Mycoses
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Review Case Reports
Meningitis caused by Filobasidium uniguttulatum: case report and overview of the literature.
Cryptococcal meningitis is mainly caused by Cryptococcus neoformans and Cryptococcus gattii, but occasionally other Cryptococcus species and phylogenetically related species are involved. Herein, we present a case of cryptococcal meningitis from China, which was caused by an azole and flucytosine resistant Filobasidium uniguttulatum. ⋯ Leukaemia and cancer were important risk factors in HIV-negative patients. Molecular identification and susceptibility testing are important for proper management of patients because the species involved may differ in susceptibility to antifungal drugs.
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Immunocompromised patients have a high risk for invasive fungal diseases (IFDs). These infections are mostly life-threatening and an early diagnosis and initiation of appropriate antifungal therapy are essential for the clinical outcome. Empirical treatment is regarded as the standard of care for granulocytopenic patients who remain febrile despite broad-spectrum antibiotics. ⋯ Pre-emptive antifungal therapy is now increasingly used to close the time gap between delayed initiation for proven disease and empirical treatment for anticipated infection without further laboratory or radiological evidence of fungal disease. Currently, some new non-invasive microbiological and laboratory methods, like the Aspergillus-galactomannan sandwich-enzyme immunoassay (Aspergillus GM-ELISA), 1,3-β-D-glucan assay or PCR techniques have been developed for a better diagnosis and determination of target patients. The current diagnostic approaches to fungal infections and the role of the revised definitions for invasive fungal infections, now IFDs, will be discussed in this review as well as old and emerging approaches to empirical, pre-emptive and targeted antifungal therapies in patients with haemato-oncological malignancies.
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Review Practice Guideline
Diagnosis and therapy of Candida infections: joint recommendations of the German Speaking Mycological Society and the Paul-Ehrlich-Society for Chemotherapy.
Invasive Candida infections are important causes of morbidity and mortality in immunocompromised and hospitalised patients. This article provides the joint recommendations of the German-speaking Mycological Society (Deutschsprachige Mykologische Gesellschaft, DMyKG) and the Paul-Ehrlich-Society for Chemotherapy (PEG) for diagnosis and treatment of invasive and superficial Candida infections. The recommendations are based on published results of clinical trials, case-series and expert opinion using the evidence criteria set forth by the Infectious Diseases Society of America (IDSA). ⋯ The duration of treatment for uncomplicated candidaemia is 14 days following the first negative blood culture and resolution of all associated symptoms and findings. Ophthalmoscopy is recommended prior to the discontinuation of antifungal chemotherapy to rule out endophthalmitis or chorioretinitis. Beyond these key recommendations, this article provides detailed recommendations for specific disease entities, for antifungal treatment in paediatric patients as well as a comprehensive discussion of epidemiology, clinical presentation and emerging diagnostic options of invasive and superficial Candida infections.
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For the specialist, the management of invasive candidiasis infections, from diagnosis to selection of the therapeutic protocol, is often a challenge. Although early diagnosis and treatment are associated with a better prognosis, apart from cases with positive blood cultures or fluid/tissue biopsy, diagnosis is neither sensitive nor specific, relying on many different factors, clinical and laboratory findings but there is certainly a need for the specific markers in this disease. Recently, new serodiagnostic assays as Candida albicans germ-tube antibodies or (1,3)-beta-D-glucan detection and molecular techniques for the detection of fungal-specific DNA have been developed with controversial results in critical care setting. ⋯ Clinical scores were built from those risk factors. For these reasons, an approach to the new diagnosis tools in the clinical mycology laboratory and an analysis of the new prediction rules and its application situations has been made. Currently, the combination of prediction rules and non-culture microbiological tools could be the clue for improving the diagnosis and prognosis of invasive fungal infections in critically ill patients.
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Invasive fungal infections on the intensive care unit are predominantly caused by Candida spp., most frequently manifesting as candidemia. In spite of increasing treatment options during the last two decades, mortality of invasive candidiasis remains high with 20 to 50%. With the echinocandins, a new class of antifungal drugs with activity against clinically relevant Aspergillus and Candida spp. has become available since the beginning of the new millennium. ⋯ All trials observed non-inferiority of the new drugs against the standard treatment; in the case of anidulafungin, superiority against fluconazole was demonstrated. These results of the trials had resulted in modification of the current guidelines for the treatment of candidemia and invasive candidiasis. Especially in ICU patients frequently showing single- or multi-organ failure and receiving a multitude of drugs with complex interactions, echinocandins have become the treatment of first choice for candidemia.