Multicenter study of epidemiological cutoff values and detection of resistance in Candida spp. to anidulafungin, caspofungin, and micafungin using the Sensititre YeastOne colorimetric method.

Neither breakpoints (BPs) nor epidemiological cutoff values (ECVs) have been established for Candida spp. with anidulafungin, caspofungin, and micafungin when using the Sensititre YeastOne (SYO) broth dilution colorimetric method. In addition, reference caspofungin MICs have so far proven to be unreliable. Candida species wild-type (WT) MIC distributions (for microorganisms in a species/drug combination with no detectable phenotypic resistance) were established for 6,007 Candida albicans, 186 C. dubliniensis, 3,188 C. glabrata complex, 119 C. guilliermondii, 493 C. krusei, 205 C. lusitaniae, 3,136 C. parapsilosis complex, and 1,016 C. tropicalis isolates. SYO MIC data gathered from 38 laboratories in Australia, Canada, Europe, Mexico, New Zealand, South Africa, and the United States were pooled to statistically define SYO ECVs. ECVs for anidulafungin, caspofungin, and micafungin encompassing ≥97.5% of the statistically modeled population were, respectively, 0.12, 0.25, and 0.06 µg/ml for C. albicans, 0.12, 0.25, and 0.03 µg/ml for C. glabrata complex, 4, 2, and 4 µg/ml for C. parapsilosis complex, 0.5, 0.25, and 0.06 µg/ml for C. tropicalis, 0.25, 1, and 0.25 µg/ml for C. krusei, 0.25, 1, and 0.12 µg/ml for C. lusitaniae, 4, 2, and 2 µg/ml for C. guilliermondii, and 0.25, 0.25, and 0.12 µg/ml for C. dubliniensis. Species-specific SYO ECVs for anidulafungin, caspofungin, and micafungin correctly classified 72 (88.9%), 74 (91.4%), 76 (93.8%), respectively, of 81 Candida isolates with identified fks mutations. SYO ECVs may aid in detecting non-WT isolates with reduced susceptibility to anidulafungin, micafungin, and especially caspofungin, since testing the susceptibilities of Candida spp. to caspofungin by reference methodologies is not recommended.

In vitro susceptibility of high virulence microorganisms isolated in heart valve banking.

Storage preparation of human heart valves for implants generally includes incubation in an antimicrobial disinfection solution and cryopreservation. Changes in patterns of microorganisms susceptibility to antibiotics is a variable process of that promote its inefficiency. The aim of this study has been an evaluation of in vitro susceptibility of high virulence microorganisms isolated in our tissue bank for 14 years in order to evaluate the efficiency, and to promote changes for further antibiotics mixtures as well. Data presented in this study show that microorganisms isolates in valve banking display susceptibility patterns similar to those shown in other clinical circumstances, and the most commonly used antibiotics regimes are useful to date. An antibiotic cocktail containing aminoglicoside in addition to ciprofloxacin and vancomycin is an efficient mixture to be used in valve banking. Further studies will be necessary for monitoring patterns changes of in vitro susceptibility of microbiological isolates in tissue banking.

Clinical differences between invasive pulmonary infection by Scedosporium apiospermum and invasive pulmonary aspergillosis.

Invasive pulmonary infection by Scedosporium apiospermum (IPSA) and invasive pulmonary aspergillosis (IPA) are clinically similar. Our objective was to identify clinical parameters that may differentiate IPSA from IPA. Ours was a prospective cohort study that included patients with different degrees of immunosuppression and respiratory isolation of S. apiospermum (SCA). Episodes of invasive infection were classified according to the EORTC and MSG criteria. Clinical variables corresponding to patients with IPSA were compared with those collected from patients with a diagnosis of IPA during the same period. Twenty-seven patients with positive culture for SCA from respiratory samples were evaluated. Of the 27 positive cultures, nine were classified as IPSA. When compared with the 89 patients with IPA, patients with IPSA were most likely to have received prophylaxis with either aerosolised (14.6% vs. 66.7%; P < 0.001) or intravenous amphotericin B (AMB; 4.5% vs. 44.4%; P = 0.002), to have prior episode of acute rejection (19% vs. 66.7%; P = 0.005), to have a later onset of infection after transplantation (251 days vs. 404 days; P = 0.009), and to have higher CD4(+) lymphocyte count (207.6 vs. 289.4; P = 0.005). Late-onset disease after transplantation and prophylaxis with AMB are more frequent in patients with IPSA compared with IPA.

Vertigo and Parinaud's syndrome as presentation of Churg-Strauss syndrome.

Intracranial complications are rare in Churg-Strauss syndrome (CSS). Cerebral infarctions are the most common intracranial presentation, usually after the clinical diagnosis of CSS had been established. We present a case of vertigo and Parinaud's syndrome as presentation of CSS in an asthmatic patient. Clinical examination revealed upward gaze limitation and bilateral midriasis. A cranial computed tomography scan showed a small round hypoattenuating lesion located in the right thalamic-mesencephalic region, which was later confirmed by magnetic resonance imaging. There was eosinophilia of more than 50%, and p-ANCA were positive. After steroid treatment was started, vertigo and diplopia resolved, and eosinophilia was reduced. After 24 months follow-up, the patient remains stable, with negative p-ANCA, taking 20 mg prednisone daily. Further magnetic resonance exams have shown findings that were similar to those of previous studies. This case shows how vertigo and transient diplopia may be the first symptoms of neurological complications in patients with CSS.

[Comparative study of three systems for in vitro activity investigation of fluconazole against yeast isolates of clinical interest]. / Estudio comparativo de tres sistemas para la investigación in vitro de la actividad del fluconazol frente a organismos levaduriformes de interés clínico.

BACKGROUND: Study of antifungal sensitivity can help in treatment screening and evaluation of patients suffering from some fungal infections. The purpose of this study is to compare fluconazole MICs obtained by E-test and agar dilution with the NCCLS method. MATERIAL AND METHODS: The in vitro activity of fluconazole against 158 yeast strains by three systems: E-test, agar dilution and the microbroth NCCLS M27P method. RESULTS AND CONCLUSION: A correlation between 84 to 100% was observed the degree varying in the result among different species. The E-test was found to be comparable to the NCCLS M27P microbroth method, was easier to perform and provides MIC result for Candida species within 24 h.

Multicenter evaluation of Neo-Sensitabs, a standardized diffusion method for yeast susceptibility testing.

The agar diffusion method Neo-Sensitabs for sensitivity testing, was evaluated with 33 reference strains by fourteen laboratories. Tablets with 5-fluorocytosine, amphotericin B, nystatin, fluconazole, itraconazole, ketoconazole and tioconazole were used on Shadomy modified medium. These tests classify each strain as susceptible, intermediate or resistant to all tested antifungals by measuring the inhibition zone diameters. Intra and interlaboratory reproducibility was studied. Neo-Sensitabs sensitivity for fungi was easy to perform and reliable method with a reproducibility of 97.1% and superior to other commercialized methods, being specially interesting for antifungal susceptibility in vitro testing of triazole derivatives fluconazole and itraconazole.

Multicenter survey of in vitro antifungal resistance in yeasts of medical importance isolated from Spanish patients.

Twelve Spanish laboratories collected 325 yeast clinical isolates during a 30 day's period, among them 224 Candida albicans, 30 Candida glabrata, and 27 Candida parapsilosis. In vitro antifungal susceptibility to amphotericin B, ketoconazole, fluconazole and itraconazole was determined by an agar diffusion test (Neo-Sensitabs, Rosco, Denmark). All the isolates tested were susceptible in vitroto amphotericin B and nearly all (97.2%) to itraconazole. In vitrosusceptibility to fluconazole and ketoconazole was high (90.2% and 91.4% of isolates, respectively) but showed variations depending on the species tested. Resistance to fluconazole and ketoconazole was low in C. albicans (4% and 3%, respectively), but 30% of Candida guilliermondii and 36% of C. glabrata isolates were resistant to fluconazole. Ketoconazole resistance was observed in 40% of C. glabrata, and 17% of Candida tropicalis. Resistance to antifungal drugs is very low in Spain and it is related to non-C. albicans isolates.

Study of the susceptibility of yeast isolates of clinical interest to five antifungal agents using the E test.

The E test is a quantitative technique for determining antimicrobial susceptibility; it is based on the diffusion of a stable predetermined gradient of a specific antifungal agent along an inert plastic strip which is applied to a solid culture medium. The E test is an alternative method for determining inhibitory concentrations of antimicrobial agents. The aim of the present study was to determine the in vitro susceptibility of different yeasts to 5 antifungal agents using the E test. The antifungal susceptibility of 87 strains, 73 of which were yeasts obtained from clinical samples, 11 were Prototheca strains and 3 controls, were examined using a gradient diffusion technique (E test). Of these isolates, 13% of Candida albicans were resistant to flucytosine, and 20%, 17% and 33% showed resistance to ketoconazole, itraconazole and fluconazole, respectively. All Candida krusei isolates showed resistance to flucytosine and fluconazole. The Candida parapsilosis and Candida tropicalis strains all presented in vitro susceptibility to all the agents tested. Prototheca strains were only susceptible in vitro to amphotericin B. It was found that the E test was easy to perform, and provided MIC values similar to those obtained with other well documented techniques. It was therefore concluded that the E test could be implemented as a standard procedure in clinical mycology laboratories.

Chronic pneumonia caused by Rhodococcus equi in a patient without impaired immunity.

A 48 year old, human immunodeficiency virus (HIV)-negative, immunocompetent male patient had a chronic progressive pulmonary infiltrate, without radiological cavitation, in the middle lobe of the right lung produced by Rhodococcus equi. He reported direct contact with a diseased dog. The patient was diagnosed by thoracotomy and treated by lobectomy. After 16 months of follow-up, the patient was asymptomatic and had neither recurrence nor immunological disturbances.

Study of onychomycosis in Córdoba, Spain: prevailing fungi and pattern of infection.

From a total of 20,004 patients seen during two years, we carried out a mycologic nail investigation (direct microscopy and repeated cultures). Ninety-three (43.2%) of the nails were judged to be infected by their clinical appearance. They fulfilled the laboratory criteria required to start antifungal treatment (isolation of the same fungus in culture on two consecutive occasions), but only in 64 cases (29.7%) was there a clinical and mycological recovery once antifungal treatment and follow up were completed. yeasts were isolated in two thirds of the cases of onychomycosis, mainly from fingernails. Candida albicans, C. parapsilosis or both were the most prevalent species. Dermatophytes were found in 18.8% of the samples, especially from toenails. Trichophyton rubrum was the predominant species. Non-dermatophytic filamentous fungi were cultured in 17.2%, Scopulariopsis brevicaulis being the most prevalent species. The highest prevalence of onychomycosis was found in patients between 50 and 70 years of age. Females were affected more frequently than males. Fingernails were affected more frequently than toenails. Proximal subungual onychomycosis, secondary to paronychia (PSOp), was the most prevalent clinical type, although primary distal and lateral subungual onychomycosis (DLSO) and total dystrophic onychomycosis (TDO) were also frequent. PSOp was only observed in fingernails, while DLSO was almost only seen in toenails and TDO in both fingernails and toenails. All the clinical types were more frequent in women except TDO, which showed a similar prevalence in both sexes.

Appearance of colonies of Prototheca on CHROMagar Candida medium.

The microorganisms capable of producing opportunist infections include the yeast-like organisms of the genus Candida, and the unicellular algae of the genus Prototheca, which share common features and can, therefore, lead to confusion. Their colonies are almost identical and they grow in the same culture media used routinely in mycology. CHROMagar Candida is a new chromogenic differential isolation medium that facilitates the presumptive differentiation of some of the most clinically important yeast-like organisms. To our knowledge, the use of CHROMagar Candida with Prototheca spp. has not been reported in the literature. This report describes the growth of 151 strains of Prototheca on CHROMagar Candida compared to the growth of a total of 326 well-characterized yeast organisms of the genera Candida, Cryptococcus, Trichosporon, Geotrichum, and Saccharomyces. It is clinically relevant to note that algae of the genus Prototheca (P. wickerhamii, P. zopfii, and P. stagnora) and of the genus Candida parapsilosis produced similar cream-colored colonies on CHROMagar Candida medium. Based on their growth on CHROMagar, a new species of Candida is described, C. zeylanoides, which has blue-green colonies. The colonies of two species of Trichosporon are also differentiated: the blue-green colonies of T. beigelii and the pink colonies of T. capitatum.

[Efficacy of the ilioinguinal and iliohypogastric block in the treatment of the postoperative pain of inguinal herniorrhaphy]. / Eficacia del bloqueo ilioinguinal e iliohipogástrico en el tratamiento del dolor postoperatorio de la herniorrafia inguinal.

INTRODUCTION: The ileoinguinal-ileohypogastric block (IHB) improves pain control in inguinal hernioplasty. OBJECTIVE: To determine the efficacy of the IHB on the treatment of postoperative pain in inguinal herniorrhaphy, and to compare the effect of its use before and after incision for diminishing pain and postponing the first dose of analgesia. PATIENTS AND METHODS: Sixty-eight patients scheduled for inguinal herniorrhaphy with mesh were enrolled and distributed randomly in 4 groups as follows: 1) IHB before incision using 0.25 ml/kg bupivacaine 0.5% with no vasoconstrictor; 2) IHB after incision with the same dose of bupivacaine; 3) IHB before incision with 0.25 ml/kg of serum; and 4) IHB after incision with 0.25 ml/kg of serum. Pain was evaluated on visual analog scales employing facial expressions and verbal description, a patient questionnaire and time elapsing between surgery and the first dose of analgesia. The evaluations were performed in the postoperative recovery unit and on the ward 8 and 24 hours after surgery. RESULTS: The total overall score for postoperative pain was lower in the bupivacaine group than in the placebo group (9.2 +/- 4.4 and 1.5 +/- 3.9, respectively; p = 0.026). The first dose of analgesia was given to those who received placebo between the second and third hour after surgery, whereas it was given between the fourth and fifth hour to the bupivacaine group. No significant differences were found between infiltration before and after incision. CONCLUSIONS: IHB decreases pain, delaying the need for a first dose of analgesic and improving patient comfort. Its use is therefore recommended for relief of postoperative pain.

[Evaluation of anesthetic techniques in ambulatory surgery]. / Evaluación de las técnicas anestésicas en cirugía ambulatoria.

Many of the surgical procedures performed in the hospital can be done on an out-patient basis, provided an appropriate anesthetic technique is applied to allow the patient to return home comfortably and safely. Choice of anesthetic technique must always be made in keeping with patient characteristics and type of surgery. Treatment of anxiety in a preoperative interview or by giving tranquilizers will be beneficial to all patients, as will reduction of gastric secretion by administration of H2 receptor blockers. Dehydrobenzoperidol at a dose of 0.5 to 1.125 mg in adults will antagonize the emetic effects of opioids, without prolonging recovery time. Propofol, alfentanyl, atracurium or vecuronium require the shortest recovery time. For epidural anesthesia, we use lidocaine and mepivacaine. Truncal blocks, endovenous regional anesthesia, and brachial plexus, retrobulbar and peribulbar blocks are all appropriate techniques for out-patient surgery.

[Selection criteria used in 1,310 patients in ambulatory major surgery]. / Criterios de selección utilizados en 1.310 pacientes de cirugía mayor ambulatoria.

From October 1990 through March 1992, 1,310 patients underwent surgery on an out-patient basis. Fifty (3.82%) could not be released on the day of surgery, most often because of surgical complications (17), postoperative pain (11), poor screening (9), and nausea and vomiting (8). Screening for out-patient surgery must not be based solely surgical procedure. Factors of social context, personality and associated pathology must also be weighed.

Detection of antibodies to Candida albicans germ tube as a possible aid in diagnosing systemic candidiasis in bone marrow transplant patients.

Indirect immunofluorescence assays to detect antibodies to Candida albicans blastospore and germ tube were performed in sera of 29 bone marrow transplant patients. Antibodies to germ tube were present in the sera of six patients, in four of whom a Candida albicans infection was highly probable, while in the other two patients it was not possible to determine the previous course. No healthy blood donors had these antibodies. On the other hand, detection of antibodies to Candida albicans blastospore showed low specificity in the diagnosis of systemic candidiasis. These preliminary findings suggest that the detection of antibodies to Candida albicans germ tube may be an important aid in the diagnosis of systemic candidiasis in bone marrow transplant patients.

[Dermatophytes and dermatophytosis in Córdoba (Spain)]. / Dermatófitos y dermatofitosis en Córdoba (España).

During a two year period all patients referred to the Dermatology Department with the diagnosis of dermatophytosis were studied. We obtained 158 dermatophyte isolated belonging to 12 species of dermatophytes. The most frequent causal agents were M. canis in 58 (36.7%), T. mentagrophytes var mentagrophytes in 36 (22.7%), E. floccosum in 29 (18.3%) and T. rubrum in 17 (10.7%). M. canis was the most prevalent causal agent of tinea capitis and tinea corporis. The most frequent species in the tinea cruris was E. floccosum. In 4 patients there were simultaneous infection by two different agents. The incidence of dermatophytosis in Córdoba is high. Due to the similarities with other diseases, the mycologic examination by culture is essential.