre study could be of great value in the future.&nbsp

Frequency of Invasive Fungal Infections in Patients Undergoing Allogeneic Stem Cell Transplantation Conditioned with Reduced BUCY2 and Antifungal Prophylaxis with Low Dose Amphotericin B

Introduction: Invasive fungal infection (IFI) is a major cause of morbidity and mortality in patients with allogeneic stem cell transplantation (allo-SCT). One well-known risk factor for fungal infection includes bowel mucosal damage due to conditioning chemotherapy regimens. The use of reduced-intensity conditioning may favorably impact the epidemiology of IFI after allo-SCT. Data for IFI in this population are scarce. On the other hand, despite the low incidence of IFI with the use of the new antifungal drugs, the costs remain to be high and sometimes unaffordable for the patients.Objective: To analyze the frequency of invasive fungal infections in patients who underwent stem cell transplantation conditioned with reduced BUCY2, at INCMNSZ, from November 1998 to December 2014.Material and methods: A retrospective analysis was performed in 58 patients receiving reduced BUCY2 as part of their SCT conditioning regimen. Most of the patients received antifungal prophylaxis with low dose of amphotericin B (˂20 mg/day) during the neutropenia following transplant.Results: Fifty eight patients undergoing allo-SCT with conditioning regimen reduced BUCY2, from November 1998 to December 2014, were included. Patients (male, 57%) had a median age of 39 years (range 17-67). The median follow-up was 90 months. The patients had a following range of underlying diseases: myelodysplastic syndrome (n=14, 24.1%), chronic myeloid leukemia (CML, n=14, 24.1%), acute myeloid leukemia (AML, n=12, 21%), acute lymphoblastic leukemia (LLA, n=10, 17%), lymphomas (n=3, 5.2%), myelofibrosis (n=2, 3.4%), or others (n=3, 5.2%). All patients were conditioned with 12mg/kg of busulfan and 80mg/kg of cyclophosphamide. 22% of patients presented mucositis grade III-IV. 85% (50/59) of patients received fungal prophylaxis with low dose amphotericin B. Four patients (6.8%) presented IFI during the first 100 days post-transplant, and one (1.7%) presented late IFI. The mortality secondary to IFI was 5%. Transplant related mortality (TRM) was 17%.Conclusion: From the beginnings of our transplant program we have had a low incidence of IFI and low TRM, with the prophylactic use of low dose amphotericin B and the modified conditioning regimen reduced BUCY2, compared to the reported literature. The use of reduced BUCY2 and low dose amphotericin B can be cost-effective in medical centers in developing countries. DisclosuresNo relevant conflicts of interest to declare.

Estimating the burden of fungal disease in Vietnam.

SummaryData regarding the prevalence of fungal infections in Vietnam are limited yet they are likely to occur more frequently as increasingly sophisticated healthcare creates more iatrogenic risk factors. In this study, we sought to estimate baseline incidence and prevalence of selected serious fungal infections for the year 2012. We made estimates with a previously described actuarial method, using reports on the incidence and prevalence of various established risk factors for fungal infections from Vietnam, or similar environments, supplemented by personal communications. Global data were used if local data were unavailable. We estimated 2 352 748 episodes of serious fungal infection occurred in Vietnam in 2012. Frequent conditions included recurrent vaginal candidiasis (3893/100 000 women annually), tinea capitis (457/100 000 annually) and chronic pulmonary aspergillosis (61/100 000/5 year period). We estimated 140 cases of cryptococcal meningitis, 206 of penicilliosis and 608 of Pneumocystis jirovecii pneumonia. This is the first summary of Vietnamese fungal infections. The majority of severe disease is due to Aspergillus species, driven by the high prevalence of pulmonary tuberculosis. The AIDS epidemic highlights opportunistic infections, such as penicilliosis and cryptococcosis, which may complicate immunosuppressive treatments. These estimates provide a useful indication of disease prevalence to inform future research and resource allocation but should be verified by further epidemiological approaches.

Invasive Fungal Infections in Renal Transplant Recipients: Epidemiology and Risk Factors.

Invasive fungal infections are a major cause of morbidity and mortality among renal transplant recipients. The aim of this study was to investigate the frequency and risk factors for fungal infections in renal transplant recipients. We retrospectively evaluated all kidney transplant recipients at our center from December 1988 to June 2010 for the epidemiology, spectrum, risk factors, and mortality of invasive fungal infections. In 32 patients (10.30 %), at least one fungal infection developed after the transplantation. The most common pathogens causing fungal infections in our patients were Candida spp. and Aspergillus spp. The independent risk factors associated with invasive fungal infection episodes were antibiotic treatment within the last 3 months (OR 15.88, 95 % CI 3.90-64.73, p < 0.001), cytomegalovirus infection (OR 18.54, 95 % CI 9.01-38.17, p < 0.001), and the presence of diabetes mellitus (OR 6.01, 95 % CI 2.95-12.25, p < 0.001). Mortality was significantly higher among patients with fungal infections than among other patients (53.10 and 17.80 %, respectively; p < 0.001). It is difficult to diagnose and treat fungal infections early, and it can be useful to determine independent risk factors in order to identify and treat high-risk patients.

English

Background: During recent years, fungal infections have risen exponentially and are a cause of significant morbidity and mortality in hospitalized patients, especially in the critical care setting. There is paucity of data from India on fungal pathogens. Methods: We prospectively studied patients admitted to medical and surgical critical care section of a tertiary care institute in northern India. The clinical samples of patients were processed in Department of Microbiology for isolation and identification of fungi by using standard protocols over a period of one year. The patients were categorized into fungal infection and colonization groups. The demographic data and risk factors for fungal infection and colonization were evaluated. Results: Ninety one (82.7%) of the 110 patients enrolled in the study, had fungal infection, whereas 19 (17.3%) had fungal colonization. Candida were isolated from 85/91 (93.4%) and 19/19 (100%) patients with fungal infection and colonization respectively. There was predominance of non-albicans Candida spp both in fungal infection 61/85 (71.7%) patients as well as fungal colonization group 16/19 (84.2% ). In non-albicans Candida spp., Candida tropicalis was the most common isolate observed in both fungal infection (85.3%) and fungal colonization (63.1%) groups. Overall, in patients with fungal infection, candiduria was detected in 68/91 (74.7%) whereas candidaemia was observed in 19/ 91 (20.8%) patients. The risk factors for fungal infections included urinary catheterization (85.7%), central line insertion (81.3%), mechanical ventilation (52.7%), use of corticosteroids (23.1%), total parentral nutrition (6.6%) and peritoneal dialysis (3.3%). Conclusions:The emergence of non-albicans Candida similar to the trends in the western countries should be a cause of concern in our country. Proper surveillance of fungal pathogens is important to improve quality of care in critical care setting and measures should be focussed to control these infections, especially in patients with these risk factors.

Study of fungal infections in pediatric intensive care unit in Menoufiya University Hospital

Objective The aim of the study was to determine the incidence and risk factors of fungal infections in patients admitted to pediatric intensive care unit (PICU) in Menoufiya University Hospital. Background Critically ill patients are immunosuppressed, invasively monitored, and exposed to aggressive interventions that put them at increased risk for infectious complications while residing in PICU. Fungal pathogens are an increasing important cause of infection among patients in PICU. Patients and methods This study was conducted on 492 critically ill pediatric patients admitted to PICU from July 2010 to July 2011; each patient was examined and sampled on the day of admission and after 5 and 7 days of admission. Samples were taken from oropharyngeal, axillary, and rectal areas in addition to blood sample. All specimens were cultured on Sabouraud dextrose agar. The analysis of samples included a direct examination, culture, and susceptibility of isolates to antifungal drugs. Results Candida albicans was the most common colonizing organisms, as about 156 (31.7%) patients were colonized by it on the day of admission. The most commonly acquired fungi were: C. glabrata in 71 (25.7%) patients, C. tropicalis in 61 (22.1%) patients, C. albicans in 46 (16.7%) patients, C. krusei in 33 (11.9%) patients, Aspergillus flavus in 20 (7.3%) patients, and mixed infection in 45 (16.3%) patients. Patients on previous antibiotic therapy, parenteral nutrition, and central venous line had an increased risk of acquiring fungal organisms. Conclusion Monitoring for colonization with Candida spp. in children admitted to PICU and children undergoing treatment for severe sepsis or septic shock in PICU for more than 5 days may offer an opportunity for early intervention for prevention of candidemia.

Real-world Experience in the Midst of an Exserohilum Meningitis Outbreak

THE OUTBREAK OF INVASIVE FUNGAL INFECTIONS AMONG patients who received injections of contaminated methylprednisolone acetate from the New England Compounding Center continues. New cases have been reported to the Centers for Disease Control and Prevention weekly and more than 740 patients in 20 states have been diagnosed with meningitis, spinal or paraspinal infections, or joint infections (ie, epidural abscess, phlegmon, diskitis, vertebral osteomyelitis, arachnoiditis, or other complications at or near the injection site). Spinal or paraspinal infections can present weeks to months after the initial injection. Current recommendations from the Centers for Disease Control and Prevention call for patients with new or worsening symptoms at or near the injection site to undergo magnetic resonance imaging (MRI) with contrast of the symptomatic areas. In this issue of JAMA, Malani et al provide important information detailing the possibility of paraspinal or spinal infections in those without a change from their baseline pain or neuropathic symptoms. These findings suggest that current screening recommendations may need reconsideration. Patients exposed to contaminated steroids can no longer be reassured that the lack of new or progressive symptoms equates to a lack of infection. In the report by Malani et al, 36 of 172 patients (21%) screened for evidence of paraspinal or spinal infection exhibited MRI abnormalities suggestive of infection. Although a review of symptoms was not available for all screened patients, among the 115 patients surveyed, 80 (70%) had no change in their symptoms. Of these 80 patients, 13 (16%) had an abnormal MRI. A total of 35 of 115 patients experienced an increase in their baseline pain or neuropathic symptoms, yet had not received an MRI (although one may have already been ordered). After diagnostic imaging was obtained, 22 of these 35 patients (63%) had imaging findings consistent with focal infection. These results suggest either reassurance at a prior clinical visit may have been offered, or patients were not aware of the need to seek care for worsening symptoms. Virtually all patients with abnormal MRI findings met criteria from the Centers for Disease Control and Prevention for probable or proven disease. Twenty-four of these 35 patients required operative intervention as a diagnostic or therapeutic maneuver, and all 35 received antifungal therapy. In light of these findings, it may seem reasonable to mandate MRI screening for all exposed patients. However, this recommendation may not be applicable to the entire exposed population. The lot (No. 06292012@26) of contaminated steroid responsible for cases in Michigan and the majority of those in Tennessee was associated with a higher attack rate than other steroid lots (Nos. 05212012@68 and 08102012@51) causally implicated in this outbreak. The reasons for differing attack rates by region and lot number remain obscure. However, storage conditions, age of the product, extent of exposure (ie, multiple exposures), and host factors, including immunogenetic differences in susceptibility, likely each play a large role. Other institution-related or region-specific factors may contribute to patient risk for fungal infection. For example, translaminar injection was an independent risk factor for fungal infection but transforminal injection was not. Geographicor region-specific practices for injection have not been reported. Furthermore, physician preference for procedure type may play a role in the variation of attack rates between locations and should be considered in the development of diagnostic and treatment recommendations. The report by Malani et al also raises the question of how infection develops in patients without worsening underlying back pain or neuropathic symptoms. Patients with preexisting chronic pain may pay less attention to the development of slightly more pain, or increases in pain frequency. It is not clear if a validated symptom questionnaire was used in the study by Malani et al to assess subtle changes from

Fungal infections after liver transplantation: outcomes and risk factors revisited in the MELD era

Antifungal prophylaxis is recommended in high-risk patients, but risk criteria remain unclear and the predictive value of Model of End-Stage Liver Disease (MELD) score is unknown. In a retrospective, single-center analysis of 667 liver transplants, potential risk factors for fungal infection were assessed, including MELD score. Antifungal prophylaxis was administered in 198 patients (29.4%). During follow-up (mean 43.6 ± 29.6 months), 263 patients (39.4%) developed ≥ 1 episode of fungal infection, and 187 (28.0%) patients developed a probable or proven invasive fungal infection requiring systemic antifungal treatment. Patients receiving antifungal prophylaxis had a lower incidence of fungal infection (29.8% vs. 43.5% without prophylaxis, p < 0.001) and invasive fungal infection (17.7% vs. 32.4%, p < 0.001). One-yr patient survival was 91%, 85% and 69%, respectively, in patients with no fungal infection, fungal colonization and treated invasive fungal infection (p < 0.001); graft survival was 88%, 85% and 66% (p < 0.001). Multivariate analysis indicated that MELD score of 20-30 or ≥ 30 was associated with a 2.0-fold or 4.3-fold increase in relative risk of fungal infection, respectively, and a 2.1-fold or 3.1-fold increase in relative risk of invasive fungal infection. In conclusion, liver transplant patients with a MELD score ≥ 20, and particularly patients with a score ≥ 30, are candidates for antifungal prophylaxis.