Mycoses
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Invasive candidiasis is a common nosocomial infection among critically ill patients, constitutes an important cause of sepsis, and is associated with significant morbidity and mortality. The Infectious Diseases Society of America (IDSA) has created evidence-based guidelines for the management of invasive candidiasis. ⋯ Further, the role of antifungals is not entirely clear in the intensive care unit (ICU) setting. Therefore, this article discusses daily problems in the prophylaxis and treatment of invasive candidasis in interdisciplinary ICUs.
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Candida species constitute the majority of nosocomial fungal pathogens in non-neutropenic patients. Candida infections are still connected with substantial mortality. ⋯ In invasive candidiasis, a delayed treatment initiation is associated with an increased mortality, thus risk stratification and empirical therapy strategies become vitally important. This review reflects the efficacy of caspofungin in the treatment of Candida infections, especially in the setting of empirical therapy in critically ill patients, and considers the option of de-escalation to fluconazole.
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Scedosporium apiospermum and its teleomorph (sexual form) Pseudallescheria boydii are ubiquitous saprophytic fungi, which under specific conditions, such as near-drowning, may cause therapy-refractory and life-threatening infections. We reviewed 22 cases (eight children and 14 adults) of S. apiospermum infection after near-drowning reported in the literature including an additional paediatric case from our institution. Scedosporiosis after near-drowning was associated with high mortality (16/23, 70%) even in immunocompetent hosts. ⋯ The majority of the patients (20/23, 87%) received antifungal treatment and underwent neurosurgery. While the optimal treatment remains undefined, the most recent reports indicated voriconazole as a potentially effective option. Better knowledge of scedosporiosis after near-drowning could lead to improved intervention and ultimately to more favourable outcome.
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A reliable diagnosis of invasive aspergillosis in patients with haematological malignancies is seldom achieved antemortem. Conventional laboratory diagnostic methods are insensitive and time-consuming, resulting in late diagnosis and treatment and contributing to unacceptably high mortality. As a result, routine antifungal prophylaxis and early empirical treatment have been recommended. ⋯ The excellent negative predictive value of these assays should convince clinicians to withhold antifungal therapy in persistently febrile neutropenic patients with no other signs of fungal infection. On the other hand, consecutive positive results in a high-risk population should at least trigger a complete diagnostic work-up. This review will focus on the diagnostic utility as well as on the pitfalls of serial screening for the presence of circulating fungal antigens in haematology patients.
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Over recent years the clinical importance of mucormycosis has significantly increased. Most frequently mucormycosis occurs in neutropenic patients with haematological diseases. It is caused by fungi of the order Mucorales. ⋯ Diagnosis of mucormycosis is difficult as it is based on culture methods or microscopy of clinical specimens. The diagnosis is often only made after a delay or even post-mortem. Therapy includes surgical intervention if possible and is based on systemic amphotericin B (conventional or liposomal).