Infecciones por Fusarium spp. en una unidad de quemados pediátrica / Fusarium spp. infections in a pediatric burn unit

Introducción: Fusarium spp. son hongos ubicuos que producen infecciones oportunistas en humanos incluyendo algunas severas en quemados. La literatura sobre infecciones por Fusarium spp. en pacientes quemados pediátricos es escasa. Objetivos: describir los hallazgos clínicos, epidemiológicos y evolutivos de infecciones por Fusarium spp. en pacientes quemados pediátricos. Pacientes y métodos: estudio retrospectivo, descriptivo de infecciones por Fusarium spp. en una unidad de cuidados intensivos pediátrica especializada entre enero de 2006 y marzo de 2015. Resultados: Quince pacientes presentaron infección por Fusarium spp. El 87% eran varones. La mediana de edad fue de 48 meses. En el 67% de los casos la quemadura fue por fuego directo. La superficie corporal quemada fue de una mediana de 45%. El 80% tuvo quemaduras profundas y el 93% presentó un índice de Garcés > 3. La infección fúngica se detectó con una mediana de 11 días desde la injuria. Todos los pacientes tuvieron catéteres centrales durante una mediana de 20 días y trece pacientes requirieron asistencia respiratoria mecánica durante una mediana de 16 días. En 14 pacientes el hongo fue aislado en la quemadura y en un paciente en el hueso. Trece pacientes tuvieron infecciones bacterianas concomitantes. Los antifúngicos de elección fueron anfotericina B y voriconazol. El tratamiento duró una mediana de 23 días. La mediana de internación fue de 55 días. Un solo paciente falleció debido a la infección fúngica. Conclusión: Fusarium spp. es un patógeno poco frecuente en pacientes quemados graves. La mortalidad fue baja (AU)

Introduction: Fusarium spp. are ubiquitous fungi recognized as opportunistic agents of human infections. They can produce severe infections in burn patients. The literature about Fusarium spp. infections in burn pediatric patients is scarce. Objectives: To describe clinical, epidemiological and outcome features of cases of Fusarium spp. infections in burn pediatric patients. Patients and Methods: Retrospective, descriptive study of Fusarium spp. infections in a specialized intensive care from January 2006 to March 2015. Results: 15 patients developed Fusarium spp infections. 87 % were male. Median age was 48 months. Direct fire injury was in ten patients. The affected burn surface was a median of 45%. Twelve patients had a full thickness burn. Fourteen patients had Garces Index>3. Fungal infection appears at a median of 11 days from injury. All patients had central lines during a median of 20 days and thirteen patients had mechanical ventilatory assistance for a median of sixteen days. Fungi vas isolated from burn wound in 14 patients and in bone in one patient. Thirteen patients had bacterial infection also. Amphotericin B was the drug of choice for treatment followed by voriconazole. Median time of complete treatment was 23 days. The median hospital stay was 55 days. One patient died of fungal infection related causes. Conclusion: Fusarium spp. is an uncommon pathogen in severely burn patients. Mortality was low (AU)

[Specific antifungal treatment in patients with neutropenia and fever: current status of the fungicidal activity of caspofungin]. / Tratamiento antifungico especifico en pacientes con neutropenia y fiebre: estado actual de la actividad fungicida de la caspofungina.

Candidiasis and aspergillosis are the most frequent mycosis in patients with febrile neutropenia. Other infections caused by emergent yeast-like organisms, such as hyalohyphomycosis, Fusarium disease and scedosporiosis, phaeohyphomycosis (caused by pigmented mycelia) and zygomycosis are becoming more frequent. The management of documented fungal infections should consider several aspects, such as clinical patterns, the patient's clinical condition, the species involved, in vitro sensitivity and the suitable treatment duration, apart from the selection of the drug and suggested regimen. Though new drugs have been developed, the therapeutic armory is still very limited. Combined treatments are promising, but their use is not yet standardized.

Geographic and temporal trends in isolation and antifungal susceptibility of Candida parapsilosis: a global assessment from the ARTEMIS DISK Antifungal Surveillance Program, 2001 to 2005.

We examined data from the ARTEMIS DISK Antifungal Surveillance Program to describe geographic and temporal trends in the isolation of Candida parapsilosis from clinical specimens and the in vitro susceptibilities of 9,371 isolates to fluconazole and voriconazole. We also report the in vitro susceptibility of bloodstream infection (BSI) isolates of C. parapsilosis to the echinocandins, anidulafungin, caspofungin, and micafungin. C. parapsilosis represented 6.6% of the 141,383 isolates of Candida collected from 2001 to 2005 and was most common among isolates from North America (14.3%) and Latin America (9.9%). High levels of susceptibility to both fluconazole (90.8 to 95.8%) and voriconazole (95.3 to 98.1%) were observed in all geographic regions with the exception of the Africa and Middle East region (79.3 and 85.8% susceptible to fluconazole and voriconazole, respectively). C. parapsilosis was most often isolated from blood and skin and/or soft tissue specimens and from patients hospitalized in the medical, surgical, intensive care unit (ICU) and dermatology services. Notably, isolates from the surgical ICU were the least susceptible to fluconazole (86.3%). There was no evidence of increasing azole resistance over time among C. parapsilosis isolates tested from 2001 to 2005. Of BSI isolates tested against the three echinocandins, 92, 99, and 100% were inhibited by concentrations of < or = 2 microg/ml of anidulafungin (621 isolates tested), caspofungin (1,447 isolates tested), and micafungin (539 isolates tested), respectively. C. parapsilosis is a ubiquitous pathogen that remains susceptible to the azoles and echinocandins; however, both the frequency of isolation and the resistance of C. parapsilosis to fluconazole and voriconazole may vary by geographic region and clinical service.

[Comparison of different methods of DNA extraction from blood to detect fungal DNA by PCR]. / Comparación de métodos de extracción de ADN de sangre para detectar ADN fúngico por PCR.

Comparison of different methods of DNA extraction from blood to detect fungal DNA by PCR. Invasive fungal infections (IFI) are associated with high mortality by reaching levels of 50%, and also with a significant failure in antifungical treatments. This fact mostly obeys to difficulties in obtaining a fast and accurate mycologic diagnosis due to the low sensitivity of conventional methods, mainly in neutropenic and AIDS patients. Various methods based on fungal DNA study are currently being used for the diagnosis of mycotic infections. We herein evaluated two procedures of extraction and purification of fungal DNA in blood for their use in PCR detection. Both of them showed equal efficiency in obtaining high performance DNA with universal primers ITS land ITS 4 as target.

Comparación de métodos de extracción de ADN de sangre para detectar ADN fúngico por PCR / Comparison of different methods of DNA extraction from blood to detect fungal DNA by PCR

La infección fúngica invasora (IFI) está asociada a un alto índice de mortalidad, que alcanza el 50% debido a la frecuente falla en el tratamiento antifúngico. Existen dificultades para realizar un diagnóstico micológico rápido y certero dada la baja sensibilidad de los métodos convencionales, especialmente en pacientes neutropénicos y con SIDA. Numerosos métodos para diagnosticar infecciones micóticas basados en el estudio del ADN fúngico están actualmente en desarrollo. Nosotros evaluamos la utilidad de dos procedimientos de extracción y purificación del ADN fúngico presente en sangre para su posterior detección por PCR. Ambos métodos resultaron igualmente eficientes para obtener ADNs de óptima calidad y para realizar la técnica de PCR con los iniciadores universales para hongos ITS 1 e ITS 4.

Invasive fungal infections (IFI) are associated with high mortality by reaching levels of 50%, and also with a significant failure in antifungical treatments. This fact mostly obeys to difficulties in obtaining a fast and accurate mycologic diagnosis due to the low sensitivity of conventional methods, mainly in neutropenic and AIDS patients. Various methods based on fungal DNA study are currently being used for the diagnosis of mycotic infections. We herein evaluated two procedures of extraction and purification of fungal DNA in blood for their use in PCR detection. Both of them showed equal efficiency in obtaining high performance DNA with universal primers ITS 1and ITS 4 as target.

Genotypic study of strains belonging to the genus Trichosporon.

Trichosporon asahii is an opportunistic fungus considered the leading etiologic agent of trichospornosis, a disease that causes great morbidity/mortality among affected patients. The identification of the etiologic agent is generally obtained through physiological and morphological studies. Molecular investigations, such as species-specific primers (PCR), have recently been developed with the aim of applying a more simple, specific, and faster technology for mycological diagnosis. The genetic material amplification technique using ad-random primers (RAPD: random amplified polymorphic DNA) is an epidemiological tool which enables research on infection by and transmission of suspected agents. In this study, the amplified polymorphic DNA technique was used to determine the intraspecific diversity of 10 Trichosporon asahii strains. Primers OPAO-15 and 1821 were used and these allowed association to 5 and 3 electrophoretic patterns, respectively. The T. asahii molecular identification, which had been previously analyzed by conventional methods, was performed by means of primers TAAF and pITS4. Our results support the use of these techniques for clonality studies of the strains of this fungus as well as for the fast and specific identification of its members in clinical cases.

Infecciones fungicas en pacientes quemados / Fungal infections in burnt patients

Las infecciones fúngicas son una importante causa de morbi mortalidad en pacientes quemados. El objetivo de este estudio fue describir las infecciones por hongos en una unidad de pacientes quemados de alta complejidad. Se realizó un estudio retrospectivo de las historias clínicas de todos los pacientes con infecciones fúngidas entre enero de 2002 y marzo de 2004. Se incluyeron 29 pacientes. La mediana de edad fue de 36 meses (r. 2 menos 144m), 21 p (72 por ciento) eran varones. La superficie quemada fue entre el 15 menos 85 por ciento (mediana 45 por ciento). La localización de la quemadura fue en miembros superiores: 29p (100 por ciento), mienbros inferiores: 23p (79 por ciento), tronco: 24p (83 por ciento)y area perineal 14 (48 por ciento). En 28p (97 por ciento)estaba el ascendente de accesos venosos centrales y arteriales con una mediana de 15 días (r: 4 menos 90d), sonda vesical en 28p(97 por ciento) con una mediana de 13.5d (r: 4 menos 90d); 27p (93 por ciento) habían recibido antibióticos previos. Ninguno de los pacientes había recibido antibióticos previos. Ninguno de los pacientes había recibido alimentación parenteral. El tiempo transcurrido entre la internación y la infección fúngica fue entre 5 y 90 días (mediana 13d). El sitio más frecuente de aislamiento fue el tejido profundo de la superficie quemada. En 3p (13 por ciento) se aisló de los hemocultivos. En 27p (93 por ciento) había una infección bacteriana concomitante. El hongo más frecuentemente aislado fue candida spp siendo C. albicans (9p) y C. parapsilosis (7p) las más reportadas. Anfotericina b fue la droga de elección al comienzo del tratamiento seguida por azoles de acuerdo al aislamiento y sensibilidad. La mediana de tiempo de tratamiento fue de 23 días (r: 9 menos 90d). Un paciente falleció (3 por ciento). Conclusión: los hongos juegan un rol importante en el área de internación de quemados. Conclusión: Los hongos juegan un rol importante en el área de internación de quemados...

[Prevalence of Candida albicans and Candida non-albicans in clinical samples during 1999-2001]. / Prevalencia de Candida albicans y Candida no albicans en diferentes muestras clínicas. Período 1999-2001.

The importance of epidemiological monitoring of yeasts involved in pathologic processes is unquestionable due to the increase of these infections over the last decade, the changes observed in species causing candidiasis, and empirical antifungal treatment. At the Mycology Center, 1006 isolates from a wide range of clinical samples were studied during 1999-2001. Candida albicans (40.3%) was the most isolated species, although, the Candida no albicans species with 54.9% showed the major prevalence. In blood cultures Candida parapsilosis (34.9%), C. albicans (30.2%) and C. tropicalis (25.6%) were recovered most frequently while C. glabrata represented only 2.3%. C. albicans with 60%-80% was the predominant specie in mucosal surface. We also detected Candida mediastinistis, which alert us over the importance at this location. Urinary tract infections caused by yeasts were more frequent in hospitalized patients, being C. albicans (47.7%), the most commonly isolated, followed by C. glabrata (24.8%) and C. tropicalis (20.0%). In the candidal onychomycoses, C. parapsilosis (37.7%) outplaced C. albicans (22.0%). Fluconazole susceptibility studies of Candida species allowed us to conclude that the majority of C. albicans islolates are susceptible, and that the highest resistance averages were observed in C. glabrata (21.41%) and C. krusei (69.23%).

Prevalencia de Candida albicans y Candida no albicans en diferentes muestras clínicas: Período 1999-2001 / Prevalence of Candida albicansand Candida no albicans inclinical samples during 1999-2001

Las levaduras implicadas en procesos patológicos son de indiscutible importancia debido al incremento experimentado por estas infecciones en las últimas décadas, a los cambios observados en las especies causales y al uso empírico de antifúngicos. En el Centro de Micología se estudiaron 1006 aislamientos provenientes de una amplia gama de muestras clínicas durante el periodo 1999-2001. Candida albicans con 40,3% resultó la especie de mayor frecuencia de aislamiento, pero las especies de Candida no albicans con 54,9% resultaron de mayor prevalencia y el 4,8% fueron otras levaduras. En los hemocultivos Candida parapsilosis con 34,9%, C. albicans con 30,2% y C. tropicalis con 25,6% resultaron las más recuperadas, mientras que C. glabrata se presentó con un 2,3%. En las secreciones mucosas C.albicans con 60%-80% fue la especie preponderante. Hemos detectado especies de Candida causantes de mediastinitis, lo que nos alerta sobre su importancia en estos procesos. Las infecciones del tracto urinario por levaduras se detectaron en mayor frecuencia en individuos hospitalizados, resultando C. albicans con 47,7% la especie más aislada, y dentro de Candida no albicans, C. glabrata con 24,8% y C. tropicalis con 20,0%. En las onixis candidiásicas C. parapsilosis con 37,7% desplazó a C.albicans con 22,0% de este lugar anatómico. Los estudios de sensiblidad al fluconazol de las especies de Candida nos permiten concluir que C.albicans es una especie sensible y que los mayores porcentajes de resistencia se observaron en C. glabrata (21,41%) y and C. krusei (69,23%).

The importance of epidemiological monitoring of yeasts involved in pathologic processes is unquestionable due to the increase of these infections over the last decade, the changes observed in species causing candidiasis, and empirical antifungal treatment. At the Mycology Center, 1006 isolates from a wide range of clinical samples were studied during 1999-2001. Candida albicans (40.3%) was the most isolated species, although, the Candida no albicans species with 54.9% showed the major prevalence. In blood cultures Candida parapsilosis (34.9%), C. albicans (30.2%) and C. tropicalis (25.6%) were recovered most frequently while C. glabrata represented only 2.3%. C. albicans with 60%-80% was the predominant specie in mucosal surface. We also detected Candida mediastinistis, which alert us over the importance at this location. Urinary tract infections caused by yeasts were more frequent in hospitalized patients, being C. albicans (47.7%), the most commonly isolated, followed by C. glabrata (24.8%) and C. tropicalis (20.0%). In the candidal onychomycoses, C. parapsilosis (37.7%) outplaced C. albicans (22.0%). Fluconazole susceptibility studies of Candida species allowed us to conclude that the majority of C. albicans islolates are susceptible, and that the highest resistance averages were observed in C. glabrata (21.41%) and C. krusei (69.23%).

Susceptibility of Candida species to fluconazole assayed by a disk diffusion method with automated reading versus a microdilution method.

In vitro susceptibilities of 290 isolates of Candida spp to fluconazole were evaluated by a new NCCLS M44-P agar disk diffusion method that was read and interpreted automatically by the BIOMIC image-analysis plate reader system. Disk test results were compared to results obtained by a modified NCCLS M27-A broth microdilution method using RPMI-1640 supplemented with 2% dextrose. Overall agreement between both methods was 90.0%. Category agreement between the broth and disk test results for susceptible, susceptible dose-dependent and resistant disk results were 99.6%, 19.05% and 52.17%, respectively. No very major discrepancies, 1.03% major discrepancies, and 8.97% minor discrepancies were observed between results of the two test methods. This analysis suggests that results from both methods correlate highly for Candida strains susceptible to fluconazole. The lower agreement between the two methods for resistant and susceptible dose-dependent isolates was due to strains near or on that breakpoint, different media (Mueller-Hinton vs RPMI), agar vs broth, 80% vs 50% endpoints, and trailing growth near the endpoints.

Susceptibility of Candida species to fluconazole assayed by a disk diffusion method with automated reading versus a microdilution method

In vitro susceptibilities of 290 isolates of Candida spp to fluconazole were evaluated by a new NCCLS M44-P agar disk diffusion method that was read and interpreted automatically by the BIOMIC image-analysis plate reader system. Disk test results were compared to results obtained by a modified NCCLS M27-A broth microdilution method using RPMI-1640 supplemented with 2

. Category agreement between the broth and disk test results for susceptible, susceptible dose-dependent and resistant disk results were 99.6

major discrepancies, and 8.97

minor discrepancies were observed between results of the two test methods. This analysis suggests that results from both methods correlate highly for Candida strains susceptible to fluconazole. The lower agreement between the two methods for resistant and susceptible dose-dependent isolates was due to strains near or on that breakpoint, different media (Mueller-Hinton vs RPMI), agar vs broth, 80

endpoints, and trailing growth near the endpoints.

Experimental coccidioidomycosis in hamsters. Disease kinetics and death curve in relation to infective dose.

A study of experimental coccidioidomycosis in hamsters (Mesocricetus auratus) is presented. Two experiments were conducted on 75 animals inoculated intracardially with the mycelial form of Coccidioides immitis. The first research (experiment I) studied the kinetics of experimental disease in 15 hamsters inoculated with 300 C. immitis arthroconidia. The parameters studied were: (a) presence of macroscopic lesions in the brain, lungs, liver, spleen and kidneys; (b) microscopic identification of spherules in wet mount preparations of these specimens; (c) samples from all organs cultured at 37 degrees C on Sabouraud glucose agar; (d) blood cultures drawn every 24 h during the first week and subsequently every 48 h and (e) histopathological studies of all organs. The second experiment (experiment II) determined the relationship between the inoculum size and death curve in six groups of 10 animals each, which had received doses of 10, 50, 100, 150, 200 and 300 arthroconidia, respectively. On day 14 post-inoculation, all the animals underwent skin tests and 1 ml of blood was obtained by cardiac puncture to detect antibodies. Disseminated disease with persistent fungaemia developed in all the studied animals. Coccidioides immitis was recovered from all organs, with the lungs being the first to present disease. Death occurred in all groups, regardless of the dose of arthroconidia and 83.3% died between day 22 and day 28 post-infection. The use of this model is proposed for the biological standardization of antigens, the study of prophylactic measures and the "in vivo" evaluation of new antifungal treatments.

New advances in antifungal treatment.

Clinical aspects of treatment of invasive aspergillosis, infections caused by dematiaceous fungi, and mycoses caused by endemic, dimorphic fungi, are described in this review.

Histopathological evolution of experimental paracoccidioidomycosis in Wistar rats.

Twenty Wistar rats were inoculated, by the intracardiac route, with 0.5 ml each of a yeast phase suspension of Paracoccidioides brasiliensis Utero strain. The rats were sacrificed at regular intervals post-infection, at which time their lungs, heart, liver, spleen and kidneys were removed, fixed and stained for study. The parameters of interest for the lung specimens were: (a) extent of the lesions; (b) number of fungi; (c) presence of a lymphomononuclear halo. Extrapulmonary lesions were also sought. Until the fourth month post-infection, the lesions were progressive in nature, contained great numbers of viable fungi, and were surrounded by an important lymphomononuclear halo which tended to be confluent. At four and a half months p.i., the extent of the pulmonary lesions was reduced, the granulomas were less compact with fewer viable fungi, macrophages showed microvacuolation, and the lymphomononuclear halo was less pronounced. Extrapulmonary lesions, which were frequently identified in the first months post-infection, diminished from the seventh month onwards. The histological characteristics of extrapulmonary lesions were always the same as those found in the lungs. Infection tended to be controlled by the animals from the fourth month, but without complete resolution of the lesions.

[Successful medical treatment of Candida tropicalis in prosthetic valve endocarditis]. / Tratamiento medico exitoso de una endocarditis en valvula protesica por Candida tropicalis.

Medical cure of fungal prosthetic valve endocarditis (PVE) is rarely reported. We describe a patient with C. tropicalis PVE in whom surgery was believed to be contraindicated. A huge tricuspid valvular vegetation was identified by two-dimensional transthoracic echocardiography. After a total of 2 g of amphotericin B, she continued with fluconazole daily with a follow-up of fifteen months. Our patient represents the first case of long term survival of C. tropicalis PVE successfully managed without surgery.

Itraconazole and flucytosine+itraconazole combination in the treatment of experimental cryptococcosis in hamsters.

The efficacy of two different daily doses of itraconazole (ITRA) and the combination of flucytosine (5-FC) with ITRA in the treatment of an experimental model of cryptococcosis in hamsters was studied. Five groups of 20 animals each were inoculated by the intracardiac route with 10(5) cells of Cryptococcus neoformans. Treatment started 3 days after the infection, and was administered by gavage for 30 days. ITRA was applied at a daily dose of 25 mg kg-1 or 50 mg kg-1 and the combination of 5-FC and ITRA was given at 75 mg kg-1 day-1 or 50 mg kg-1 day-1 respectively. One group of 20 hamsters received the vehicle and was used as a control group. Treatment evaluation was based on the following parameters: number of surviving animals 60 days after the infection; presence of encapsulated yeasts on microscopic examination of wet preparations of brain, lungs, liver, spleen and kidneys at necropsy; and brain qualitative (massive seeding) and quantitative cultures (determination of colony forming units, CFU). ITRA 50 (50 mg kg day-1) was the most effective treatment according to the studied parameters; 70% of brain cultures became negative and 95% of the treated hamsters survived to the end of the study period. ITRA efficacy was dose dependent. The combination of ITRA with 5-FC was less effective than administering the drugs separately; the reason for this finding is not known. The results obtained in this study should encourage the use of high doses of ITRA in cases of disseminated cryptococcosis in humans.

Blood culture as a parameter of treatment effectiveness in experimental histoplasmosis of the hamster

The aim of this study was to determine the value of blood culture as a parameter of treatment efectiveness in experimental histoplasmosis. A total of thirty five hamsters, weighing approximately 120g, were inoculated intracardiacly with 0.1 ml of a suspension containing 4 x 10 a setima potencia cells/ml of the yeast phase of H. capsulatum. Treatments were started one week after the infection and lasted for 3 weeks...

Blood culture as a parameter of treatment effectiveness in experimental histoplasmosis of the hamster.

The aim of this study was to determine the value of blood culture as a parameter of treatment effectiveness in experimental histoplasmosis. A total of thirty five hamsters, weighing approximately 120g, were inoculated intracardially with 0.1 ml of a suspension containing 4 x 10(7) cells/ml of the yeast phase of H. capsulatum. Treatments were started one week after the infection and lasted for 3 weeks. The azoles, (itraconazole, saperconazole and fluconazole) were administered once a day by gavage, at a dose of 8 mg/kg; Amphotericin B was given intraperitoneally every other day at a dose of 6mg/kg. Blood samples (1 ml) were obtained by heart punction from the 4th day after infection and were seeded in Sabouraud honey-agar and BHI-agar. The hamsters that survived were killed one week after treatment completion and the following criteria were considered for treatment evaluation: 1) rate of spontaneous death, at the end of the experience; 2) microscopic examination of Giemsa smears from liver and spleen and 3) determination of CFU in spleen cultures. Amphotericin B was the most effective drug, with negative blood cultures at day 20, negative spleen cultures in all cases and all the animals survived until the end of the study. Fluconazole was the less effective drug, blood cultures were positive during the whole experience, spleen cultures showed a similar average of CFU when compared with the control animals and 42.8% of these animals died. Saperconazole and itraconazole showed a similar activity, with survival of all hamsters and negative blood cultures at 23 and 26 days respectively. Blood culture seems to be valuable parameter for treatments' evaluation in experimental histoplasmosis of the hamster.