Incidence of candidaemia in prolonged venovenous extracorporeal membrane oxygenation.

This single-centre retrospective study reports the dynamics of the incidence of candida bloodstream infection (CBSI) in 145 patients receiving venovenous extracorporeal membrane oxygenation (ECMO) for respiratory support between January 2014 and December 2018. The incidence rate and odds ratio (OR) of CBSI were calculated, stratified by week of ECMO exposure. Weekly incidence increased throughout the ECMO run, with an increasing trend in OR (P=0.005), and a window of continued risk after decannulation was observed. Of the 13 patients who developed CBSI, five (38%) received empirical micafungin treatment before positive culture due to clinical suspicion. There is a need for prospective studies aiming to improve ECMO diagnostic stewardship practices and discourage unnecessary antifungal prophylaxis or empiric management.

High-volume culture and quantitative real-time PCR for the detection of Aspergillus in sputum.

OBJECTIVES: Sputum culture is an insensitive method for the diagnosis of pulmonary aspergillosis. Growth of the organism allows identification of the causative species and susceptibility testing, both of which can inform treatment choices. The current practice is to culture an aliquot of diluted sputum. We assessed the value of culturing large volumes of unprocessed sputum, a method that we have termed high-volume culture (HVC). METHODS: Specimens were processed by conventional culture (using an aliquot of homogenized, diluted sputum on Sabouraud agar at 37°C and 45°C for up to 5 days) and HVC (using undiluted sputum on Sabouraud agar at 30°C for up to 14 days). A separate specimen was tested by quantitative real-time PCR. Antifungal susceptibility testing was performed by the EUCAST standard. RESULTS: We obtained sputum specimens from 229 individuals with the following conditions: chronic pulmonary aspergillosis (66.8%, 153/229), allergic bronchopulmonary aspergillosis (25.3%, 58/229) and Aspergillus bronchitis (7.9%, 18/229). Individuals with invasive pulmonary aspergillosis were not included. The positivity rate of conventional culture was 15.7% (36/229, 95% CI 11.6%-21.0%) and that of HVC was 54.2% (124/229, 95% CI 47.7%-60.5%) (p < 0.001). The higher positivity rate of HVC was demonstrated regardless of administration of antifungal treatment. Quantitive real-time PCR had an overall positivity rate of 49.2% (65/132, 95% CI 40.9%-57.7%), comparable to that of HVC. CONCLUSION: Detection of Aspergillus spp. in sputum is greatly enhanced by HVC. HVC allows for detection of azole-resistant isolates that would have been missed by conventional culture. This method can be performed in any microbiology laboratory without the need for additional equipment.

Impact of a diagnostics-driven antifungal stewardship programme in a UK tertiary referral teaching hospital.

Objectives: A concise invasive candidosis guideline (based on the ESCMID candidaemia guideline) utilizing an informative biomarker [serum ß-1-3-d-glucan (BDG)] was developed in 2013 by an antifungal stewardship (AFS) team and implemented with the help of an AFS champion in 2014. The main aims of the AFS programme were to reduce inappropriate use of antifungals and improve patient outcomes. The aim of this project was to evaluate the compliance of the ICU teams with the invasive candidosis guideline and the impact of the AFS programme on mortality and antifungal consumption on the ICUs (total of 71 beds). Methods: All patients who were prescribed micafungin for suspected or proven invasive candidosis during 4 month audit periods in 2014 and 2016 were included. Prescriptions and patient records were reviewed against the guideline. Antifungal consumption and mortality data were analysed. Results: The number of patients treated for invasive candidosis decreased from 39 in 2014 to 29 in 2016. This was mainly due to the reduction in patients initiated on antifungal therapy inappropriately: 18 in 2014 and 2 in 2016. Antifungal therapy was stopped following negative biomarker results in 12 patients in 2014 and 10 patients in 2016. Crude mortality due to proven or probable invasive candidosis decreased to 19% from 45% over the period 2003-07. Antifungal consumption reduced by 49% from 2014 to 2016. Conclusions: The AFS programme was successful in reducing the number of inappropriate initiations of antifungals by 90%. Concurrently, mortality due to invasive candidosis was reduced by 58%. BDG testing can guide safe cessation of antifungals in ICU patients at risk of invasive candidosis.

The role of unfinished root canal treatment in odontogenic maxillofacial infections requiring hospital care.

OBJECTIVES: The aim of this study was to evaluate clinical and radiological findings and the role of periapical infection and antecedent dental treatment of infected focus teeth in odontogenic maxillofacial abscesses requiring hospital care. MATERIALS AND METHODS: In this retrospective cohort study, we evaluated medical records and panoramic radiographs during the hospital stay of patients (n = 60) admitted due to odontogenic maxillofacial infection originating from periapical periodontitis. RESULTS: Twenty-three (38 %) patients had received endodontic treatment and ten (17 %) other acute dental treatment. Twenty-seven (45 %) had not visited the dentist in the near past. Median age of the patients was 45 (range 20-88) years and 60 % were males. Unfinished root canal treatment (RCT) was the major risk factor for hospitalisation in 16 (27 %) of the 60 cases (p = .0065). Completed RCT was the source only in 7 (12 %) of the 60 cases. Two of these RCTs were adequate and five inadequate. CONCLUSIONS: The initiation of inadequate or incomplete primary RCT of acute periapical periodontitis appears to open a risk window for locally invasive spread of infection with local abscess formation and systemic symptoms. Thereafter, the quality of the completed RCT appears to have minor impact. However, a considerable proportion of the patients had not received any dental treatment confirming the importance of good dental health. Thus, thorough canal debridement during the first session is essential for minimising the risk for spread of infection in addition to incision and drainage of the abscess. If this cannot be achieved, tooth extraction should be considered. CLINICAL RELEVANCE: Incomplete or inadequate canal debridement and drainage of the abscess may increase the risk for spread of endodontic infection.