Severe hypercalcemia as a result of disseminated Candida krusei infection.

Candida krusei disseminated infection is a rare complication of protracted neutropenia. Herein, we report a case of a 31-year-old male with relapsed acute myeloid leukemia who developed Candida krusei fungemia with cutaneous, ocular, splenic, renal, bone marrow and osseous involvement leading to severe hypercalcemia, treated with parenteral antifungals followed by oral ibrexafungerp.

Candida colonization as a predictor of invasive candidiasis in non-neutropenic ICU patients with sepsis: A systematic review and meta-analysis.

BACKGROUND: Candida colonization is a risk factor for the development of invasive candidiasis. This study sought to estimate the magnitude of this association, and determine if this information can be used to guide empirical antifungal therapy initiation in critically ill septic patients. METHODS: PubMed/MEDLINE and Embase were systematically reviewed for all published studies evaluating predictors of invasive candidiasis in ICU patients with sepsis. Meta-analysis was used to determine the pooled odds ratio for invasive candidiasis among colonized versus non-colonized patients. Sensitivity (SN), specificity (SP), positive and negative predictive values (PPV, NPV), and positive and negative likelihood ratios (+LR, -LR) were then calculated by considering the presence/absence of Candida colonization as the diagnostic test, and the presence/absence of invasive candidiasis as the disease of interest. RESULTS: Out of 9825 patients in the 10 eligible studies, 3886 (40%) were colonized with Candida and 462 patients (4.7%) developed invasive candidiasis. Meta-analysis indicated that critically ill patients with sepsis who are colonized with candida are more likely to develop invasive candidiasis (odds ratio 3.32; 95% CI 1.68-6.58) compared with non-colonized patients. The pooled SN was 75.2% (95% CI 59.6-86.2%), while the pooled SP was 49.2% (95% CI 33.2-65.3%).The NPV of Candida colonization was high (96.9%; 95% CI 92.0-98.9%), but the PPV was low (9.1%; 95% CI 5.5-14.6%). CONCLUSION: Candida colonization is strongly associated with the likelihood of invasive candidiasis among ICU patients with sepsis. Available data argue against initiating empirical antifungal treatment in non-neutropenic septic patients without prior documented Candida colonization.

HIV postexposure prophylaxis-in-pocket: long-term follow-up of individuals with low-frequency, high-risk HIV exposures.

BACKGROUND: HIV preexposure prophylaxis and postexposure prophylaxis are two major biomedical HIV prevention modalities. The utility of these prevention tools for individuals with infrequent high-risk HIV exposures remains uncertain. HIV postexposure prophylaxis-in-pocket ('PIP') may be an effective HIV prevention tool in such situations. Here, we present long-term follow-up of a cohort of patients initiated on PIP for HIV prevention. METHODS: We retrospectively evaluated clinical characteristics of patients initiated on PIP as a primary HIV prevention tool between 1 January 2016 to 31 May 2019 at the Toronto General Hospital HIV Prevention Clinic and St. Michael's Hospital HIV Clinic, both in Toronto, Canada. Patients were referred for consideration of a biomedical HIV prevention modality. Individuals with a low frequency of high-risk exposures to HIV were initiated on PIP after counselling, and were followed at regular intervals. Demographic and clinical data was collected with a standardized form. RESULTS: In total, 79 patients were initiated on PIP as a primary HIV prevention modality and followed for a mean duration of 14.8 months combining for a total of 97.3 patient-years. Twenty-one (26.6%) patients used their PIP, and 32 courses of PIP were taken during the study period. Transitions between HIV prevention modalities included 13 (16.5%) patients who transitioned from PrEP to PIP, and 22 (27.8%) patients who transitioned from PIP to PrEP. No HIV seroconversions were detected during the course of this study. CONCLUSION: PIP is helpful HIV prevention modality for individuals with a low frequency of high-risk HIV exposures.

Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus.

BACKGROUND: Middle East respiratory syndrome (MERS) is caused by a coronavirus (MERS-CoV) and is characterized by hypoxemic respiratory failure. The objective of this study is to compare the outcomes of MERS-CoV patients before and after the availability of extracorporeal membrane oxygenation (ECMO) as a rescue therapy in severely hypoxemic patients who failed conventional strategies. METHODS: We collected data retrospectively on MERS-CoV patients with refractory respiratory failure from April 2014 to December 2015 in 5 intensive care units (ICUs) in Saudi Arabia. Patients were classified into two groups: ECMO versus conventional therapy. Our primary outcome was in-hospital mortality; secondary outcomes included ICU and hospital length of stay. RESULTS: Thirty-five patients were included; 17 received ECMO and 18 received conventional therapy. Both groups had similar baseline characteristics. The ECMO group had lower in-hospital mortality (65 vs. 100%, P = 0.02), longer ICU stay (median 25 vs. 8 days, respectively, P < 0.01), and similar hospital stay (median 41 vs. 31 days, P = 0.421). In addition, patients in the ECMO group had better PaO2/FiO2 at days 7 and 14 of admission to the ICU (124 vs. 63, and 138 vs. 36, P < 0.05), and less use of norepinephrine at days 1 and 14 (29 vs. 80%; and 36 vs. 93%, P < 0.05). CONCLUSIONS: ECMO use, as a rescue therapy, was associated with lower mortality in MERS patients with refractory hypoxemia. The results of this, largest to date, support the use of ECMO as a rescue therapy in patients with severe MERS-CoV.

Superiority of peginterferon α-2a and ribavirin combination over peginterferon α-2a monotherapy in the management of hemodialysis patients with chronic Hepatitis C virus infection.

Hepatitis C virus (HCV) is a common infection affecting 15% of hemodialysis population in Saudi Arabia resulting in delay in transplantation and long-term complications. The use of peginterferon resulted in sustained virologic response (SVR) in 40%-85% of patients, especially if combined with ribavirin. The treatment is hampered by the high dropout due to anemia and requirement of blood transfusion resulting from this therapy. Some studies have shown that the addition of increasing dose of erythropoiesis-stimulating agents (ESA) and reduced dose of ribavirin results in reduced dropout rate with high SVR. We conducted an open-label prospective study using either peginterferon α-2a alone (Group I, 32 patients) or peginterferon α-2a plus adjusted dose ribavirin (Group II, 26 patients). A total of seven patients dropped from the study (2 in Group I and 5 in Group II). Analysis was done only on patients who completed the study (thirty patients in Group I and 21 in Group II). There was no significant difference in the demographic data, HCV genotype, liver biopsy grade and stage, and laboratory tests between the two groups. Patients received ESA to combat expected anemia. Group II had a better early virologic response than Group I [17 out of 21 (80%) and 14 out of 30 (47%) respectively, P = 0.014] and better SVR [18 out of 21 (85%) and 15 out of 30 (50%) respectively, P = 0.009]. There were no differences in mean white blood cells, hemoglobin, and platelets between the two groups at any time with only four patients dropping out due to anemia or side effect of medications. Alanine aminotransferase was lower in both treatment groups compared to baseline with no difference between the groups. Peginterferon α-2a and ribavirin are superior to peginterferon α-2a alone in treating hemodialysis patients with chronic HCV infection.