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Background:Candida spp can cause a variety of infections known as candidiasis, ranging from severe invasive infections to superficial mucosal infections of the mouth and vagina. Fluconazole, a triazole antifungal, is commonly prescribed to treat candidiasis but increasing fluconazole resistance is a growing concern for several Candida spp. Although C. albicans has historically been the most common cause of candidiasis, other species are increasingly common and antifungal resistance is more prevalent in these non-albicans species, including C. glabrata, C. parapsilosis, and C. tropicalis, which were the focus of this analysis. Methods: We used the PINC AI healthcare data (PHD) database to examine fluconazole resistance for inpatient isolates between 2012 and 2021 from 187 US acute-care hospitals with at least 1 Candida spp culture with a fluconazole susceptibility result over the entire period. We calculated annual percentage fluconazole resistance for C. glabrata, C. tropicalis, and C. parapsilosis isolates using the clinical laboratory interpretation for resistance. Results: We identified 4,264 C. glabrata, 2,482 C. parapsilosis, and 2,283 C. tropicalis isolates between 2012 and 2021 with susceptibility results. The percentage of C. glabrata isolates resistant to fluconazole doubled between 2020 and 2021 (14.6% vs 29.3%) (Fig. 1a). The percentage of C. parapsilosis isolates resistant to fluconazole steadily increased since 2017 (Fig. 1b), with an 82% increase in 2021 compared with 2020 (3.8% in 2020 vs 6.9% in 2021). Fluconazole resistance among C. tropicalis isolates varied over the years, with a 0.3% decrease in 2021 from 2020 (Fig. 1c). Of hospitals reporting at least 1 result each year 2020–2021, 44% observed an increase in the proportion of C. glabrata isolates resistant to fluconazole in 2021 compared to 2020. Conclusions: Our analysis highlights a concerning increase in fluconazole resistance among C. glabrata and C. parapsilosis isolates in 2021 compared with previous years. Further investigation of the observed increases in fluconazole resistance among these Candida spp could provide further insight on potential drivers of resistance or limitations in reported results from large databases. More analyses are needed to understand rates, sites of Candida infections, and risk factors (eg, antifungal exposure) associated with resistance.
Indoor mold after flooding poses health risks, including rare but serious invasive mold infections. The purpose of this study was to evaluate use of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes for mold infection and mold exposure in Houston, Texas, during the year before and the year after Hurricane Harvey.
This study used data from MarketScan, a large health insurance claims database.
The incidence of invasive mold infections remained unchanged in the year after Hurricane Harvey; however, the incidence of diagnosis codes for mold exposure nearly doubled compared with the year before the hurricane (6.3 vs 11.0 per 100 000 enrollees, rate ratio: 1.7, 95% confidence interval 1.0–3.1).
Diagnosis codes alone may not be sufficiently sensitive to detect changes in invasive mold infection rates within this population and time frame, demonstrating the need for more comprehensive studies.
Widespread inappropriate antibiotic prescribing is a major driver of resistance. Little is known about antifungal prescribing practices in the United States, which is concerning given emerging resistance in fungi, particularly to azole antifungal agents.
We analyzed outpatient antifungal prescribing data in the United States to inform stewardship efforts.
Descriptive analysis of outpatient antifungal prescriptions dispensed during 2018 in the IQVIA Xponent database.
Prescriptions were summarized by drug, sex, age, geography, and healthcare provider specialty. Census denominators were used to calculate prescribing rates among demographic groups.
Healthcare providers prescribed 22.4 million antifungal courses in 2018 (68 prescriptions per 1,000 persons). Fluconazole was the most commonly prescribed drug (75%), followed by terbinafine (11%) and nystatin (10%). Prescription rates were higher among females versus males (110 vs 25 per 1,000 population) and adults versus children (82 vs 27 per 1,000 population). Prescription rates were highest in the South (81 per 1,000 population) and lowest in the West (48 per 1,000 population). Nurse practitioners and family practitioners prescribed the most antifungals (43% of all prescriptions), but the highest prescribing rates were among obstetrician-gynecologists (84 per provider).
Prescribing antifungal drugs in the outpatient setting is common, with enough courses dispensed for 1 in every 15 US residents in 2018. Fluconazole use patterns suggest vulvovaginal candidiasis as a common indication. Regional prescribing differences could reflect inappropriate use or variations in disease burden. Further study of higher antifungal use in the South could help target antifungal stewardship practices.
With this survey, we investigated healthcare-associated invasive mold infection (HA-IMI) surveillance and air sampling practices in US acute-care hospitals. More than half of surveyed facilities performed HA-IMI surveillance and air sampling. HA-IMI surveillance was more commonly performed in academic versus nonacademic facilities. HA-IMI case definitions and sampling strategies varied widely among respondents.
A common type of fungal disease investigation involves hospital-associated clusters of invasive mold infections (IMIs), which typically occur among immunocompromised patients. Responding to IMI clusters can be challenging for public health and hospital personnel for several reasons such as difficulty of confirming the existence of an outbreak, difficulty of determining source. Although many resources exist to guide patient notification about healthcare incidents (eg, bloodborne exposures, disease outbreaks), IMI clusters involve special considerations related to the complex diseases, uncertain exposures, and differential benefits and risks of notification. Early, nuanced communication about hospital-associated IMI clusters is almost always the best course of action to help reduce risks to patients’ health and foster trust between patients and hospitals.
Background:Candida auris is of global concern due to its increasing frequency in intensive care units (ICUs), reported resistance to antifungal agents, propensity to cause outbreaks, and persistence in clinical environments. We investigated an increase in C. auris cases in an ICU in Kenya to determine the source of transmission and to control the spread of the disease. Methods: To identify cases, we reviewed laboratory records of patients with blood cultures yielding C. auris and organisms for which it is commonly misidentified by Vitek 2 v 8.01 software (ie, C. haemulonii, C. duobushaemulonii and C. famata) during January 2018–May 2019. We retrospectively reviewed medical charts of C. auris patients to extract information on demographics, underlying conditions, hospital procedures, treatments, and outcomes. We also enhanced infection control efforts by implementing contact precautions, equipment, and environmental disinfection, and hand hygiene training and compliance observations. Results: We identified 32 C. auris patients (Fig. 1). Median patient age was 55 years (IQR, 43–65), and 57% were male. Length of hospitalization before C. auris isolation was 30 days (IQR, 14–36). All had been admitted to the ICU. The most common reasons for admission were sepsis (50%), pneumonia (34%), surgery (25%), and stroke or other neurologic diagnosis (25%). Underlying comorbidities included hypertension (38%), diabetes mellitus (25%), and malignancy (29%). Two patients had HIV. Moreover, 61% of cultures yielded multidrug-resistant bacteria. Also, 33% of the patients had been admitted to this hospital in the preceding 3 months; 21% had been admitted to a hospital outside of Kenya; and 10% had been admitted to another hospital in Kenya in the previous year. Almost all (97%) had a central venous catheter, 45% had an acute dialysis catheter, 66% had an endotracheal tube, and 34% had a tracheostomy, with 69% receiving mechanical ventilation before C. auris isolation. Most (94%) had urinary catheters, 84% had nasogastric tubes, 91% had received total parenteral nutrition, and 75% had received blood products. All patients received broad-spectrum antibiotics and 49% received an antifungal before C. auris isolation. All-cause in-hospital mortality was 64% for the 28 patients whose outcomes were available. Following implementation of a hand hygiene campaign and improved equipment and environmental disinfection, no further cases were identified. Conclusions: We identified C. auris bloodstream infections associated with high all-cause mortality in a Kenyan hospital ICU. All patients had treatments and procedures suggesting severe underlying illness. Enhanced infection control contained the outbreak.
Background: In February 2019, the Orange County Health Care Agency (OCHCA) identified an outbreak of Candida auris, an emerging fungus that spreads rapidly in healthcare facilities. Patients in long-term acute-care hospitals (LTACHs) and skilled nursing facilities that provide ventilator care (vSNFs) are at highest risk for C. auris colonization. With assistance from the California Department of Public Health and the Centers for Disease Control and Prevention, OCHCA instituted enhanced surveillance, communication, and screening processes for patients colonized with or exposed to C. auris. Method: OCHCA implemented enhanced surveillance by conducting point-prevalence surveys (PPSs) at all 3 LTACHs and all 14 vSNFs in the county. Colonized patients were identified through axilla/groin skin swabbing with C. auris detected by PCR and/or culture. In facilities where >1 C. auris colonized patient was found, PPSs were repeated every 2 weeks to identify ongoing transmission. Retrospective case finding was instituted at 2 LTACHs with a high burden of colonized patients; OCHCA contacted patients discharged after January 1, 2019, and offered C. auris screening. OCHCA tracked the admission or discharge of all colonized patients, and facilities with ongoing transmission were required to report transfers of any patient, regardless of colonization status. OCHCA tracked all patients discharged from facilities with ongoing transmission to ensure that accepting facilities conducted admission surveillance testing of exposed patients and implemented appropriate environmental and contact precautions. Result: From February–October 2019, 192 colonized patients were identified. All 3 LTACHs and 6 of 14 VSNFs had at least 1 C. auris–colonized patient identified on initial PPS, and 2 facilities had ongoing transmission identified on serial PPS. OCHCA followed 96 colonized patients transferred a total of 230 times (an average of 2.4 transfers per patient) (Fig. 1) and 677 exposed patients discharged from facilities with ongoing transmission (Fig. 2). Admission screening of 252 exposed patients on transfer identified 13 (5.2%) C. auris–colonized patients. As of November 1, 2019, these 13 patients were admitted 21 times to a total of 6 acute-care hospitals, 2 LTACHs, and 3 vSNFs. Transferring facilities did not consistently communicate the colonized patient’s status and the requirements for isolation and testing of exposed patients. Conclusion: OCHCA oversight of interfacility transfer, though labor-intensive, improved identification of patients colonized with C. auris and implementation of appropriate environmental and contact precautions, reducing the risk of transmission in receiving healthcare facilities.
Background: Candidemia is associated with high morbidity and mortality. Although risk factors for candidemia and other bloodstream infections (BSIs) overlap, little is known about patient characteristics and the outcomes of polymicrobial infections. We used data from the CDC Emerging Infections Program (EIP) candidemia surveillance to describe polymicrobial candidemia infections and to assess clinical differences compared with Candida-only BSIs. Methods: During January 2017–December 2017 active, population-based candidemia surveillance was conducted in 45 counties in 9 states covering ~6% of the US population through the CDC EIP. A case was defined as a blood culture with Candida spp in a surveillance-area resident; a blood culture >30 days from the initial culture was considered a second case. Demographic and clinical characteristics were abstracted from medical records by trained EIP staff. We examined characteristics of polymicrobial cases, in which Candida and ≥1 non-Candida organism were isolated from a blood specimen on the same day, and compared these to Candida-only cases using logistic regression or t tests using SAS v 9.4 software. Results: Of the 1,221 candidemia cases identified during 2017, 215 (10.2%) were polymicrobial. Among polymicrobial cases, 50 (23%) involved ≥3 organisms. The most common non-Candida organisms were Staphylococcus epidermidis (n = 30, 14%), Enterococcus faecalis (n = 26, 12%), Enterococcus faecium (n = 17, 8%), and Staphylococcus aureus, Klebsiella pneumoniae, and Stenotrophomonas maltophilia (n = 15 each, 7%). Patients with polymicrobial cases were significantly younger than those with Candida-only cases (54.3 vs 60.7 years; P < .0004). Healthcare exposures commonly associated with candidemia like total parenteral nutrition (relative risk [RR], 0.82; 95% CI, 0.60–1.13) and surgery (RR, 0.99; 95% CI, 0.77–1.29) were similar between the 2 groups. Polymicrobial cases had shorter median time from admission to positive culture (1 vs 4 days, P < .001), were more commonly associated with injection drug use (RR, 1.95; 95% CI, 1.46–2.61), and were more likely to be community onset-healthcare associated (RR, 1.91; 95% CI, 1.50–2.44). Polymicrobial cases were associated with shorter hospitalization (14 vs 17 days; P = .031), less ICU care (RR, 0.7; 95% CI, 0.51–0.83), and lower mortality (RR, 0.7; 95% CI, 0.50–0.92). Conclusions: One in 10 candidemia cases were polymicrobial, with nearly one-quarter of those involving ≥3 organisms. Lower mortality among polymicrobial cases is surprising but may reflect the younger age and lower severity of infection of this population. Greater injection drug use, central venous catheter use, and long-term care exposures among polymicrobial cases suggest that injection or catheter practices play a role in these infections and may guide prevention opportunities.
We tested 9 disinfectants against Candida auris using the quantitative disk carrier method EPA-MB-35-00: 5 products with hydrogen peroxide or alcohol-based chemistries were effective and 4 quaternary ammonium compound-based products were not. This work supported a FIFRA Section 18 emergency exemption granted by the US Environmental Protection Agency to expand disinfectant guidance for C. auris.
Whole-genome sequencing confirmed the presence of a Malassezia pachydermatis outbreak among neonates in a neonatal intensive care unit. This technology supports the importance of adhering to infection prevention measures.
Cardiovascular and respiratory disorders
Brendan Carvalho, Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA,
Ethan Jackson, Clinical Assistant Professor of Cardiothoracic Anesthesia; Director of Intraoperative Transesophageal Echocardiography; Division Chief of Adult Congenital Cardiothoracic Anesthesia, Stanford University, Medical Center, Lucille Packard Children's Hospital Stanford, CA, USA
This chapter will outline the physiological changes, hemodynamic goals, management, and anesthetic options with regards to patients with acquired or congenital structural heart disease during pregnancy, labor, and delivery. There is no consensus as to the optimal anesthetic technique for the conditions being discussed. General and regional anesthesia can have significant cardiovascular effects on a parturient with cardiac disease. In addition, many pharmacological agents commonly used in anesthetic and obstetric practice can have adverse hemodynamic effects (Table 1.1).
Due to the nature and the rarity of the cardiac diseases discussed, there is a lack of randomized controlled studies to guide our practice. As a result, case reports and expert opinion will form the basis of discussing the anesthetic techniques. However, management options and anesthetic techniques must be individualized and based on the prevailing hemodynamic condition and obstetric needs.
Scope of the problem
An estimated 0.2–3.0% of pregnant patients have cardiac disease, an increasing cause of maternal mortality. The 2000– 2 Confidential Enquiries into Maternal Deaths in the United Kingdom reported that cardiac disease was the second most common nonobstetric cause of maternal death after psychiatric disease. Cardiac disease is also more common than the leading direct causes of maternal death. The maternal mortality rate ranges from 0.4% in New York Heart Association (NYHA) class I–II women to 6.8% in class III–IV (Tables 1.2 and 1.3).