RESUMEN
The present study used two molecular typing methods to investigate a cluster of eight cases of Candida parapsilosis fungemia in a hospital in Rio de Janeiro, Brazil. Candida parapsilosis is an important opportunistic pathogen that is frequently involved in outbreaks of nosocomial fungemia. Identification of a common source of infection and determination of genetic relatedness among the strains involved in outbreaks are important for infection control. Candida parapsilosis strains were isolated from the bloodstream of patients housed in an intensive-care unit (n=5) and in individual rooms (n=3). An additional strain of Candida parapsilosis was isolated from a hyperalimentation infusion flask, which was implicated by molecular typing to be the source of infection. All strains were identified using morphological and biochemical methods. The genetic relationship between patients' strains and the hyperalimentation infusion strain was assessed by electrophoretic karyotype (EK) analysis and random amplification of polymorphic DNA (RAPD). Both methods resulted in patterns that allowed differentiation of the isolates. Candida parapsilosis fungemia, in three of the eight patients, resulted from a common source of infection, as demonstrated by molecular typing methods. Image analysis of EK patterns indicated that these strains were closest to Candida parapsilosis Group II, a grouping that is a less frequent clinical isolate than the major Group I strains.
Asunto(s)
Candida/clasificación , Fungemia/microbiología , Técnicas de Tipificación Micológica , Candida/efectos de los fármacos , ADN de Hongos/análisis , Fungemia/genética , Pruebas de Sensibilidad Microbiana , Técnica del ADN Polimorfo Amplificado AleatorioRESUMEN
To evaluate the efficacy of itraconazole capsules in prophylaxis for fungal infections in neutropenic patients, we conducted a prospective, double-blind, placebo-controlled, randomized trial. Patients with hematologic malignancies or those who received autologous bone marrow transplants were assigned either a regimen of itraconazole (100 mg orally twice daily; n=104) or of placebo (n=106). Overall, fungal infections (superficial or systemic) occurred more frequently in the placebo group (15% vs. 6%; P=.03). There were no differences in the empirical use of amphotericin B or systemic fungal infections. Among patients with neutropenia that was profound (<100 neutrophils/mm3) and prolonged (for at least 7 days), those receiving itraconazole used less empirical amphotericin B (22% vs. 61%; P=.0001) and developed fewer systemic fungal infections (6% vs. 19%; P=.04). For patients with profound and prolonged neutropenia, itraconazole capsules at the dosage of 100 mg every 12 h reduce the frequency of systemic fungal infections and the use of empirical amphotericin B.
Asunto(s)
Antifúngicos/administración & dosificación , Fungemia/prevención & control , Itraconazol/administración & dosificación , Neutropenia/complicaciones , Administración Oral , Adolescente , Adulto , Anciano , Anfotericina B/administración & dosificación , Aspergilosis/diagnóstico , Aspergilosis/etiología , Aspergilosis/mortalidad , Aspergilosis/prevención & control , Trasplante de Médula Ósea , Candidiasis/diagnóstico , Candidiasis/etiología , Candidiasis/mortalidad , Candidiasis/prevención & control , Niño , Preescolar , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Femenino , Estudios de Seguimiento , Fungemia/diagnóstico , Fungemia/etiología , Fungemia/mortalidad , Neoplasias Hematológicas/complicaciones , Neoplasias Hematológicas/terapia , Humanos , Masculino , Persona de Mediana Edad , Neutropenia/mortalidad , Estudios Prospectivos , Tasa de Supervivencia , Trasplante Autólogo , Resultado del TratamientoRESUMEN
In order to evaluate the epidemiology of candidemia in Brazil, we performed a prospective multicenter study conducted in six general hospitals from São Paulo and Rio de Janeiro, We enrolled a total of 145 candidemic patients (85 males) with a median age of 32 years. Non-albicans species accounted for 63% of all episodes and the species most frequently causing candidemia were C. albicans (37%), C. parapsilosis (25%), C. tropicalis (24%), C. rugosa (5%), and C. glabrata (4%). Systemic azoles were used before the onset of candidemia in only six patients. There were no differences in the coexisting exposures or underlying diseases associated with the species most frequently causing candidemia. The overall crude mortality rate was 50%. Nosocomial candidemias in our tertiary hospitals are caused predominantly by non-albicans species, which are rarely fluconazole resistant. This predominance of non-albicans species could not be related to the previous use of azoles.
Asunto(s)
Candida/clasificación , Candidiasis/etiología , Fungemia/microbiología , Adolescente , Adulto , Anciano , Animales , Antifúngicos/uso terapéutico , Brasil/epidemiología , Candida/aislamiento & purificación , Candidiasis/tratamiento farmacológico , Candidiasis/epidemiología , Niño , Preescolar , Infecciones Comunitarias Adquiridas/epidemiología , Infección Hospitalaria/epidemiología , Femenino , Fungemia/tratamiento farmacológico , Fungemia/epidemiología , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
To evaluate the value of a positive nasal swab for Aspergillus in the diagnosis of invasive aspergillosis, we prospectively evaluated nasal colonization in 173 episodes of neutropenia in 92 patients with hematological malignancies. Weekly nasal swabs were taken, and the patients were followed until death or resolution of neutropenia. The outcome variables were the development of invasive aspergillosis, empirical antifungal therapy and death. In 31 episodes of neutropenia (18%) there was at least one positive nasal swab for Aspergillus sp. Only two patients developed invasive aspergillosis, both with a positive nasal swab (p = 0.03). The positive and negative predictive values of a nasal swab were 6.4% and 100%, respectively. There was no difference between patients with positive or negative swabs regarding antifungal therapy or death. In this population of patients, a nasal swab for Aspergillus sp. had a low positive predictive value and a high negative predictive value for invasive aspergillosis.
Asunto(s)
Aspergilosis/diagnóstico , Aspergillus/aislamiento & purificación , Neoplasias Hematológicas/complicaciones , Enfermedades Pulmonares Fúngicas/diagnóstico , Cavidad Nasal/microbiología , Neutropenia/complicaciones , Adolescente , Adulto , Anciano , Aspergilosis/complicaciones , Aspergilosis/microbiología , Niño , Reacciones Falso Positivas , Femenino , Humanos , Enfermedades Pulmonares Fúngicas/complicaciones , Enfermedades Pulmonares Fúngicas/microbiología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios ProspectivosRESUMEN
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 case 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.
Asunto(s)
Candida/aislamiento & purificación , Candidiasis/epidemiología , Fungemia/epidemiología , Neoplasias/complicaciones , Brasil/epidemiología , Candidiasis/complicaciones , Candidiasis/microbiología , Recolección de Datos , Femenino , Fungemia/complicaciones , Fungemia/microbiología , Humanos , Masculino , Estudios ProspectivosRESUMEN
In order to identify prognostic factors for death among cancer patients with fungemia, an 18-month survey of fungemia in patients with cancer was undertaken in three hospitals in Rio de Janeiro. For the assessment of risk factors for death, the following variables were analyzed: age; gender; underlying cancer; last treatment for the underlying disease; previous surgery; use of antibiotics, antifungal agents, steroids, or total parenteral nutrition; use of a central venous catheter; chemotherapy; radiotherapy; presence and duration of neutropenia; etiologic agent of the fungemia; treatment of the fungemia; clinical manifestations; and performance status (Karnofsky score) on the day of the positive blood culture. In multivariate analysis, the variables associated with an increased risk for death were older age, persistent neutropenia, and low performance status. Identifying risk factors for death may help to define a group-risk patients for whom new therapeutic options should be tried.
Asunto(s)
Fungemia/complicaciones , Fungemia/mortalidad , Neoplasias/complicaciones , Neoplasias/mortalidad , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pronóstico , Factores de Riesgo , Estadísticas no Paramétricas , Análisis de SupervivenciaRESUMEN
In this paper we report a eight-year prospective study designed to further characterize incidence, epidemiology, specific syndromes, treatment and prognosis associated with fungal infections in neutropenic patients. During the study period 30 fungal infections were diagnosed in 30 patients among 313 episodes of fever and neutropenia (10%). There were 15 cases of candidiasis, 5 pulmonary aspergillosis, 3 sinusitis by Aspergillus fumigatus, 5 infections by Fusarium sp., one infection by Trichosporon sp., and one infection due to Rhodotorula rubra. Blood cultures were positive in 18 cases (60%). The predisposing factors for fungal infection in multivariate analysis were the presence of central venous catheter (p < 0.001), longer duration of profound (< 100/mm3) neutropenia (p < 0.001), the use of corticosteroids (p < 0.001), gram-positive bacteremia (p = 0.002) and younger age (p = 0.03). In multivariate analysis only recovery of the neutropenia (p < 0.001) was associated with good prognosis whereas the diagnosis of infection by Fusarium sp. (p = 0.006) was strongly associated with a poor outcome. The death rate was 43%. There was no statistically significant difference in the death rate between patients who did receive (52%) or did not receive (50%) antifungal treatment. Identifying patients at risk, specific syndromes and prognostic factors may help to reduce the high mortality associated with disseminated fungal infections in neutropenic patients.
Asunto(s)
Micosis/complicaciones , Neutropenia/complicaciones , Adolescente , Adulto , Antifúngicos/administración & dosificación , Niño , Preescolar , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Micosis/diagnóstico , Micosis/tratamiento farmacológico , Neutropenia/sangre , Pronóstico , Estudios Prospectivos , Factores de RiesgoRESUMEN
Three cases are reported of disseminated infection due to Fusarium species in severely neutropenic patients. The clinical findings in all patients included fever, painful disseminated nodular skin lesions and severe myalgia. The outcome was fatal despite early administration of amphotericin B. The portal of entry of the organism was probably the nasal sinus in two cases.