Systemic Antifungal Agents Research Articles

Current situation of sporotrichosis in China.

Sporotrichosis, a mycosis resulting from cutaneous or subcutaneous infection with the dimorphic fungus Sporothrix, has been reported in China, particularly in the northeast region. In this review, we conducted a thorough examination of the recent advancements in sporotrichosis in China, encompassing aspects such as etiology, epidemiology, pathogenesis, clinical manifestations, diagnosis and treatment strategies. Within the Chinese context, fixed cutaneous sporotrichosis represents the prevailing clinical manifestation. Fungal culture stands as the gold standard for diagnosing sporotrichosis, while polymerase chain reaction techniques can enhance both the specificity and sensitivity of diagnosis. Besides conventional systemic antifungal agents, alternative modalities such as Chinese herbal medicines, photodynamic therapy and laser therapy show potential efficacy against sporotrichosis.

Issues in the diagnosis and evaluation of pulmonary aspergillosis in patients with chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) may present with various forms of pulmonary aspergillosis, including invasive pulmonary aspergillosis (IPA), chronic cavitary pulmonary aspergillosis, and allergic bronchopulmonary aspergillosis. Accurate diagnosis and disease evaluation are essential for tailoring individualized treatment strategies. Key aspects include: (1) Comprehensive assessment of IPA risk factors, with enhanced monitoring for critically ill patients; (2) Understanding the clinical manifestations and radiological features of different forms of pulmonary aspergillosis and emphasizing the importance of bronchoscopic examination; (3) Obtaining microbiological evidence whenever possible; (4) Differentiating colonization from infection to avoid overdiagnosis; (5) Vigilance for co-existing sensitization to Aspergillus. During treatment and long-term disease management, the use of inhaled or systemic corticosteroids and antifungal agents should be dynamically adjusted according to the patient's condition.

Triazole antifungal drug interactions-practical considerations for excellent prescribing.

Systemic antifungal therapy is critical for reducing the mortality from many invasive and chronic fungal infections. Triazole antifungals are the most frequently prescribed antifungals but require attention to dosing and drug interactions. Nearly 600 severe drug-drug interactions and over 1100 moderate interactions requiring dose modifications are described or anticipated with systemic antifungal agents (see https://www.aspergillus.org.uk/antifungal-drug-interactions/). In this article, we address the common and less common, but serious, drug interactions observed in clinical practice with triazole antifungals, including a group of drugs that cannot be prescribed with all or most triazole antifungals (ivabradine, ranolazine, eplerenone, fentanyl, apomorphine, quetiapine, bedaquiline, rifampicin, rifabutin, sirolimus, phenytoin and carbamazepine). We highlight interactions with drugs used in children and new agents introduced for the treatment of haematological malignancies or graft versus host disease (midostaurin, ibrutinib, ruxolitinib and venetoclax). We also summarize the multiple interactions between oral and inhaled corticosteroids and triazole antifungals, and the strategies needed to optimize the therapeutic benefits of triazole antifungal therapy while minimizing potential harm to patients.

Allergic bronchopulmonary aspergillosis in a lung transplant recipient treated with mepolizumab

Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction to Aspergillus spp. ABPA diagnosis may be challenging due to its non-specific presentation. Standard ABPA treatment consists of systemic corticosteroids and antifungal agents. Mepolizumab, a monoclonal antibody against interleukin-5 seems to be a promising treatment for ABPA. Data about ABPA following lung transplantation (LuTx) are scarce. LuTx recipients are at higher risk for adverse effects of ABPA treatment compared to the general population.Here we present a case of a LuTx recipient who was successfully treated with mepolizumab for ABPA following LuTx. Prolonged administration of high dose prednisone was thus avoided. To our knowledge, this is the first case describing mepolizumab administration following LuTx. Mepolizumab seems particularly attractive as a corticosteroid-sparing agent or as an alternative option to antifungal treatments, because of its excellent safety profile and low risk of drug interactions.

Clinical and microbiological characteristics of onychomycosis in a tertiary hospital: a cross-sectional study

BACKGROUND Onychomycosis is a common fungal nail infection with a low cure rate. While dermatophytes are the most common causal agent for onychomycosis, the incidence of Candida and nondermatophyte mold (NDM) onychomycosis is increasing. This study aimed to analyze the clinical and microbiological characteristics of patients with onychomycosis. METHODS Patients who visited the Department of Dermatology and Venereology, Cipto Mangunkusumo Hospital, and were diagnosed with onychomycosis from 2017 to 2022 were included. Diagnosis was established through clinical examination, supported by the result of direct microscopic examination with potassium hydroxide. RESULTS Of 171 patients, 93.6% had onychodystrophy, 65.5% were females, and 62.0% were aged 19–59 years. Most patients had onychodystrophy in more than three nails, affecting fingernails (31.6%) and toenails (34.5%). Interestingly, 84.8% of patients had no history of nail diseases. The median onset of disease was 24.0 (1–1,040) weeks, while the median onychomycosis severity index was 10.0 (2–40). Most cases were caused by Candida albicans (48.3%). Fusarium was the only NDM documented (2.3%). Some patients were resistant to itraconazole (11.4%) and miconazole (4.5%). Overall, 49.1% of the patients were declared not cured. CONCLUSIONS Candida was the predominant cause of onychomycosis, and onychodystrophy was the dominant feature. Current treatment regimens with systemic or topical antifungal agents did not yield satisfactory results, with more than half of the patients deemed not cured.

Disseminated Basidiobolomycosis Caused by Basidiobolus omanensis in a Child with Acute Lymphoblastic Leukemia (ALL). Case Report and Literature Review

Basidiobolomycosis is an uncommon fungal infection caused by the genus Basidiobolus. In immunocompetent children, it usually causes cutaneous infection and rarely affects the gastrointestinal tract, and it is extremely rare for the disease to spread. The present study reports the first case of disseminated basidiobolomycosis caused by Basidiobolus omanensis in a child with acute lymphoblastic leukemia who died as a result of uncontrolled infection and multi-organ failure despite surgical and antifungal therapy with L-AMB and voriconazole. A review of the literature yielded 76 cases, including the current case with the majority of which were reported as invasive gastrointestinal infection. The median age was 4 years (61 male and 15 female) and the majority of these children were from the Middle East (80%), specifically Saudi Arabia (45%). Most patients were treated with systemic antifungal agents (mostly itraconazole and amphotericin B). Surgical intervention was done in 25% of these patients and the death rate was 12%.

Clinical Manifestation and Treatment of Allergic Bronchopulmonary Aspergillosis.

Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction to airway colonization by Aspergillus fumigatus in patients with asthma and cystic fibrosis. The pathophysiology of ABPA involves a complex interplay between the fungus and the host immune response, which causes persistent inflammation and tissue damage. Patients present with chronic cough, wheezing, and dyspnea due to uncontrolled asthma. Characteristic symptoms include the expectoration of brownish mucus plugs. Radiographic findings often reveal fleeting pulmonary infiltrates, bronchiectasis, and mucus impaction. However, the definitive diagnosis of ABPA requires a combination of clinical, radiological, and immunological findings. The management of ABPA aims to reduce symptoms, prevent disease progression, and minimize the future risk of exacerbations. The treatment approach involves systemic glucocorticoids or antifungal agents to suppress the inflammatory response or fungal growth and prevent exacerbations. Biological agents may be used in patients with severe disease or glucocorticoid dependence. This review provides an overview of the clinical manifestations and current treatment options for ABPA.

Beauveria bassiana Keratitis: A Case Series and Review of Literature.

Beauveria bassiana is a filamentous fungus commonly used as an insecticide that rarely causes keratitis. Patients affected by Beauveria bassiana keratitis were retrospectively recruited at San Raffaele Hospital (Milan, Italy) between 2020 and 2022. All subjects underwent comprehensive ophthalmic evaluation, including in vivo confocal microscopy (IVCM) and microbiologic examination of corneal scrapings. Beauveria bassiana was identified using 18S rDNA targeted PCR. Four eyes of four patients (51 ± 8.8 years old) were evaluated. The main risk factors were soft contact lens wear (75%) and trauma with vegetative matter (50%). A superficial infiltrate was displayed in the majority of patients. Three cases (75%) showed hyphae on IVCM. All patients showed clinical improvement after topical antifungal therapy, although mostly through a combination of two antifungals (75%). One patient with a deeper infection required a systemic antifungal agent after one month of topical therapy. All cases required debridement to reduce the microbial load and enhance drug penetration. All patients experienced keratitis resolution following medical treatment (average: 3.3 months). The identification of risk factors and the early diagnosis of Beauveria bassiana keratitis are fundamental in order to avoid its penetration in the deeper corneal stromal layers. Topical antifungal drugs, possibly accompanied by ulcer debridement, may be a successful treatment if instilled from the early phases of the disease.

Evaluation of the Effectiveness of Antifungal Prophylaxis in Adult Acute Lymphoblastic Leukemia during Induction Chemotherapy

Background and Objectives: Due to immune suppression, patients with hematological malignancies are at a high risk of invasive fungal disease (IFD) during chemotherapy. For patients with myeloid tumors, antifungal prophylaxis is generally recognized. However, there are evident interactions between agents used in acute lymphoblastic leukemia (ALL) remission-induction and antifungal agents, resulting in most clinical trials excluding ALL patients. The need for primary antifungal prophylaxis in ALL patients during chemotherapy is still under debate. This study analyzed the efficacy of primary antifungal prophylaxis (PAP) and the incidence of IFD during the first remission induction in the PDT-ALL-2016 cohort, as well as evaluated the impact of PAP on the outcomes of ALL patients. Methods: The PDT-ALL-2016 cohort consists of 408 newly diagnosed ALL patients aged ≥ 14 years, treated between January 2016 and December 2021. All patients were treated using the GRAALL-2003 backbone, a pediatric-like regimen. This study included 280 patients, with a total of 128 exclusions. Excluded patients consisted of 103 individuals who received initial induction treatment in other hospitals, 12 individuals who died without IFD during the induction period, 9 individuals who experienced fungal infection before induction treatment, 2 individuals who did not complete induction remission treatment and were discharged, and 2 individuals who had lost their cases. PAP was defined as the administration of any systemic antifungal agent for two or more consecutive days to a patient without any evidence or history of IFD during the neutropenic period. The diagnosis of IFD was based on the European Organization for Research and Treatment of Cancer/Mycosis Study Group criteria. Results: Among the 280 patients, 232 received PAP, with caspofungin (n=104), voriconazole (n=59), micafungin (n=44), and others being used as prophylaxis. The baseline characteristics of patients who did or did not receive PAP were similar, except for the age difference (prophylaxis group median age 28.7 versus without prophylaxis group 23.0, P<0.01). In the cohort, 11 proven/probable and 21 possible IFD cases were identified. The incidence of IFD in patients who did or did not receive PAP was 8.6% and 25.0%, respectively. The cumulative incidence of IFD was significantly lower in patients receiving PAP compared to those who did not (HR 0.3, 95% CI 0.1-0.6; P=0.001). In the cohort, the infections of IFD negatively affected overall survival (HR 1.6, 95% CI 0.9-2.7, P=0.093). Conclusions: Our study demonstrates, in a real-life setting, that IFD is a poor prognostic factor for adult ALL and that PAP significantly reduces the incidence of IFD during induction chemotherapy, thereby improving patient survival. Furthermore, compared to published studies (4.3%-18.3%), the incidence of IFD in the prophylaxis group within our cohort is relatively lower. This research was supported by the National Natural Science Foundation of China(NFSC82170163, 81970147), Clinical Study of Nanfang Hospital(LC2016ZD009/2019CR012).

Simultaneous Quantification of Seven Antifungal Agents in Human Serum Using Liquid Chromatography-Tandem Mass Spectrometry.

Systemic antifungal agents are essential for high-risk patients undergoing immunosuppressive therapy or cancer chemotherapy because of the rapid increase in opportunistic fungal infections. Therapeutic drug monitoring is crucial to ensuring the efficacy and safety of antifungal agents owing to their pharmacokinetic variability. In the present study, we developed and validated a quantitative method for the simultaneous detection of seven commonly used antifungal drugs (amphotericin B, isavuconazole, voriconazole, fluconazole, posaconazole, caspofungin, and micafungin) using liquid chromatography-tandem mass spectrometry. Methanol (containing 0.1% formic acid) was used for protein precipitation and only 50 μL of serum was required for the analysis. Chromatographic separation was conducted using a Waters Acquity UPLC C8 column, and one stable isotope-labeled agent and two analogs were used as internal standards. The calibration curves ranged from 0.1 to 50 μg/mL for all agents, and the correlation coefficient (R2) for all calibration curves was above 0.9835. The intra-day precision (1.2-11.2%), inter-day precision (2.4-13.2%), and mean bias values (-10.9 to 13.6%) were within an acceptable range of ±15%. Successful implementation of the developed method in clinical practice would facilitate the effective monitoring of these antifungal agents.

Drug Utilization Evaluation of Systemic Antifungals in a Tertiary Care Hospital

Introduction: The incidence of Invasive Fungal Infection has increased, and it constitutes a serious threat to human health and life, especially in immunocompromised and critically ill patients. We aimed to evaluate the appropriateness of antifungal agents along with their risk factors and sensitivity pattern. Methods: It is a retrospective, cross-sectional study, which includes details of patients prescribed with systemic antifungal agents during a period of five years (01-06-2016 to 31-05-2021). Collected details were compared with Infectious Diseases Society of America (IDSA) guidelines and mycological results to determine the overall appropriateness. Results: A total of 102 patients prescribed with systemic antifungals were selected for the study. The majority of the drugs were prescribed as Definitive (59.19%) and T Fluconazole (39.4%) was the most common drug given. The most common indication for antifungal prescriptions was found to be Respiratory tract infection. Appropriateness of antifungal use was assessed on indication, dosage, contraindication, and drug-drug interaction. Overall assessment of antifungal agents and treatment strategy demonstrated that antifungal treatment was appropriate in 41.6% cases, debatable in 36% cases and inappropriate in 22.4% of cases. The most common culture specimen collected was urine and Candida tropicalis (42.86%) was the frequently separated organism from it. Sepsis (21.4%) was the most common risk factor associated with invasive fungal infection. Conclusion: By implementing an effective antifungal stewardship program, we could improve the rational use of systemic antifungals and thereby prevent the future resistance and improve clinical outcome.

THE INFLUENCE OF MEDICINAL AND AROMATIC PLANTS EXTRACTS ON THE ANTIFUNGAL EFFECT OF FLUCONAZOLE REGARDING C. ALBICANS AND C. TROPICALIS ISOLATED FROM PATIENTS WITH DENTURE STOMATITS

Candida albicans is one of the most common and virulent representatives of Candida fungi which causes fungal lesions of the mucous membranes predominantly in people with compromised immune system. Candida resistance to classical antifungals such as polyenes, azoles, allylamines is a serious practical problem. Imidazole and triazole are the most commonly used antifungal agents for candidiasis today. Their mechanism of action lies in the inhibition of ergosterol biosynthesis which is indispensable for maintaining the structural integrity of fungal cell membranes. Activation of elimination systems is often associated with changes in the structure of fungal membranes, leading to a decrease in the supply of azoles into the fungal cell Screening of antifungal activity and synergism of antifungal activity of 166 aqueous-ethanol plant extracts with Fluconazole in relation to 2 clinical strains of Candida fungi (C.) (C. albicans and C. tropicalis) with different mechanisms of azole resistance isolated from patients with prosthetic stomatitis was conducted by means of agar diffusion method. The expressed direct antifungal activity of extracts of Calendula officinalis L. inflorescences, flowers of Limonium platyphyllum Lincz., flowers of Grataegus monogyna Jacq., roots of Potentilla repens L., the grass of Melilotus albus Medik, leaves of Peucedanum ruthenicum Bieb, leaves of Rhus coriaria L. and aerial part of Polythridum commune Hedw was determined in reference to the tested strains. Synergism of antifungal action with 1/4, 1/8 and 1/32 of Fluconazole MIC (minimal inhibiting concentration) in relation to both test strains of yeast-like Candida fungi was demonstrated by the flowers of Calendula officinalis L, aerial part of Melilotus albus Medik. The main purpose of the screening was to discriminate extracts in order to select those that would be promising for further testing by a more accurate сheckerboard titration method. The efflux mechanism of resistance to triazoles (in C. tropicalis test strain) is more susceptible to modification by biologically active compounds of medicinal plants. Regarding C. albicans test strain which combines the efflux mechanism of resistance with mutation(s) of ergosterol biosynthesis enzymes, the modifying effect of plant extracts is much less frequent and less pronounced. Therefore, it may be assumed that mutations of ergosterol biosynthesis enzymes provide high stability of the phenotypic manifestation of Candida azole resistance. Should that be the case, determining the azole resistance mechanism of Candida clinical isolates may be important for clinical practice. Combination therapy is more beneficial than monotherapy because it may provide more effective destruction or suppression of pathogens. The combined action of synergistic agents is quite easy to achieve in case of localized superficial lesions (which occur on the mucous membranes of the prosthetic bed in candidal prosthetic stomatitis): for example, using a systemic antifungal agent and a topical agent that contains a modifier of resistance of plant origin fungi. Synergistic interactions will increase the therapeutic efficacy of drugs, reduce the likelihood of resistance occurrence or further development, and will reduce dose-related toxicity.

Antifungal Stewardship Programs in Children: Challenges and Opportunities.

Antifungal Stewardship Programs in Children: Challenges and Opportunities.

Candida Lusitaniae Endophthalmitis: A Brief Literature Review with a Focus on Treatment Options

Intraocular fungal infections are uncommon. They may originate either exogenously, as occurs with penetrating trauma and postoperative infections, or endogenously, through hematogenous spread. Patients at the highest risk of endogenous endophthalmitis are those with central venous catheters, total parenteral nutrition, and active intravenous drug use, as well as those who are immunosuppressed [1]. Candida species are the most common fungi identified from endogenous sources related to the above. Although the incidence of ocular involvement is unclear, a few studies provide a range of 2.2–16% in patients with candidemia [2,3]. Non-albicans species of candida infections are very rare. In particular, C. lusitaniae is found in only approximately 1% of patients with candida blood stream infections [4]. Treating candida ophthalmologic infections usually requires expertise of both ophthalmology and infectious diseases. Patients who have evidence of only chorioretinitis should be treated with systemic antifungal agents. Intravitreal injection in combination with systemic antifungals is recommended for patients with infections involving the macula or vitreous humor. Vitrectomy along with intravitreal injection and systemic antibiotic therapy is needed for patients with heavy vitritis [5]. The duration of treatment is decided on a case-by-case basis but typically consists of four to six weeks of systemic antifungal therapy.

483. Use of Terbinafine in Combination with Other Systemic Anti-fungal Agents As Treatment for Invasive Mold Infections. Experience from A National Cancer Institute Designated Cancer Center.

Abstract Background The severely Immunocompromised are at an increased risk of fatal infection caused by invasive molds. Amphotericin B and triazole agents with anti-mold activity are commonly used in treating invasive mold infections. There is some data from in-vitro experiments to suggest an enhanced killing of some molds when terbinafine is used in combination with certain azoles or amphotericin B. At our center, terbinafine is occasionally used in combination with other systemic anti-fungal agents in treating severely immunocompromised patients with invasive mold infections. Methods The study was a retrospective review of electronic medical records. Sixty-four patients treated for culture confirmed infection with mold isolates at the Moffitt Cancer Center from 1/1/2015 to 6/1/2021 were included in this study. There were 2 treatment groups: Group A comprised of those treated with a terbinafine containing regimen and Group B comprised of patients that were not treated with a terbinafine containing regimen. Results Treatment group A: Comprised of 14 patients. Twenty-nine percent (4/14) had skin/soft tissue infections, 21% (3/14) had rhinosinusitis, 21% (3/14) had pulmonary infections and 4 patients (29%) had disseminated infection. Thirty-six percent (5/14) were discharged with treatment response, 57% (8/14) did not respond to treatment or died due to the invasive mold infection and 7% (1/14) died as a result of malignancy. Treatment group B: Had 50 patients. thirty-eight percent (19/50) had pulmonary infections, 28% (14/50) with skin/soft tissue infections, 16% (8/50) had rhinosinusitis, 2% (1/50) were diagnosed with central nervous system infection, 2% (1/50) had gastrointestinal infection, 14% (7/50) had an unclear source of infection. Forty-eight percent (24/50) were discharged with treatment response, 42% (21/50) had treatment failure or died due to the invasive mold infection and 10% (5/50) died as a result of malignancy. Table 1Figure 1 Conclusion There was no statistically significant improvement in outcome observed in this study when terbinafine was used in addition to other systemic anti-fungal medications as treatment of invasive mold infections. There is a need for larger studies to determine if terbinafine has a role in the treatment of invasive mold infections. Disclosures All Authors: No reported disclosures.

Prescribing patterns of systemic antifungal medications in Indian patients with invasive fungal infections: a multicenter retrospective study

Background: Objectives of the study was to describe the utilization pattern of systemic antifungal agents in Indian patients with invasive fungal infections (IFIs).Methods: This real-world, multicenter (127 centers), retrospective analysis included data of patients receiving systemic antifungal medications at various centers across India. The study data was collected between April 2021 and March 2022.Results: Data of a total of 323 patients was analyzed. The mean age of patients was 54±13.52 years. There was male preponderance seen in this study (72.4%). Diabetes was the most common comorbidity (36.8%) followed by concomitant diabetes and hypertension (31.9%), hypertension (9.6%) and hematological malignancies (9.6%). The most common indication occurring in >10% of the patients and for whom systemic antifungals were used included pulmonary mucormycosis (33.1%) followed by invasive candidiasis (16.1%), sepsis (13.3%) and fungal pneumonia (11.8%). In total 323 patients, the most common antifungal drug prescribed was posaconazole (38.6%) followed by anidulafungin (32.8%), caspofungin (10.5%), fluconazole (9.3%) and micafungin (8.7%). Posaconazole was most commonly used for pulmonary mucormycosis (84.8%), fluconazole for sepsis (33.3%), caspofungin for fungal pneumonia (23.5%) and anidulafungin (33.1%), and micafungin (39.3%) for invasive candidiasis.Conclusions: This study provides real-world evidence on the demographics of Indian patients with IFIs and utilization pattern of systemic antifungals by health care physicians in clinical practice.

Study of Fractional Carbon Dioxide Laser in Treatment of Onychomycosis (100 Cases)

Background: Onychomycosis is a fungal infection of nail unit. Tinea unguium is dermatophytic nail infection. common dermatophytes causing onychomycosis is Trichophyton rubrum. Onychomycosis increase in frequency with age, amongst them adult males are more frequently affected than females. There are various topical and systemic antifungal agents available for onychomycosis. Despite this it is difficult to treat onychomycosis as higher local concentration of drug is required for clearing the infection and it is difficult to achieve. Aim and objectives: To ascertain efficacy of fractional carbon dioxide laser in onychomycosis. To evaluate fractional carbon dioxide laser's effectiveness in total clearance of onychomycosis from nails. Materials and methods: Methods: 100 patients of clinically diagnosed onychomycosis were selected. All patient’s KOH smear examination was done by collecting samples from scrapings of nail material. All patients were given systemic antifungals along with topical antifungals. Laser sittings had been done at an interval of 1 month. Total 6 monthly sittings were done. Topical lignocaine hydrochloride 2% w/v gel were applied for 20-30minutes before giving laser therapy. Standard digital photographs were taken before initiating the therapy and then repeated monthly. After completion of 6 months all patients were followed up for 9 months with an interval of 3 and 6 months. Results: At 6 months after completion of 6 sittings of CO2 laser 68 patients had complete response, 16 patients had significant response, 8 patients had moderate response, 8 patients had no response at 6 months of therapy. Limitations: Small population size, absence of control group, mycological culture was not performed were the main limitations of our study. Conclusion: Fractional carbon dioxide laser is effective in treating onychomycosis along with topical and systemic antifungals and it has minimal side effects. Keywords: Onychomycosis, fractional carbon dioxide (CO2) laser.

Nystatin Effectiveness in Oral Candidiasis Treatment: A Systematic Review & Meta-Analysis of Clinical Trials.

Oral candidiasis is the most common opportunistic fungal infection caused by commensal Candida species. Since there are various local and systemic predisposing factors for the disease, the treatment also varies from topical to systemic antifungal agents. Nystatin is a common antifungal agent used topically. The aim of this systematic review was to evaluate and compare the efficacy of different antifungal agents and the safety of nystatin in the treatment of oral candidiasis. Three electronic databases were searched for randomized controlled trials comparing nystatin with other anti-fungal therapies or placebo. Clinical and/or mycological cure was the outcome evaluation. A meta-analysis and descriptive study on the efficacy, treatment protocols, and safety of nystatin was also conducted. The meta-analysis included five studies, which compared the efficacy of nystatin suspensions with photodynamic therapy. A significant difference in the colony-forming units per milliliters (CFU/mL) of Candida species was observed at 60 days intervals for both palatal mucosa and denture surfaces, with both groups favoring nystatin with low heterogeneity at a 95% confidence interval. Nystatin and photodynamic therapy were found to be equally effective for the clinical remission of denture stomatitis as well as a significant reduction of CFU/mL of Candida species from dentures and palatal surfaces of the patients.

Effect of empirical antifungal treatment on mortality in non-neutropenic critically ill patients: a propensity-matched retrospective cohort study.

To evaluate the effect of empirical antifungal treatment (EAFT) on mortality in critically ill patients without invasive fungal infections (IFIs). This was a single-center propensity score-matched retrospective cohort study involving non-transplanted, non-neutropenic critically ill patients with risk factors for invasive candidiasis (IC) in the absence of IFIs. We compared all-cause hospital mortality and infection-attributable hospital mortality in patients who was given EAFT for suspected IC as the cohort group and those without any systemic antifungal agents as the control group. Among 640 eligible patients, 177 patients given EAFT and 177 control patients were included in the analyses. As compared with controls, EAFT was not associated with the lower risks of all-cause hospital mortality [odds ratio (OR), 0.911; 95% CI, 0.541-1.531; P = 0.724] or infection-attributable hospital mortality (OR, 1.149; 95% CI, 0.632-2.092; P = 0.648). EAFT showed no benefit of improvement of infection at discharge, duration of mechanical ventilation, and antibiotic-free days. However, the later initiation of EAFT was associated with higher risks of all-cause hospital mortality (OR, 1.039; 95% CI, 1.003 to 1.076; P = 0.034) and infection-attributable hospital mortality (OR, 1.046; 95% CI, 1.009 to 1.085; P = 0.015) in patients with suspected IC. This effect was also found in infection-attributable hospital mortality (OR, 1.042; 95% CI, 1.005 to 1.081; P = 0.027) in septic patients with suspected IC. EAFT failed to decrease hospital mortality in non-neutropenic critically ill patients without IFIs. The timing may be critical for EAFT to improve mortality in these patients with suspected IC. ChiCTR2000038811, registered on Oct 3, 2020.

Post-traumatic orbital subperiosteal hematoma presenting as proptosis with Curvularia keratitis

A 13-year child presented with protrusion of the left eye (LE) with redness, pain, and diminution of vision following blunt head trauma. The best-corrected visual acuity (BCVA) in the LE was hand movement. On examination, LE had abaxial proptosis with lagophthalmos and severe exposure keratopathy. There was a large corneal ulcer with feathery margins and superficial brown pigmentation, confirmed as Curvularia spp. on microbiological assessment. A computed tomography (CT) scan of the orbit and brain demonstrated superior subperiosteal hematoma of the orbit and frontal epidural hematoma. Aspiration of blood from subperiosteal orbital hematoma resulted in an immediate reduction of proptosis. The epidural hematoma resolved spontaneously. Treatment with topical and systemic antifungal agents resulted in complete healing of the keratitis with a residual leucomatous corneal opacity. Emergency treatment of subperiosteal orbital hematoma through needle aspiration helps in the early resolution of proptosis, exposure keratopathy, and visual loss.