COVID-19 associated mold infections: Review of COVID-19 associated pulmonary aspergillosis and mucormycosis.

COVID-19-associated mold infection (CAMI) is defined as development of mold infections in COVID-19 patients. Co-pathogenesis of viral and fungal infections include the disruption of tissue barrier following SARS CoV-2 infection with the damage in the alveolar space, respiratory epithelium and endothelium injury and overwhelming inflammation and immune dysregulation during severe COVID-19. Other predisposing risk factors permissive to fungal infections during COVID-19 include the administration of immune modulators such as corticosteroids and IL-6 antagonist. COVID-19-associated pulmonary aspergillosis (CAPA) and COVID-19-associated mucormycosis (CAM) is increasingly reported during the COVID-19 pandemic. CAPA usually developed within the first month of COVID infection, and CAM frequently arose 10-15 days post diagnosis of COVID-19. Diagnosis is challenging and often indistinguishable during the cytokine storm in COVID-19, and several diagnostic criteria have been proposed. Development of CAPA and CAM is associated with a high mortality despiteappropriate anti-mold therapy. Both isavuconazole and amphotericin B can be used for treatment of CAPA and CAM; voriconazole is the primary agent for CAPA and posaconazole is an alternative for CAM. Aggressive surgery is recommended for CAM to improve patient survival. A high index of suspicion and timely and appropriate treatment is crucial to improve patient outcome.

Candidemia in hospitalized cirrhotic patients with bloodstream infection: A retrospective analysis and brief summary of published studies.

BACKGROUND: Candidemia is a life-threatening condition; however, the predictive markers for candidemia and mortality are inadequate in cirrhotic patients. This study was conducted to propose candidate predictors for the occurrence of candidemia and 30-day mortality in hospitalized cirrhotic patients with bloodstream infection (BSI) and review the related literature. METHODS: Cirrhotic patients with BSI between January 2011 and March 2020 were screened from the databank of a medical center and eligible patients were enrolled. Patients were separated into candidemia and bacteremia groups according to the results of blood cultures. Baseline characteristics, clinical presentation, and biochemistry data were collected at this time, as were microbiological data, medical management, use of antimicrobial agents, and outcome of the patients. The parameters and 30-day mortality were compared between candidemia and bacteremia groups. A combination of the MeSH terms and text terms related to candidemia and cirrhosis was searched in the electronic databases. RESULTS: Four hundred and sixty cirrhotic patients with BSI were enrolled. Thirty-five patients with candidemia (7.6%) were identified. Nosocomial infection, intensive care unit (ICU) admission, antibiotics exposure ≥14 days, white cell count >10 K/mm3, and model for end-stage liver disease (MELD) score >24 were associated with candidemia. The 30-day mortality was 65.7% in the candidemia group and 37.9% in the bacteremia group (p = 0.001). Nosocomial infection, ICU admission, hepatoma, hepatic encephalopathy, international normalized ratio ≥1.2, platelet ≤150 K/mm3, estimated glomerular filtration rate <60 mL/min/1.73m2, and MELD score >24 were associated with 30-day mortality. Six studies were identified. The results were consistent with our findings regarding low incidence of candidemia, and relevant risk factors are listed. CONCLUSION: Candidemia had low incidence but high mortality in hospitalized cirrhotic patients with BSI. New predictors were proposed for the occurrence of candidemia and 30-day mortality in these patients.

Bloodstream infection with extended-spectrum beta-lactamase-producing Escherichia coli: The role of virulence genes.

BACKGROUND: Extraintestinal pathogenic Escherichia coli (ExPEC) strains hold the responsibility for the majority of E. coli infections. Numerous extraintestinal virulence factors (VFs) were possessed by ExPEC which are involved in the pathogenesis of infection. However, the effect of comorbidities or infection syndrome in the association of VFs and mortality remains inconclusive. METHOD: This study addressed whether specific sequence type (ST) and VFs of extended-spectrum beta-lactamase-producing E. coli (ESBL-EC) are associated with different outcomes in patients with bloodstream infection. 121 adults from southern Taiwan with ESBL-EC bloodstream infections were enrolled during a 6-year period. Demographic data, including infection syndromes, underlying disease and outcomes, were collected. The virulence factors in isolates were analyzed by PCR and multilocus sequence typing analyses were also performed. RESULT: Positivity for the virulence genes iha, hlyD, sat, iutA, fyuA, malX, ompT, and traT was associated with ST131 positivity (P < 0.05). Some ESBL-EC virulence genes associated with urinary tract infection (UTI) were revealed. Positivity for ST405 and the virulence genes iroN and iss were significantly associated with increased 30-day mortality (death within 30 days) on univariate analysis (P < 0.05). Independent risk factors of 30-day mortality in bacteremic patients with UTI included underlying chronic liver disease and malignancy. ST131 was borderline associated with 30-day mortality. Independent risk factors associated with 30-day mortality among bacteremic patients without UTI included comorbidities and iroN positivity. CONCLUSION: In bacteremic patients with UTI, and the ST131 clone was borderline associated with mortality. Positivity for the virulence gene iroN may be linked to mortality in bacteremic patients without UTI.

Differential diagnosis of tuberculous and malignant pleurisy using pleural fluid adenosine deaminase and interferon gamma in Taiwan.

Accurately differentiating tuberculous pleurisy from lung cancer is important for disease management but difficult using conventional laboratory methods. This study assessed the value of adenosine deaminase (ADA) and interferon gamma (IFN-γ) for differentiating the two conditions in a region of Taiwan with a high prevalence of tuberculosis. The study population comprised patients with lymphocytic exudative pleural effusions: tuberculous (n=24) and malignant (n=42). Mean levels of ADA and IFN-γ in pleural fluid, measured with commercial standardized kits, were significantly higher for tuberculous than for malignant pleurisy (p<0.001 for both). For differentiating the two effusions, results for ADA versus IFN-γ were: sensitivity, 70.8% versus 91.7%; specificity, 95.2% versus 97.6%; positive predictive value, 89.5% versus 96.7%; and negative predictive value, 85.1% versus 95.3%. IFN-γ allows precise diagnosis of pleural tuberculosis, but ADA is easier to use, has a low cost, and results are quickly available. Our study confirms previous studies and extends the usefulness of these diagnostic methods to a wider group of clinical laboratories by showing the reliability of standardized relatively inexpensive commercial kits. We recommend that initial ADA screening be used in conjunction with IFN-γ measurements for differential diagnosis of tuberculous pleurisy.

Trends in fluoroquinolone resistance of Mycobacterium tuberculosis complex in a Taiwanese medical centre: 1995-2003.

OBJECTIVES: Fluoroquinolones are being used more frequently for the treatment of multidrug-resistant (MDR) strains of Mycobacterium tuberculosis complex (MTB). This study was designed to determine the frequency of the emergence of fluoroquinolone-resistant strains in Taiwan and to assess whether this might be due to use of fluoroquinolones for treatment of patients with MDR or because of increased use of fluoroquinolones in the community for treatment of other infections. We also sought to determine whether there might be clonal spread of fluoroquinolone resistance. METHODS: A total of 3497 clinical isolates of M. tuberculosis complex were obtained during 1995-2003, of which 141 were selected. They consisted of 62 isolates fully susceptible to four first-line drugs, 33 isolates resistant to rifampicin and isoniazid (MDR), and 46 isolates with a variety of any drug resistant patterns other than MDR (combination group). The MICs were determined for ciprofloxacin, ofloxacin and levofloxacin. RESULTS: An increase in the MIC90 and rates of resistance to ciprofloxacin, ofloxacin and levofloxacin were noted only in the MDR group. The rates were higher among strains isolated between 1998-2003 compared with those obtained between 1995-1997 (rate of resistance, 20% versus 7.7%; MIC > or = 4 mg/L versus 1-2 mg/L). Among the 10 fluoroquinolone-resistant isolates, five (50%) possessed mutations other than S95T in the gyrA gene. No gyrB mutation was found in any of the clinical isolates. CONCLUSIONS: These findings suggest that fluoroquinolone resistance is the result of treatment of patients with MDR strains rather than from use in the general community in Taiwan. The emergence of fluoroquinolone resistance among MDR strains reinforces the need for routine fluoroquinolone susceptibility testing whenever these drugs might be used.