[The modified Brussels scale as a predictor of mortality in the Intensive Care Unit]. / La escala modificada de Bruselas como predictor de mortalidad en la Unidad de Terapia Intensiva.

PURPOSE: To compare discrimination and calibration of the modified Brussels score with the Simplified Acute Physiology Score version 3 (SAPS-3) in predicting mortality. DESIGN: A prospective cohort study was carried out. SETTING: The Respiratory Intensive Care Unit (RICU) of Mexico General Hospital. PATIENTS: A total of 251 patients out of 285 admissions to the RICU in 2012 were included. The mean age was 48.4±17.1 years, and 132 of the patients were men (52.8%). INTERVENTIONS: None. VARIABLES OF INTEREST: Demographic data, SAPS-3 score upon admission and the modified Brussels score on the day 1 of stay in the RICU. RESULTS: On day 1, the modified Brussels and SAPS-3 scores were 4.7 ± 3.8 and 54.7 ± 17.8, respectively. Areas under the ROC curve for the modified Brussels score on day 1 and the SAPS-3 were 0.837 ± 0.025 (95% CI 0.787-0.887) and 0.813 ± 0.027 (95% CI 0.761-0.865), respectively. Hosmer-Lemeshow goodness-of-fit values were 5,885 (P=.660) and 4,026 (P=.855), respectively. CONCLUSIONS: The modified Brussels score on day 1 offers excellent discrimination and calibration in predicting mortality in the RICU, comparable to that of the SAPS-3.

Sertaconazole antifungal profile determined by a microdilution method versus nine topical substances against dermatophyte fungi.

Antifungal activity and in vitro inhibition time for sertaconazole (STZ) and 9 other topical drugs, namely amorolfine, bifonazole, clotrimazole, econazole, ketoconazole, miconazole, oxiconazole, terbinafine, and tioconazole were determined against 124 clinical isolates of dermatophyte (12 species) fungi by the microdilution method in a liquid medium and the measurement of optical density. STZ's antifungal activity was not always affected by the tested dermatophyte genus, as was the case with the remaining antifungals. In vitro antifungal activity was at the same level for all the studied azole derivatives, but, in terms of partial inhibitory concentrations, STZ starts its in vitro inhibitory activity in a shorter time than the other tested substances, particularly in those incubation periods when the growth of the dermatophyte fungi was more developed.

Activity of caspofungin and voriconazole against clinical isolates of Candida and other medically important yeasts by the CLSI M-44A disk diffusion method with Neo-Sensitabs tablets.

In vitro activity of caspofungin and voriconazole against 184 clinical isolates of Candida and other medically important yeasts in comparison with that of fluconazole, ketoconazole, itraconazole and amphotericin B was determined by using a disk diffusion method (Neo-Sensitabs) standardized according to the recommendations of the CLSI documents M44-A and M44-S1 (same medium: Mueller-Hinton plus methylene blue; inoculum and minimal inhibitory concentration/zone breakpoints). Seventy-two percent of clinical isolates were susceptible to caspofungin, 23.6% showed an intermediate susceptibility (most of them were Candida parapsilosis) and 4.3% were resistant (values for Candida spp. were 71.2, 23.8 and 5%, respectively). For voriconazole, 96.7% of clinical isolates were susceptible and 3.3% were resistant (Candida spp.: 96 and 3.8%, respectively). Both caspofungin and voriconazole showed high activity against a wide variety of clinically important yeasts.

In vitro activity of voriconazole against dermatophytes, Scopulariopsis brevicaulis and other opportunistic fungi as agents of onychomycosis.

Using a reference microdilution method, we studied the antifungal susceptibility to voriconazole and fluconazole of 304 clinical isolates from four species of onychomycosis-causing dermatophytes, 196 isolates of dermatophytes not related to nail infection as well as Scopulariopsis brevicaulis, Fusarium spp. and Scytalidium dimidiatum. Results showed a high antifungal activity of voriconazole against dermatophytes (geometric mean minimal inhibitory concentration (MIC)=1.14 microg/mL; MIC for 50% of the organisms (MIC(50))=0.062 miccrog/mL; MIC for 90% of the organisms (MIC(90))=0.25 microg/mL). For S. brevicaulis, the in vitro activity of voriconazole was considerably lower (geometric mean MIC=8.52 microg/mL; MIC(50) and MIC(90)=16 microg/mL). Although voriconazole is not among the drugs recommended for the management of onychomycosis, it can be a useful alternative for recalcitrant infections.

Comparison of tablet and disk diffusion methods for fluconazole and voriconazole in vitro activity testing against clinical yeast isolates.

We have compared a commercially available tablet diffusion method for the in vitro antifungal susceptibility testing of fluconazole (FCZ) and voriconazole (VCZ) with the disk diffusion method M44 (CLSI) with 282 clinical yeast isolates. The superior stability of antifungal agents in tablets can explain the differences for each category of susceptibility by both methods.Neo-Sensitabs tablets antifungal susceptibility testing showed an excellent correlation (0.98 for FCZ and 0.98 for VCZ at 24h and 0.96 for FCZ and 0.94 for VCZ at 48 h ), a reduced percentage of disagreements (4.6% and 8.2% for FCZ at 24h and 48 h respectively; 1.1% and 2.1% for VCZ at 24h and 48 h respectively) and the absence of statistically significant difference in comparison with the reference protocol for performing antifungal susceptibility testing with the agar diffusion method.

Antifungal agents: mode of action in yeast cells.

Different kinds of mycoses, especially invasive, have become an important public health problem as their incidence has increased dramatically in the last decades in relation to AIDS, hematological malignancies, transplant recipients and other immunosuppressed individuals. Management of fungal infections is markedly limited by problems of drug safety, resistance and effectiveness profile. Current therapy for invasive mycoses uses a relatively reduced number of antifungal drugs, such as amphotericin B, fluconazole and itraconazole. Other new antifungal agents from old and new chemical families, like voriconazole, posaconazole, ravuconazole, caspofungin and micafungin, have been introduced into the armamentarium for fungal infections management. This review is focused on the mode of action of those antifungal drugs used against pathogenic yeasts. The interaction of amphotericin B with ergosterol and other membrane sterols results in the production of aqueous pores of drug and the ergosterol biosynthetic pathway is the target of the allylamines, phenylmorpholines and azole antifungal agents. The main molecular target of azole antifungals is the cytochrome P-450 protein Erg11p/Cyp51p. Echinocandins, a new class of antifungal drugs, are fungal secondary metabolites that act against beta-1-3-D-glucan synthesis. The phenylmorpholines, of which amorolfine is the sole representative in human therapy, affect two targets in the ergosterol pathway: Erg24p (delta 14 reductase) and Erg2p (delta 8-delta 7 isomerase). The sordarins group are protein synthesis inhibitors that work by blocking the function of fungal translation elongation factor 2. Other protein inhibitors are zofimarin, BE31045, SCH57504, xylarin, hypoxysordarin and GR135402. In order to overcome the problems derived from the exploitation of azole drugs, macrolides and echinocandins, novel targets were explored. Proposed antifungal drugs have been developed against potential targets like the N-myristylation of fungal proteins, with inhibitors like myristate and histidine analogues or myristoylpeptide derivatives, aminobenzothiazoles, quinolines and benzofurans. Polymerization of cell wall carbohydrates from uridine di-phospho sugars is another potential target.

[Identification and in vitro antifungal susceptibility of vaginal Candida spp. isolates to fluconazole, clotrimazole and nystatin]. / Identificación y sensibilidad antifúngica in vitro de Candida spp. de origen vaginal a fluconazol, clotrimazol y nistatina.

OBJECTIVE: The aim of this study was to identify and determine the in vitro antifungal susceptibility testing to clotrimazole, fluconazole, and nystatin of 145 clinical isolates of Candida spp. METHODS: M27-A3 microdilution method was used to determine minimal inhibitory concentrations (MIC) and partial MICs (MIC50 and MIC90) of drugs. A total of 145 isolates were studied, 126 were C. albicans, 16 C. glabrata, 2 C. parapsilosis y 1 C. tropicalis. RESULTS: MIC50 and MIC90 for FLZ against C. albicans were 0.25 mg/L and 1 mg/L respectively and for C. glabrata was achieved at 8 mg/L and 16 mg/L for fluconazole. Five isolates of C. albicans and one isolate of C. tropicalis were in vitro resistant to fluconazole (M27-S4). In C. albicans MIC50 and MIC90 for clotrimazole were of 0.03 mg/L and 0.06 mg/L, respectively. These values for C. glabrata were 0.25 mg/L and 1 mg/L, respectively. Five C. glabrata and 1 C. tropicalis were in vitro resistant to clotrimazole. MIC50 and MIC90 of nystatin were of 1 mg/L and 2 mg/L, respectively for C. albicans and C. glabrata. CONCLUSIONS: In this study, C. albicans is the most frequently isolated yeast, followed by C. glabrata. The antifungals tested were found to be in vitro active for the isolates, except for 6 isolates for fluconazole and 6 to clotrimazole.

Ciclopiroxolamine: in vitro antifungal activity against clinical yeast isolates.

The in vitro susceptibility of 225 clinical isolates of yeasts to ciclopiroxolamine (CPO) was compared with that of clotrimazole, econazole, ketoconazole, miconazole, tioconazole, fluconazole, itraconazole and nystatin using a standardized agar diffusion method (NeoSensitabs). Two hundred and eight strains of yeasts comprising 16 species of Candida and 22 strains belonging to other yeast genera were tested. One strain (0.4%) was resistant, four strains (1.8%) of intermediate susceptibility and 220 strains (97.3%) susceptible to CPO. More strains were susceptible to CPO than to the other antifungals studied. Susceptibility patterns of antifungal agents were not linked to species. The in vitro antifungal susceptibility profile of CPO was better than topical azole derivatives or fluconazole and itraconazole against a wide variety of clinically important yeasts.

Comparative evaluation of four commercial tests for presumptive identification of Candida albicans.

Four commercially available tests (Albicans ID2, Chromalbicans Agar, CHROMagar Candida, and BactiCard Candida) and the germ tube (GT) test for presumptive identification of Candida albicans were evaluated using clinical isolates of C. albicans (n=89) and of non-albicans yeasts (n=107). Sensitivities and specificities of all tests regarding the identification of C. albicans were greater than 92%, except for Chromalbicans Agar plates (88.7% after 48 h) and their specificity was 86%. Overall, the four commercial systems were easy to use and are good systems for the routine identification of C. albicans.

In vitro antifungal activity of sertaconazole against 309 dermatophyte clinical isolates.

Three hundred and nine strains belonging to 11 species of dermatophyte moulds were tested against sertaconazole following mainly the National Committee for Clinical Laboratory Standards (M38-P) for filamentous fungi. However, several important factors such as the temperature (28 degrees C vs 35 degrees C) and time of incubation (4-10 d vs 21-74 h), have been modified. Sertaconazole was active against all the clinically important dermatophyte moulds involved in human infections tested. Overall geometric mean MIC of sertaconazole was 0.21 microg/ml with a MIC range of 0.01-8 microg/ml. MIC50 and MIC90 were respectively of 0.25 and 1 microg/ml. Sertaconazole was very active against Epidermophyton floccosum, Trichophyton rubrum, Trichophyton tonsurans and Microsporum canis (geometric means 0.08, 0.13, 0.13 and 0.19 microg/ml respectively). Microsporum audouinii had the lowest susceptibility in the study (geometric mean 0.59 microg/ml). Considering MIC50 and MIC90 these differences were significantly in favor of the activity of sertaconazole against E. floccosum (0.06 and 0.5 microg/ml respectively).

Sertaconazole: in-vitro antifungal activity against vaginal and other superficial yeast isolates.

The in vitro susceptibilities of 183 clinical yeast isolates to sertaconazole (STZ) were compared to their susceptibilities to clotrimazole (CTZ), econazole (ECZ), ketoconazole (KTZ), miconazole (MNZ), fluconazole (FLZ), itraconazole (ITZ), tioconazole (TCZ), amphotericin B (AMB) and flucytosine (5FC) by using a commercial agar diffusion method. Strains were isolated from vaginal and other superficial clinical samples (18 species of Candida and five strains belonging to other yeast genera). Only one strain (0.5%) was resistant to STZ out of 87.4% of susceptible strains (n=160). The percentage of susceptible strains was higher than those obtained with the other agents evaluated and the percentage of resistant strains was lower than for most of the other antifungals. The pattern of susceptibility of C. albicans to STZ, TCZ, ITZ and CLZ was similar and superior to the pattern of susceptibility of this species to MNZ, ECZ, FLZ, 5FC and KTZ. C. dubliniensis was more susceptible to STZ, MNZ, MNZ, FLZ, ITZ, CLZ than to TCZ, ECZ, 5FC, AMB or KTZ. Ten susceptible strains to STZ were resistant to FLZ and one strain was resistant to ITZ. The overall antifungal activity of STZ in vitro against a wide range of clinically important yeasts from vaginal and cutaneous samples indicates the therapeutic potential of this agent for the treatment of infections caused by these fungi. However, the activity of STZ and the clinical value of in vitro data need to be verified in human clinical trials.

Antifungal activity of amphotericin B and itraconazole against filamentous fungi: comparison of the Sensititre Yeast One and NCCLS M38--a reference methods.

The susceptibilities of 81 clinical isolates of Aspergillus spp., Fusarium spp., and Scedosporium spp., to amphotericin B and itraconazole were determined by the colorimetric microdilution method Sensititre and the reference microdilution method of NCCLS standard M38-A for filamentous fungi. No major discrepancies were found and agreement ranged between 86.4% to 84% and 69.1% to 86.4% for amphotericin B and itraconazole respectively at 48 h and 72 h of incubation by using the recommended endpoints. Within two two-fold dilutions, high levels of agreement were found in general for amphotericin B at 48 or 72 h (86.4 to 87.7%) and itraconazole (91.4 to 93.8%). Relatively better agreement was found for itraconazole at 72 h of incubation and 48 for amphotericin B.

Comparative study of the in vitro antifungal activity of bifonazole, naftifine and sertaconazole against yeasts.

The in vitro activity of three antifungal agents was tested and compared against 151 yeast strains, including ten Candida species, Cryptococcus neoformans, Rhodotorula rubra, and Trichosporon cutaneum. Minimum inhibitory concentrations (MICs) were determined by a microdilution technique in Shadomy modified liquid medium. The mean MICs of sertaconazole (0.34 mg/L) were lower than those of naftifine (16.3 mg/L) and bifonazole (13.2 mg/L). These results suggest that sertaconazole is more active against Candida spp than other topical agents such as bifonazole and naftifine.

[Evaluation of Chromalbicans Agar for presumptive identification of Candida albicans]. / Evaluación del medio Chromalbicans Agar para la identificación presuntiva de Candida albicans.

The utility of Chromalbicans Agar (Biolife Italiana, Milano, Italy) was evaluated with 723 clinical isolates and type culture collection strains from different genera including Candida, Cryptococcus, Pichia, Rhodotorula, Saccharomyces, Trichosporon y Zygosaccharomyces. Presumptive identification was confirmed by germ tube test and carbohydrate assimilation on API-ATB ID 32C (bioMerieux, France). Growth on Chromalbicans Agar was very useful for the presumptive identification of C. albicans isolates, and sensitivity and specificity values were significantly high (>97%), since a very low number of isolates were found to be false negative or false positive.

[In vitro activity of a liposomal nystatin formulation (Nyotran) against Cryptococcus neoformans]. / Actividad in vitro de una formulación liposómica de nistatina (Nyotran) frente a Cryptococcus neoformans.

The in vitro antifungal activity of a new liposomal nystatin formulation (NISTL, Nyotran, Aronex Ltd., EE.UU.) was evaluated by a microdilution method with RPMI based on the M27A document of the National Committee for Clinical Laboratory Standards (NCCLS) against 22 isolates of Cryptococcus neoformans. This antifungal activity was compared with those of other seven antifungal agents, such as nystatin (NIST), amphotericin B deoxycholate, liposomal amphotericin B, amphotericin B lipid complex, amphotericin B colloidal dispersion, fluconazole, and itraconazole. NISTL was more active in vitrothan NIST, showing MIC values 2-3 fold smaller in 90% of the isolates. The results obtained suggest that this new formulation would be very helpful for the treatment of cryptococcosis.

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.

[In vitro resistance to fluconazole and itraconazole in clinical isolates of Candida spp and Cryptococcus neoformans]. / Resistencia in vitro al fluconazol e itraconazol en aislamientos clínicos de Candida spp y Cryptococcus neoformans.

An in vitro susceptibility testing of 181 strains of six species of Candida and 21 strains of Cryptococcus neoformans was carried out in order to investigate the resistance to new antifungal drugs. We have studied clinical isolates from 200 different patients of Hospital del Mar (Barcelona) and Hospital La Inmaculada (Almería). An agar diffusion method (NeoSensitabs, Rosco, Taastrup, Denmark), was employed with fluconazole, itraconazole, and reference drugs amphotericin B, flucytosine, tioconazole and ketoconazole. A high level of susceptibility was found for amphotericin B in C. neoformans strains while 19% of them were resistant to flucytosine. All the strains of C. neoformans and Candida guilliermondii were susceptible to the new azoles derivatives and also Candida parapsilosis and Candida albicans had a great susceptibility to this antifungals. A greater level of resistance was found for Candida krusei, Candida tropicalis and Candida glabrata to fluconazole, itraconazole and ketoconazole, but resistance to fluconazole and itraconazole is not always linked because ten resistant strains for fluconazole were susceptible to itraconazole, and two other resistant to itraconazole were susceptible to fluconazole.

[Scedosporium apiospermum external otitis.]. / Otitis externa por Scedosporium apiospermum.

We report a case of Scedosporium apiospermum external otitis. The patient was topically treated with miconazole cream and achieved a clinical and mycological cure. The etiology, diagnosis and treatment of external fungal otitis are discussed.

[Comparison of two methods for the study of the in vitro susceptibility to sertaconazole of yeast clinical isolates]. / Comparación de dos métodos para el estudio de la sensibilidad in vitro al sertaconazol en aislamientos clínicos de levaduras.

We evaluated a commercial method for studying the in vitro susceptibility to sertaconazole based on its diffusion in agar with standardized tablets, with the aim of determining its correlation with the method of microdilution in Shadomy modified liquid medium (YNBg). A total of 110 Candida genus strains (50 C. albicans, 26 C. tropicalis, 15 C. glabrata, 8 C. parapsilosis, 8 C. krusei, 2 C. guilliermondii and 1 C. kefyr) from pathological clinical processes were used. The results of both techniques showed a statistically significant correlation that depended on the type of reading used in the liquid medium microdilution technique, with results being -0. 4199 with IC50; -5135 with IC90: -0.6634 with MIC24 h; and -0.4945 with MIC48 h. These values demonstrate the existence of a correlation for sertaconazole, and that it is bigger when it is compared with the logarithm of the MIC obtained after 24 hours of incubation.