Cryptococcal infections over a 15 year period at a tertiary facility & impact of guideline management

Introduction: The aim of this research paper is to determine the incidence, risk factors and clinical outcome of all patients diagnosed and treated for cryptococcosis at our institution. We also aim to compare treatment outcome following introduction of the 2010 Infectious Disease Society of America (IDSA) guidelines. Methods: Retrospective analysis of all patients diagnosed and treated for cryptococcal infection occurring between January 2001 and December 2015. Results: Of 102 patients diagnosed with cryptococcal infection, 97 were eligible for study inclusion. There appears to be an overall increased incidence of cryptococcosis in both transplant and non-transplant cohorts with a peak in 2015 of 6 transplant and 13 non-transplant cases. 38/52 (73%) of identified isolates were C. neoformans, and 14/52 (27%) were C. gattii. Notably, 14/14 (100%) of C. gattii isolates were associated with meningitis, as compared to only 38/64 (59%) C. neoformans associated with meningitis (p: 0.003). It appears that patients presenting with cough are less likely to have meningitis, 17/27 (63%), (p: 0.005). When stratifying for culture positive meningitis lumbar puncture opening pressure, the median in the culture positive cohort was 31.5cmH2 O compared with 15.5cmH2O (p:0.036). Multiple admissions were required prior to diagnosis in the majority of cases with only 18/72 (25%) diagnosed on 1st presentation. Post-guideline mortality has improved from 17.1% to 6.1% (p: 0.046). Conclusion: Cryptococcal infection remains relatively uncommon, but there appears to be an increasing trend in incidence. Overall mortality is relatively low and has improved since introduction of the 2010 IDSA guidelines

Mucormycosis in Australia: Contemporary epidemiology and outcomes

Mucormycosis is the second most common cause of invasive mould infection and causes disease in diverse hosts, including those who are immuno-competent. We conducted a multicentre retrospective study of proven and probable cases of mucormycosis diagnosed between 2004–2012 to determine the epidemiology and outcome determinants in Australia. Seventy-four cases were identified (63 proven, 11 probable). The majority (54.1%) were caused by Rhizopus spp. Patients who sustained trauma were more likely to have non-Rhizopus infections relative to patients without trauma (OR 9.0, p 0.001, 95% CI 2.1–42.8). Haematological malignancy (48.6%), chemotherapy (42.9%), corticosteroids (52.7%), diabetes mellitus (27%) and trauma (22.9%) were the most common co-morbidities or risk factors. Rheumatological/autoimmune disorders occurred in nine (12.1%) instances. Eight (10.8%) cases had no underlying co-morbidity and were more likely to have associated trauma (7/8; 87.5% versus 10/66; 15.2%; p <0.001). Disseminated infection was common (39.2%). Apophysomyces spp. and Saksenaea spp. caused infection in immuno-competent hosts, most frequently associated with trauma and affected sites other than lung and sinuses. The 180-day mortality was 56.7%. The strongest predictors of mortality were rheumatological/autoimmune disorder (OR = 24.0, p 0.038 95% CI 1.2–481.4), haematological malignancy (OR = 7.7, p 0.001, 95% CI 2.3–25.2) and admission to intensive care unit (OR = 4.2, p 0.02, 95% CI 1.3–13.8). Most deaths occurred within one month. Thereafter we observed divergence in survival between the haematological and non-haematological populations (p 0.006). The mortality of mucormycosis remains particularly high in the immuno-compromised host. Underlying rheumatological/autoimmune disorders are a previously under-appreciated risk for infection and poor outcome

Determinants of mortality in non-neutropenic ICU patients with candidaemia

Introduction: Candidaemia in critically-ill intensive care unit (ICU) patients is associated with high crude mortality. Determinants of mortality – particularly those amenable to potential modification – are incompletely defined. Methods: A nationwide prospective clinical and microbiological cohort study of all episodes of ICU-acquired candidaemia occurring in non-neutropenic adults was undertaken in Australian ICUs between 2001 and 2004. Multivariate Cox regression analyses were performed to determine independently significant variables associated with mortality. Results: 183 episodes of ICU-acquired candidaemia occurred in 183 patients during the study period. Of the 179 with microbiological data, Candida albicans accounted for 111 (62%) episodes and Candida glabrata, 32 (18%). Outcome data were available for 173: crude hospital mortality at 30 days was 56%. Host factors (older age, ICU admission diagnosis, mechanical ventilation and ICU admission diagnosis) and failure to receive systemic antifungal therapy were significantly associated with mortality on multivariate analysis. Among the subset who received initial fluconazole therapy (n = 93), the crude mortality was 52%. Host factors (increasing age and haemodialysis receipt), but not organism- (Candida species, fluconazole MIC), pharmacokinetic- (fluconazole dose, time to initiation), or pharmacodynamic-related parameters (fluconazole dose:MIC ratio) were associated with mortality. Process of care measures advocated in recent guidelines were implemented inconsistently: follow-up blood cultures were obtained in 68% of patients, central venous catheters removed within five days in 80% and ophthalmological examination performed in 36%. Conclusions: Crude mortality remains high in Australian ICU patients with candidaemia and is overwhelmingly related to host factors but not treatment variables (the time to initiation of antifungals or fluconazole pharmacokinetic and pharmacodynamic factors). The role and timing of early antifungal intervention in critically-ill ICU patients requires further investigation.Deborah J.E. Marriott, E. Geoffrey Playford, Sharon Chen, Monica Slavin, Quoc Nguyen, David Ellis and Tania C. Sorrell for the Australian Candidaemia Stud

Supervised self-administration of outpatient parenteral antibiotic therapy: a report from a large tertiary hospital in Australia

Introduction: Outpatient parenteral antibiotic therapy (OPAT) has become established as a standard of care in most Australian hospitals to treat a variety of infections. Since 1998, the Alternate Site Infusion Service (ASIS) has provided an OPAT service to five hospitals in southern Brisbane, Queensland, using predominantly a patient or carer administration model (self-administered, S-OPAT). The aim of this study was to evaluate outcomes of our S-OPAT programme. Methods: Consecutive patients treated by ASIS at the Princess Alexandra Hospital from January 1, 2011 to December 31, 2011 were reviewed. Data on patient demographics, diagnoses, microbiology, antimicrobial therapy, duration, outcome, and complications were sourced from a prospectively collected database and from patient medical records. Results: There were 150 episodes involving 144 patients resulting in 3520 days of OPAT; the median duration on the programme was 22 days (range 4–106 days). Patient or carer administration occurred in the majority of episodes. The most common indication by far was bone or joint infection (47% of patients), followed by infective endocarditis (9%). Staphylococcus aureus was the most frequently treated organism. The overall cure rate was 93%. On multivariate analysis, patients with two or more comorbidities had an increased risk of failure. Line-related complications occurred in 1.4/1000 catheter-days. Rash was the most common drug-related event. Despite the extensive use of broad-spectrum antibiotics there were no cases of Clostridium difficile infection during therapy and for up to 28 days post cessation of intravenous antibiotics. The cost of OPAT per patient excluding drug administration and home visits was approximately A$150.00/day, significantly lower than the cost of an inpatient bed, which is estimated to be A$ 500–800/day.5 Conclusion: OPAT using a patient or carer administration model is an effective and safe option for the management of selected patients with infection requiring intravenous antibiotics

Cryptococcal infections over a 15 year period at a tertiary facility & impact of guideline management

Introduction: The aim of this research paper is to determine the incidence, risk factors and clinical outcome of all patients diagnosed and treated for cryptococcosis at our institution. We also aim to compare treatment outcome following introduction of the 2010 Infectious Disease Society of America (IDSA) guidelines. Methods: Retrospective analysis of all patients diagnosed and treated for cryptococcal infection occurring between January 2001 and December 2015. Results: Of 102 patients diagnosed with cryptococcal infection, 97 were eligible for study inclusion. There appears to be an overall increased incidence of cryptococcosis in both transplant and non-transplant cohorts with a peak in 2015 of 6 transplant and 13 non-transplant cases. 38/52 (73%) of identified isolates were C. neoformans, and 14/52 (27%) were C. gattii. Notably, 14/14 (100%) of C. gattii isolates were associated with meningitis, as compared to only 38/64 (59%) C. neoformans associated with meningitis (p: 0.003). It appears that patients presenting with cough are less likely to have meningitis, 17/27 (63%), (p: 0.005). When stratifying for culture positive meningitis lumbar puncture opening pressure, the median in the culture positive cohort was 31.5cmH2 O compared with 15.5cmH2O (p:0.036). Multiple admissions were required prior to diagnosis in the majority of cases with only 18/72 (25%) diagnosed on 1st presentation. Post-guideline mortality has improved from 17.1% to 6.1% (p: 0.046). Conclusion: Cryptococcal infection remains relatively uncommon, but there appears to be an increasing trend in incidence. Overall mortality is relatively low and has improved since introduction of the 2010 IDSA guidelines

Nuevos registros palinológicos en los depósitos glacimarinos de la formación el paso (Serpukhoviano tardío-Bashkiriano), Precordillera Argentina: implicancias bioestratigráficas.

Se presenta nueva información palinológica para la Formación El Paso. Esta unidad aflora en el sector austral de la Sierra de Barreal, provincia de San Juan, Argentina (Cuenca Calingasta-Uspallata), y las asociaciones palinológicas se recuperaron de la parte media a superior de la sección. Contiene abundantes esporas trilete (75–907%) e hilate (1–57%), asignadas a Cyclogranisporites rinconadensis, Apiculatisporis variornatus, Raistrickia rotunda, Tricidarisporites gutii, Ahrensisporites sp. cf. A. cristatus, Cristatisporites stellatus, Indotriradites volkheimeri, Vallatisporites ciliaris y Psomospora detecta, entre otros. También, granos de polen subordinados (1,5–20%): Circumplicatipollis plicatus, Costatascyclus crenatus, Plicatipollenites sp. cf. P. malabarensis, Potonieisporites spp., Divarisaccus sp. cf. D. stringoplicatus. Acritarcos retrabajados y autóctonos (e.g., Cymatyogalea sp., Gorgonisphaeridium sp., Verhyachium sp.) y algas Zygnematalean (Tetraporina sp., Brazilea scisa) estan presentes con menos de 2,57%. Se propone una edad serpukhoviana tardía-bashkiriana y la correlación con la Subzona A de la Biozona Raistrickia densa-Convolutlspora muriornata (DM) para las asociaciones de la Formación El Paso.New palynological information from the El Paso Formation cropping out at the southern Sierra de Barreal (Calingasta-Uspallata Basin), San Juan Province, Argentina is presented. The palynologic assemblages were recovered from the middle to upper part of the section. Abundant trilete (75–90%) and hilate (1–57%) spore species are recognized: Cyclogranisporites rinconadensis, Apiculatisporis variornatus, Raistrickia rotunda, Tricidarisporites gutii, Ahrensisporites sp. cf. A. cristatus, Cristatisporites stellatus, Indotriradites volkheimeri, Vallatisporites ciliaris and Psomospora detecta, among others. Also, subordinate pollen grains (1.5–207%): Circumplicatipollis plicatus, Costatascyclus crenatus, Plicatipollenites sp. cf. P. malabarensis, Potonieisporites spp. and Divarisaccus sp. cf. D. stringoplicatus. Recycled and autochthonous acritarchs (e.g., Cymatiogalea sp., Gorgonisphaeridium sp., Verhyachium sp.) and Zygnematalean algae (Tetraporina sp., Brazilea scisa) with less of 2.57% are also present. We propose a late Serpukhovian-Bashkirian age, and a correlation with the Subzone A of the Raistrickia densa-Convolutispora muriornata (DM) Biozone to the El Paso assemblages.Fil: Vergel, Maria del Milagro. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Tucumán. Instituto Superior de Correlación Geológica. Universidad Nacional de Tucumán. Facultad de Ciencias Naturales e Instituto Miguel Lillo. Departamento de Geología. Cátedra Geología Estructural. Instituto Superior de Correlación Geológica; ArgentinaFil: Cisterna, Gabriela Adriana. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional de La Rioja; ArgentinaFil: Sterren, Andrea Fabiana. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Córdoba. Centro de Investigaciones en Ciencias de la Tierra. Universidad Nacional de Córdoba. Facultad de Ciencias Exactas Físicas y Naturales. Centro de Investigaciones en Ciencias de la Tierra; Argentina. Universidad Nacional de Córdoba. Facultad de Ciencias Exactas Físicas y Naturales. Centro de Investigaciones Paleobiológicas; Argentin