Fungemia in cancer patients in Brazil: Predominance of non-albicans species

The objective of this study was to characterize the epidemiology of candidemia in cancer patients in the city of Rio de Janeiro, Brazil. An 18-month survey of fungemia in patients with cancer was undertaken in three Hospitals in Rio de Janeiro. Forty-three episodes of candidemia were identified in 43 patients, 43 of which were episodes of candidemia; in ten cases the strains were not available for further identification of species and were excluded from this analysis. The overall distribution of fungi causing fungemia was: Candida albicans (5), Candida tropicalis (16), Candida parapsilosis (6), Candida guilliermondii (4), Candida lusitaniae (1) and Candida stellatoidea (1). Antifungal prophylaxis had been administered before the episode of fungemia in only six patients (18.2%): oral itraconazole in three patients and oral nistatin, low dose intravenous amphotericin B and oral fluconazole in one patient each. There was no difference in the presence of risk factors, clinical characteristics or in the outcome between albicans and non-albicans species, nor between Candida tropicalis and other non-albicans species. There was a clear predominance of non-albicans species, regardless of the underlying disease, antifungal prophylaxis or the presence of neutropenia. This revised version was published online in June 2006 with corrections to the Cover Date.     

Isolation of Candida auris in large hospitals in the Autonomous Community of Valencia; population-based study (2013–2017)

BackgroundCandida auris is an emerging multidrug-resistant and highly virulent yeast that spreads easily among patients.AimsTo describe the characteristics of candidemia caused by C. auris in the southeast of Spain (Autonomous Community of Valencia – ACV) through a 5-year population-based study.MethodsAn analysis of all the episodes of candidemia diagnosed in the ACV, with approximately 4,500,000 inhabitants, during 2013–2017, was done. Data were obtained from the Epidemiological Surveillance Valencian Network, a network that collects all the microbiological data from the hospitals in the study region.ResultsBased on the records, 1.9% of the isolates recovered from the positive blood cultures (corresponding to 1789 patients) were yeasts. This implies an annual rate of 7.09 cases/100,000 inhabitants. Of the 23 yeast species isolated, Candida albicans was the most frequent (37.3%), showing a higher frequency than Candida parapsilosis (28.4%) and Candida glabrata (15.6%) (p < 0.0001). It is remarkable the emergence of C. auris during 2016 and 2017, as this species became the fourth more prevalent in 2016 (9.2%), and the third in 2017 (15.7%). Fungemia was more common in hospitals with >500 beds (63.3% versus 36.7% in small hospitals) (p < 0.0001), and C. auris was mostly isolated in large hospitals (8.5% versus 0.3%); its incidence was higher in autumn and among the age group of 65–84 years.ConclusionsThe information about the local epidemiology of candidemia is essential in order to decide the best empirical treatment approach. This study reports the novel presence of C. auris in large hospitals. This pathogen has usually resistance to several antifungals and causes severe fungemia, so the results of this work reveal the need to monitor the presence of this species systematically.     

Epidemiology of invasive pneumococcal disease in older people in Spain (2007-2009): implications for future vaccination strategies

Background

Recently, the 13-valent pneumococcal conjugate vaccine (PCV13) has been recommended for adults. We analyzed the epidemiology of invasive pneumococcal disease (IPD) in older adults in Spain before PCV13 introduction.

Methodology/Principal Findings

IPD episodes, defined as clinical findings together with an invasive pneumococcal isolate, were prospectively collected from patients aged over 65 years in three hospitals in Spain from 2007 to 2009. A total of 335 IPD episodes were collected. Pneumonia was the main clinical syndrome, while chronic obstructive pulmonary disease, diabetes mellitus and cancer were the main underlying diseases. Pneumococcal isolates were serotyped and the molecular typing was performed by PFGE/MLST. PCV13 serotypes accounted for 59.3% of isolates, the most prevalent being serotypes 19A (15.1%), 3 (9.6%), 7F (7.5%), 14 (6.9%) and 1 (5.4%). The most frequent non-PCV13 serotypes were serotypes 16F (4.5%), 22F (3.6%), 24F (3.3%) and 6C (2.1%). The most common genotypes were CC230 (8.5%, serotypes 19A and 24F), CC156 (8.2%, serotypes 9V and 14), ST191 (7.9%, serotype 7F), CC260 (6.6%, serotype 3), ST306 (5.2%, serotype 1), CC30 (4.6%, serotype 16F) and ST433 (3.6%, serotype 22F). Comparing the 335 IPD isolates to 174 invasive pneumococci collected at the same hospitals in 1999–2000, PCV7 serotypes decreased (45.4% vs 18.4%,p<0.001), non-PCV7 serotypes included in PCV13 increased (26.4% vs 41.0%,p = 0.001) and two non-PCV13 serotypes increased (serotype 6C 0% vs 2.1%, p = 0.05; serotype 24F 0.6% vs 3.3%, p = 0.04,).

Conclusion

In our older adult population two serotypes (19A and 3) included in PCV13 accounted for about a quarter of IPD episodes in people ≥65 years. Non-PCV13 emerging serotypes should be carefully monitored in future surveillance studies.     

Bloodstream infections in late-stage acquired immunodeficiency syndrome patients evaluated by a lysis centrifugation system

Opportunistic infections, which affect acquired immunodeficiency syndrome (Aids) patients, are frequently disseminated and may cause bloodstream infections (BSI). The aim of this study was to evaluate the main causes of BSI in Aids patients with advanced stage of the disease, with special emphasis on the identification of fungemia. During a 21 months period, all patients with Aids (CD4 < 200) and febrile syndrome admitted to 3 university hospitals were systematically evaluated. For each patient presenting fever, a pair of blood cultures was collected and processed by using a commercial lysis-centrifugation system. One hundred and eleven patients (75 males) with a mean age of 36 years (median 33 years) and mean CD4 count of 64 cells/ml were included. Among the 111 patients evaluated we documented 54 episodes of BSI, including 46 patients with truly systemic infections and 8 episodes considered as contaminants. BSI were caused by gram-positive bacteria (43%), fungi (20%), gram-negative bacteria (15%), mycobacteria (15%), and mixed flora (7%). The crude mortality rate of our patients was 39%, being 50% for patients with BSI and 31% for the others. In conclusion, BSI are a common related to systemic infections on Aids patients with advanced stage of disease and is associated with a high rate of mortality.     

Analysed yeast-like fungi isolated from blood of febrile neutropenic children with neoplastic disease

The aim of the study was the analysis of frequency of yeast-like fungi as etiological agents of fungemias in 181 children suffering from cancer treated in the years 1997-2000 in the Pediatric, Hematology and Oncology Clinique of the State Clinical Hospital in Bydgoszcz. Peripheral blood samples an collected from vascular catheters were incubated in VITAL 200 (bio Mérieux). Positive blood samples were inoculated on Sabouraud medium with chloramphenicol (bio Mérieux), of cultivation from 24 hours at 37 degrees C, following two hours at 22 degrees C. Fungal strains were identified by standard mycological procedures using ID 32 strips (bioMérieux). The total number of positive blood cultures was 1032 (22,1%). There have been recognized 22 fungemia by the children with fever in neutropenia period. Among fungi isolated from peripheral blood samples Candida spp. (13.4%), C. tropicalis (8.2%), stranis dominated. From blood samples collected from vascular catheters most often Candida spp. (29.9%), Candida parapsilosis (14.4%) and C. tropicalis (9.3%) were isolated.     

Etiologic agents of fungemia in hospitalized patients]

The aim of performed examinations was the analysis of fungi as etiological agents of blood infections in patients hospitalized in surgical wards, internal medicine wards and intensive care units of the Medical Academy Central Clinical Hospital in Warsaw. Blood samples from patients hospitalized in 1997 were examined. Peripheral blood samples were incubated in BacT/Alert system (Organon Teknika, USA). Positive blood samples were inoculated on Sabouraud medium with chloramphenicol (bioMerieux, France or Oxoid, England). The time of cultivation was from 48 hours to 7 days at 30 degrees C. Fungal strains were identified by standard mycological procedures with the use of chromogenic medium BBL CHROMagar Candida (Becton Dickinson, USA) and biochemical test ID 32 C (bioMerieux, France). Susceptibility of strains to antifungal agents was determined by ATB FUNGUS method (bioMerieux, France). The total number of positive blood cultures in 1997 was 1380. Forty-two fungal strains were isolated from blood samples (3%). Strains belonged to the following species: C. albicans (17 isolates), C. parapsilosis (15), C. glabrata (3), melibiosica (2), C. pelliculosa (2), C. guilliermondii (1), C. tropicalis (1) and T. beigelii (1). Among fungi cultured from patients hospitalized in operative wards dominated C. parapsilosis (11) and C. albicans (10) strains, whereas from patients hospitalized in conservative wards most often C. albicans (6) strains were isolated. Candida strains were mostly susceptible to antifungal agents tested. It was interesting to culture Trichosporon beigelii (T. cutaneum) strain as an etiological agent of fungemia. This strain was multidrug-resistant.     

Prevalence of nosocomial infections in selected hospitals

A point prevalence survey of NI in 10 hospitals has been carried out with the aim to obtain more valid results about their occurrence and to raise the interest of clinicians in this problem. Altogether data on 5,553 hospitalized patients have been evaluated. An epidemiologist along with a clinician jointly found a total 365 of NI in 344 patients a point prevalence 6.6%. The prevalence ranged between 3.6 and 10.5% for different hospitals. The highest NI prevalence was found in surgical wards (urology 19.6%, surgery 12.2%). Undesirably high prevalence of NI was observed in paediatrics (mainly diarrhoeal diseases) and neonatal (conjunctivitis) wards. Infections of the upper respiratory tract were most frequently followed by surgical wound infections and infections of the urinary tract. The occurrence of NI of surgical wounds, urinary tract infections and infections of skin was increasing, while the occurrence of infections of gastrointestinal tract and of the eye was decreasing with age. Gram-negative bacteria were more frequently isolated than Gram-positive bacteria (2:1).     

Fungemia in acute leukemia patients: a single institution's experience

A retrospective study was conducted in 22 episodes of candidemia in 445 patients with acute leukemia (AL) (incidence 4.9%) observed at our Institution between February 1996 and November 2003 to evaluate the variables related to the onset and outcome of infection. Of 22 patients, 20 (90.9%) had refractory/relapsed AL. C. albicans was responsible for 7/22 of the fungemia cases (32%) and C. non albicans for 15/22 (68%). The median absolute neutrophil count was 0.1 x10(9)/L (range 0.04-0.3) at the time of the candidemia diagnosis. The fungemia responded to antifungal therapy in 15/22 (68.1%) patients; among patients with a positive outcome of the fungemia, in 14/15 (93.3%) the neutrophil count recovered within 7 days after the diagnosis of candidemia (p < 0.05). The mortality rate due to candidemia was 31.9% (1/7: 14.2% and 6/15: 40% in the C. albicans and C. non albicans groups, respectively). In our experience the determinants of a positive outcome of fungemia were infection by the C. albicans species and recovery of the neutrophil count.     

Species distribution and antifungal susceptibility profile of Candida spp. bloodstream isolates from Latin American hospitals

From March 1999 to March 2000, we conducted a prospective multicenter study of candidemia involving five tertiary care hospitals from four countries in Latin America. Yeast isolates were identified by classical methods and the antifungal susceptibility profile was determined according to the National Committee for Clinical Laboratory Standards microbroth assay method. During a 12 month-period we were able to collect a total of 103 bloodstream isolates of Candida spp. C. albicans was the most frequently isolated species accounting for 42% of all isolates. Non-albicans Candida species strains accounted for 58% of all episodes of candidemia and were mostly represented by C. tropicalis (24.2%) and C. parapsilosis (21.3%). It is noteworthy that we were able to identify two cases of C. lusitaniae from different institutions. In our casuistic, non-albicans Candida species isolates related to candidemic episodes were susceptible to fluconazole. Continuously surveillance programs are needed in order to identify possible changes in the species distribution and antifungal susceptibility patterns of yeasts that may occurs after increasing the use of azoles in Latin American hospitals.     

Epidemiology, species distribution, antifungal susceptibility and outcome of nosocomial candidemia in a tertiary care hospital in Italy

Candida is an important cause of bloodstream infections (BSI), causing significant mortality and morbidity in health care settings. From January 2008 to December 2010 all consecutive patients who developed candidemia at San Martino University Hospital, Italy were enrolled in the study. A total of 348 episodes of candidaemia were identified during the study period (January 2008-December 2010), with an incidence of 1,73 episodes/1000 admissions. Globally, albicans and non-albicans species caused around 50% of the cases each. Non-albicans included Candida parapsilosis (28.4%), Candida glabrata (9.5%), Candida tropicalis (6.6%), and Candida krusei (2.6%). Out of 324 evaluable patients, 141 (43.5%) died within 30 days from the onset of candidemia. C. parapsilosis candidemia was associated with the lowest mortality rate (36.2%). In contrast, patients with C. krusei BSI had the highest mortality rate (55.5%) in this cohort. Regarding the crude mortality in the different units, patients in Internal Medicine wards had the highest mortality rate (54.1%), followed by patients in ICU and Hemato-Oncology wards (47.6%).This report shows that candidemia is a significant source of morbidity in Italy, with a substantial burden of disease, mortality, and likely high associated costs. Although our high rates of candidemia may be related to high rates of BSI in general in Italian public hospitals, reasons for these high rates are not clear and warrant further study. Determining factors associated with these high rates may lead to identifying measures that can help to prevent disease.     

2013年中国侵袭性酵母菌感染流行病学和唑类药物耐药性分析

目的通过对中国侵袭性真菌监测网(CHIF-NET)2013年中国48家综合医院收集的1 562株酵母菌进行流行病学分布及唑类耐药性分析,为临床侵袭性酵母菌的唑类用药提供数据基础。方法收集2013年中国侵袭性真菌监测网48家医院共1 562株酵母菌菌株及其原始信息,采用基质辅助激光解析电离飞行时间质谱(MALDI-TO MS,法国生物梅里埃公司)结合核糖体DNA测序明确菌种鉴定;根据美国临床实验室标准化协会(CLSI)M44-A2纸片扩散法检测菌株对氟康唑及伏立康唑的敏感性。结果本研究共分离出酵母菌1 562株,其中白念珠菌分离率最高(38.4%),其次为近平滑念珠菌复合体(18.4%)、热带念珠菌(16.4%)、光滑念珠菌复合体(9.4%)及其他少见菌种(<6.4%);患者性别中男性占比(60.7%)高于女性(38.9%);患者年龄中,65岁以上年龄段患者最多(34.2%),其次为50~65岁(30.6%)、15~49岁(29.9%)和0~14岁患者(<1.9%);标本来源中以血液标本(46.4%)为主,其次为腹水(10.2%)、导管(9.2%)及引流液(8.5%)、分泌物(5.2%),其他标本类型均较少(<4.7%)。住院患者分离率(93%)显著高于门急诊患者(7%);科室类型中以外科患者(33.8%)为主,其次为重症监护病房(ICU)患者(27.5%)、内科患者(20.5%)及其他病房(<18.2%);药敏结果显示,白念珠菌及近平滑念珠菌复合体对氟康唑及伏立康唑敏感性均较高(>94%),热带念珠菌对氟康唑及伏立康交叉耐药率最高(21.9%),光滑念珠菌复合体交叉耐药率次之(15%),其次为季也蒙念珠菌(8.1%)和菌膜念珠菌(4.3%)。结论应持续加强中国地区侵袭性酵母菌监测,在使用抗菌药物过程中,合理控制其用量,防止耐药率的上升。     

Study of acute vulvovaginitis in sexually active adult women, with special reference to candidosis, in patients of the Francisco J. Muñiz Infectious Diseases Hospital

The results of microbiological vaginal secretions samples obtained from 749 women (from July 2001 to July 2002) were studied in the Bacteriology Unit of the Francisco Javier Mu?iz Hospital from Buenos Aires. All patients suffered acute vulvovaginitis were child bearing and sexually active women, 334 of them were HIV-positive. The following are the results of the microbiological studies: Lactobacillus spp 50.6%, Gardnerella vaginalis 25.6%, Candida spp 17.4%, Trichomonas vaginalis 5.3%, Neisseria gonorrhoeae 0.3% and B group Streptococcus 0.8%. Candida vaginitis was significantly more frequent in HIV-positive patients, (21.6% vs 14%; p = 0.0086); meanwhile, trichomoniasis was less common although the difference was not statistically significant (3.6 vs 6.7%, p = 0.0810). The following Candida species were isolated in this study: Candida albicans 76.8%, Candida glabrata 15.6%, Candida parapsilosis 2.9%, Candida tropicalis 1.5% and Candida krusei 0.7%. Eight cases (6.2%) of vaginitis were produced by two Candida species (C. albicans and C. glabrata), and in three cases (2.17%) Saccharomyces cerevisiae were isolated. Five women suffering acute vaginitis with Candida spp presented another etiologic agent of vaginal infection, three cases T. vaginalis and two cases G. vaginalis. The following are some of the most important findings of this study: 1) Half of the patients presented a normal microbial biota; 2) Candida spp vaginitis was significantly more frequent among HIV-positive women; 3) we observed a high incidence of Candida glabrata infections (15.9%), 4) 6.2% of vaginal candidiasis were caused by more than one Candida species and, 5) the susceptibility pattern of C. albicans and C. glabrata isolates against fluconazole was similar to the one observed in other studies. The majority of C. albicans isolates were susceptible to fluconazole (MIC90 = 0.5 microg/ml) meanwhile C. glabrata strains were much less susceptible to this drug (MIC50 and MIC90 = 32 microg/ml).     

外科危重病人呼吸道院内感染的调查分析

目的：了解外科危重病人呼吸道院内感染致病菌及其细菌耐药性情况．为临床防治提供依据。方法：对我院SICU1997年1月～1999年12月三年间从痰标本中所分离的致病菌及其细菌耐药性进行回顾性调查。结果：外科危重病人呼吸道内感染仍以G^-菌为主,占58．0％,其次真菌25．4％、G^ 菌16．6％,致病菌前四位分别铜绿假单胞菌、白色念珠菌、嗜麦芽窄食黄单胞菌和耐甲氧西林金黄色葡萄球菌。体外药物敏感试验显示主要的致病菌均呈多重耐药特性。结论：本SICU呼吸道院内感染的致病菌仍以G^-菌为主,致病菌呈多重耐药特性,掌握本科室呼吸道内感染致病菌谱及其耐药特性具有重要意义。     

Rhodotorula infection. A systematic review of 128 cases from literature

Rhodotorula is an emerging opportunistic pathogen, particularly in immunocompromised patients. Many cases of fungemia associated with catheters, endocarditis, peritonitis, meningitis, and endophthalmitis are infections incited by this yeast. The main purpose of this study was to review all cases of Rhodotorula infection reported in the literature and to describe risk factors, underlying conditions and outcome. From 128 cases, 79% were fungemia (103 cases), 7% eye infections (nine cases) and 5% (six cases) peritonitis associated with continuous ambulatory peritoneal dialysis. Eighty seven percent of Rhodotorula infections are associated with underlying immunosuppression or cancer. The most common isolated risk factor associated with Rhodotorula infection was the use of a central venous catheter, which was found in 83.4% of Rhodotorula fungemia (86 cases). Rhodotorula mucilaginosa was the most common species of fungemia (74% of cases), followed by Rhodotorula glutinis with 7.7%. The species was not identified in 17% of the cases of fungemias. Amphotericin was the drug of choice in the treatment of fungemia and most of the eye infections were treated with topical amphotericin, although all patients lost their vision. All peritonitis cases associated with continous ambulatory peritoneal dialysis needed to have the Tenckoff catheter changed. The overall mortality of Rhodotorula infection was 12.6%.     

Care of dying patients in hospital.

OBJECTIVE--To study the process of care of dying patients in general hospitals. DESIGN--Non-participant observer (MM) carried out regular periods of continuous comprehensive observation in wards where there were dying patients, recording the quantity and quality of care given. Observations were made in 1983. SETTING--13 wards (six surgical, six medical, and one specialist unit) in four large teaching hospitals (bed capacity 504-796) in west of Scotland. SUBJECTS--50 dying patients (29 female, 21 male) with mean age of 66 (range 40-89); 29 were dying from cancer and 21 from non-malignant disease. RESULTS--Final period of hospitalisation ranged from 6 hours to 24 weeks. More than half of all patients retained consciousness until shortly before death. Basic interventions to maintain patients'' comfort were often not provided: oral hygiene was often poor, thirst remained unquenched, and little assistance was given to encourage eating. Contact between nurses and the dying patients was minimal; distancing and isolation of patients by most medical and nursing staff were evident; this isolation increased as death approached. CONCLUSIONS--Care of many of the dying patients observed in these hospitals was poor. We need to identify and implement practical steps to facilitate high quality care of the dying. Much can be learned from the hospice movement, but such knowledge and skills must be replicated in all settings.     

Epidemiology of candidemia in Spain - Multicenter study

The results of the epidemiological study on candidemias with the highest number of cases carried out in Spain is presented. This study is included in the Epidemiological Survey of Candidemia in Europe supported by the ECMM in which another five countries take part. In the Spanish study, 19 hospitals participated, 290 candidemia episodes were analysed (80 in children under 15 years and 210 in adults), 293 strains of yeasts being isolated. Both in children and in adults, the risks factors more frequently observed were the intravenous catheter and previous antibiotic therapy. In adults, the most habitual underlying disease was the solid tumor and, in children, hematological diseases. Candida albicans was the most prevalent species isolated in adults (46.1%) and Candida parapsilosis in children (50%). As part of the therapy, the intravenous line was removed and antifungal treatment was prescribed to 74% and 92.5% of children, respectively and to 43.8% and 73.8% of adults. The antifungal agent of election in adults was fluconazole (54.8%) and liposomal amphotericin B (58.1%) in children. The global mortality of the study was 38.9%, which for ages was major in adults (41.4%) than in children (38.7%). The geographical distribution of the isolated species was homogeneous, C. albicans being the predominant species, with the exception of Galicia and Extremadura where C. parapsilosis was the most frequent.     

Chronic recurrent candidiasis of the genitalia in females due to non-albicans Candida spp.]

1346 women with the symptoms of chronic recurrent urogenital infection were examined. The diagnosis of genital candidiasis was confirmed by the clinical manifestations (not less than its 4 episodes a year) and laboratory tests: budding fungal cells, mycelium and/or pseudomyselium in the vaginal smears detected microscopically, growth of Candida spp. on the Sabouraud's medium. The species of the isolates were determined by the standard morphological and biochemical tests. The in vitro susceptibility to fluconazole and voriconazole was evaluated by the disk diffusion method (Protocol CLSI M44-A). The frequency of chronic recurrent genital candidiasis in women with chronic urogenital infection amounted to 19%. The pathogens of the disease belonged to 12 species of Candida. The main pathogen was Candida albicans (83%). Most of the isolates (88%) were susceptible to fluconazole. 99.5% of the isolates was susceptible to voriconazole. The isolates resistant to fluconazole mainly belonged to non-albicans (41% vs. 1% of Candida albicans) and were obviously more frequent under the following conditions: the age of the females above 36 years (including the periods of peri- and postmenopause), frequent relapses (at least 7 a years), atypical clinical and laboratory signs.     

Pichia anomala (Candida pelliculosa) Fungemia in a Patient with Sickle Cell Disease

This case report discusses a patient with sickle cell disease who presented with fungemia from Pichia anomala (teleomorph: Candida pelliculosa). The organism was identified as P. anomala by MALDI-TOF VITEK mass spectrometry and VITEK 2 yeast identification card. Pichia anomala should be considered in sickle cell patients with recurrent fungemia.     

<Emphasis Type="Italic">Coccidioides</Emphasis> Fungemia in Six Patients,with a Review of the Literature

To identify demographics, clinical manifestations, and outcomes of patients with Coccidioides fungemia, we searched our institutional medical records to identify patients with Coccidioides fungemia treated between 1998 and 2008 and conducted a comprehensive search of the medical literature to identify previously reported cases. Coccidioides fungemia is an uncommon manifestation of coccidioidomycosis, a fungal infection caused by Coccidioides sp. endemic to the southwestern United States. Six Coccidioides fungemia patients were treated at our institution during the 10-year period. All 6 had underlying comorbid disease; three were receiving immunosuppressants. Three patients survived longer than 2 years. The literature review identified 107 patients, bringing the total cohort to 113 (mean age, 42 years). Forty-three patients (38%) had infection with the human immunodeficiency virus, 20 (18%) were receiving corticosteroids, 11 (10%) had solid organ transplants, and 5 (4%) were pregnant. Sites of extrapulmonary dissemination were reported for 97 (86%); the most common sites were liver (26/97 [27%]), spleen (21/97 [22%]), and meninges/central nervous system (17/97 [18%]). No patient showed evidence of endocarditis. At least 1 serologic test was positive in 45 (87%) of 52 patients for whom results were available. Overall mortality at 30 days was 62% (70/113; mean survival, 11.4 days). Survival was significantly worse in immunocompromised versus immunocompetent patients (22/72 [31%] vs. 19/36 [53%], respectively; P = .04). Lack of antifungal therapy predicted poor survival (8/38 [21%] vs. 32/65 [49%], respectively; P = .004). Coccidioides fungemia is an uncommon manifestation of fulminant, disseminated coccidioidomycosis. Survival is poorest in immunocompromised patients or those not receiving antifungal therapy.     

Successful Surgical Intervention for the Management of Endocarditis due to Multidrug Resistant <Emphasis Type="Italic">Candida parapsilosis</Emphasis>: Case Report and Literature Review

Candida parapsilosis is an uncommon cause of invasive endocarditis. This pathogen induces severe complications and carries a high mortality rate. We describe a case of C. parapsilosis endocarditis in a 54-year-old man with a history of HIV and Hepatitis C infection who previously underwent prosthetic valve replacement due to bacterial endocarditis. The patient presented with prolonged febrile episodes and fungemia with repeat blood cultures positive for C. parapsilosis. The patient failed multiple regimens of antifungal therapy and the C. parapsilosis isolate progressively acquired resistance to a number of drugs. Due to the multidrug resistant nature of the isolate, replacement of the infected valve was required to resolve his fungemia, and the patient remained asymptomatic for two years. This case is unusual due to the multidrug resistant nature of the isolate requiring both combined medical and surgical intervention. A review of published reports indicates that endocarditis due to C. parapsilosis responds well to a combination of medical and surgical interventions; the latter is particularly suitable for immunocompromised hosts.