InvasivecandidiasisBlood cultures are limited for diagnosing invasive candidiasisCandidemiaDeep-seated candidiasisMoredifficulttobedetectedbycultureCatheter-AcuteCandidiasis ofrelateddisseminateddeep organ/candidemiatissuecandidemiaModifiedfrom:RexJHetal.AdvInternMed43:321-71,1998ClancyCL,etal.ClinInfectDis56:1284-92.2013
Invasive candidiasis Candidemia Deep-seated candidiasis Catheterrelated candidemia Acute disseminated candidemia Candidiasis of deep organ/ tissue Modified from: Rex JH et al. Adv Intern Med 43:321-71, 1998. Clancy CL, et al. Clin Infect Dis 56:1284-92, 2013. More difficult to be detected by culture Blood cultures are limited for diagnosing invasive candidiasis 11
Diagnosis of IFl in patients with neutropenia after anti-cancer chemotherapyProlonged (persistingafterz4daysofbroad-spectrumantibiotcs)febrileneutroneniaEvaluationofdeepmycosisindicationsincludingbioodtest,symptoms,andsignsigevalualionshcdbeimplemendedrrespoctiveofthcpresence of findings other than febrie neutropenieunresponsivetobroad-specfrumantibioficsSerologicaltestChestCTRightBlood culturehypochondraigiaandHalosignsincreasedserumAir-crescent signsSinusitisAl-Pin.neutrophilCavity lesionssymptomsrecoverystageGMantigenWedge-shapedopacitiesAbdominalultraProvendiagnosisOkβ-D-glucansoundgraphycandidemiaAbdominaiCTParanasal sinusCTandMRIBuits eye signHepatosplenicDestuctiandfmicroabscessSssitlediagnosisorsinus wallBronchoscopymold infecton+ClinitallyClinicallydiagnosedGMantigenchronicdiagnosedarcytologyPuncturefluidBALdisseminatedinvasiveaFouuecuiture'sFunduscopycandidiasisaspergillosisOcularsymptomsPuncture fluidBiopsycultureLungbiopsyBiopsy+?AProvendiagnosisfovendiagnosisProvenofmucomycosisof invasiveProvendiagnosis ofaspergilosisdagnosisofchronieCandidadisseminatedendophthalmitiscandidiasis+:PositiveNegative.1Perfomedincaseswheretherisk ofhemorrhage is low,wherethediagnosis cannotbe established by bronchoalveolar lavage (BAL),andwheretheresponsetotreatmentisooor*2ifa positiveGMantigen test is obtained,even with.negativechest CTfindings,paranasal sinus CT imaging should be considered.12*3When Mucor is detected in the paranasal sinus, this condition deems thecase as a clinically diagnosed mucormycosis.MedmvcolJ57E117-163.2016
Med mycol J 57E117-163, 2016. Diagnosis of IFI in patients with neutropenia after anti-cancer chemotherapy 12
Culture-based mycological diagnosisTABLE2.Number of blood cultures required to detect common microorganisms causing unimicrobial bacteremia and fungemiaFour blood cultures obtainedThreeblood cultures obtainedCumulative %detected byCumulative % detected byMicroorganism(s)No.ofBSINo.ofBSIculture no:culture no.:episodesepisodes11233429397758793100100100S.aureus6485417198100100Coagulase-negative66staphylococci36678089476887100100Enterococcus spp7785208526100100Streptococci72439195206590100100Escherichia coli40789025889810076100Klebsiella pneumoniae156085166294100100Pacriginosa85152060.951006083100Calbicans751001088880100Caudida alahrataVUpto4blood culturepairs havetobetakenfromvariousbodysitesto increasetheyield>90%forfungemia.13LeeA,etal.JClinMicrobiol45(11):3546-3548,2007
Culture-based mycological diagnosis ✓ Up to 4 blood culture pairs have to be taken from various body sites to increase the yield >90% for fungemia. Lee A, et al. J Clin Microbiol 45(11):3546–3548, 2007. 13
TimetoBloodCulturePositivityasaMarkerforCatheter-Related CandidemiaDefinite catheterrelated1.0candidemia.1NOJYes0.80.6LogranktestP<0.001VTimetopositivityofmorethan3ohin0.4peripheralbloodcanhelpexcludean02intravascularcatheterasthepossiblesourceof candidemia.10.00.0040.0060.0020.0080:00100.00120.00Timetopositivity(hours)TABLE3.AccuracyofaTTPcutoffof30hforthediagnosis of CRCin50patientswithindwelling CVCsNo.ofpatientswithCRCdiagnosis with thefollowingSensitivitySpecificityArea underPPV (%)Patient groupNPV (%)TTPcutof:(%)(%)ROCcurveTIP30hTTP>30 h13BDefiniteCRC10051.441.91000.76Possible + non-CRC18237275.957.171.063.20.66Definite+possibleCRCNon-CRC14Ben-AmiR,etal.JClinMicrobiol46:2222-6,2008
✓ Time to positivity of more than 30 h in peripheral blood can help exclude an intravascular catheter as the possible source of candidemia. Time to Blood Culture Positivity as a Marker for Catheter-Related Candidemia Ben-Ami R, et al. J Clin Microbiol 46:2222-6, 2008. 14
Additionofspecialfungalmediamayenhancethespeed&recoveryofcandidemiaJoURNALOF CLINICAL MICROBIOL.OGY,SepL.2007,P,3062-3064Vol. 45, No.,90095-1137/07/S08.00+0doi:10.1128/JCM.00966-07Detection of Fifteen Species of Candida in an Automated BloodCulture Systemy心Lynn L.Horvath,*Benjamin J.George,andDuaneR.HospenthalDeparmentof Medicine,BrookeAmyMedical Center,FortSamHouston,TexasReceived9May2007/Returnedformodification11June2007/Accepted28June2007Candidemia was simulated with 15 Candida spp.by using an automated blood culture system.Candidagrowthwasdetected in479/648(74%)bottles:211/216(98%)aerobicbottles,58/216(27%)anaerobicbottlesand 210/216 (97)mycology bottles.Only thegrowth of Candida lipolytica failed to be detected in all media.TABLE1,Numberof Candida isolates withgrowth detected bythe BacT/ALERT3DsystemNo, (%) of isolates detected in the following media with the indicated inoculae:Candida spp.Anaerobic medium (SN)Mycology medium (MB)Aerobic medium (FA)(no.of isolates)All media1010100101001001,0001,0001,000m.o5555555550550555555555352555955555555555255525555555555525552540.55555555352555155nn555nmn2555gC atbicans (5)43 (96)C. dubliniensis (5)34(76)00501100200024005012002000130 (67)C famata (5)15Cfimetaria (5)31 (69)45 (100))Cglabrata (5)1132030Cguilliermondi (5)31 (69)C. inconspicua (5)33(73)36 (80)Ckefr (5)32 (71)C. krusei (5)C. lipolytica (5)19 (42)52555835 (78)C. lusitaniae (5)100128Cnonegensis (2)12 (67)30 (67)Cparapsilosis (5)31 (69)C.nugosa (5)35 (78)C.tropicalis (5)16Total (72) Inoculum size in CFU per blood culture bottie. Each Candida species except C norvgensis had 45 botles, C.-nonvegensir had only 18.15C glabrata was the only species for which 100% growth was detected in all media at all inoculum sizes.cC. lipolyrica had the lowest growth detection rate (42%) of any of the Candida species
Addition of special fungal media may enhance the speed & recovery of candidemia 15