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      Incidence and Outcome of Documented Fungal Endocarditis

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          Abstract

          Background:

          Fungal endocarditis, the most severe form of infective endocarditis, is characterized by excessive mortality and morbidity.

          Objectives:

          The present study aimed to analyze the characteristics of fungal endocarditis to improve the management of these patients.

          Materials and Methods:

          In this cross-sectional study, vegetations on the mitral or tricuspid valves and embolic material surgically removed from the patients with suspected infective endocarditis between December 2009 and November 2011 were examined for fungal infection by direct smear and culture, and the susceptibility patterns of the isolated species were determined. Then, blood samples were cultured on BACTEC media and real-time PCR was done with blood and tissue samples.

          Results:

          Of the 31 patients with suspected infective endocarditis who did not respond to antibacterial therapy, 11 had confirmed fungal endocarditis. The most frequent predisposing risk factors were previous surgery and drug abuse. The organisms isolated were Aspergillus spp. and Candida albicans. Resistance to amphotericin B and itraconazole was observed in Aspergillus species, and to fluconazole in Candida albicans. Positive PCR results were obtained in blood and tissue samples.

          Conclusions:

          Fungal endocarditis should be considered in the patients not responsive to antimicrobials. Moreover, management of these patients can be improved with molecular diagnostic methods and by determining the susceptibility patterns of the etiologic agents.

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          Most cited references22

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          Fungal endocarditis: evidence in the world literature, 1965-1995.

          We analyzed 270 cases of fungal endocarditis (FE) that occurred over 30 years. Vascular lines, non-cardiac surgery, immunocompromise and injection drug abuse are increasing risk factors. Delayed or mistaken diagnosis (82% of patients), long duration of symptoms before hospitalization (mean +/- standard deviation, 32+/-39 days) and extracardiac manifestations were characteristic. From 1988 onwards, 72% of patients were diagnosed preoperatively, compared with 43% before 1988 (P=.0001). The fungi most commonly isolated were Candida albicans (24% of patients), non-albicans species of Candida (24%), Apergillus species (24%), and Histoplasma species (6%); recently-emerged fungi accounted for 25% of cases. The mortality rate was 72%. Survival rates were better among patients who received combined surgical-antifungal treatment, were infected with Candida, and had univalvular involvement. Improvement in the survival rate (from or =4 years while on prophylactic antifungal therapy.
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            Fungal endocarditis, 1995-2000.

            One hundred fifty-two cases of fungal endocarditis (FE) were identified in the English-language literature between January 1, 1995, and June 30, 2000. Although the median age of patients (44 years) was relatively young, injection drug use was identified as a risk factor in only 4.1% of cases. Other factors, including underlying cardiac abnormalities (47.3%), prosthetic valves (44.6%), and central venous catheters (30.4%), were more commonly identified as predisposing conditions and reflect the changing epidemiology of the syndrome. Unfortunately, mortality remains unacceptably high, particularly for patients with Aspergillus-related FE. Novel therapies are needed to improve patient outcomes.
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              In vitro susceptibilities of Candida spp. to caspofungin: four years of global surveillance.

              Caspofungin is being used increasingly as therapy for invasive candidiasis. Prospective sentinel surveillance for emergence of in vitro resistance to caspofungin among invasive Candida spp. isolates is indicated. We determined the in vitro activity of caspofungin against 8,197 invasive (bloodstream or sterile-site) unique patient isolates of Candida collected from 91 medical centers worldwide from 1 January 2001 to 31 December 2004. We performed antifungal susceptibility testing according to the Clinical and Laboratory Standards Institute (CLSI, formerly NCCLS) M27-A2 method and used a 24-h prominent inhibition endpoint for determination of the MIC. Of 8,197 invasive Candida spp. isolates, species distribution was as follows: 54% Candida albicans, 14% C. glabrata, 14% C. parapsilosis, 11% C. tropicalis, 3% C. krusei, and 4% other Candida spp. Overall, caspofungin was very active against Candida (MIC50/MIC90, 0.03/0.25 microg/ml; 98.2% were inhibited at a MIC of 1 microg/ml, 12 isolates were C. parapsilosis, 6 isolates were C. guilliermondii, 2 isolates were C. rugosa, and 1 isolate each was C. albicans, C. glabrata, C. krusei, C. lusitaniae, and C. tropicalis. There was no significant change in caspofungin activity over the 4-year study period. Likewise, there was no difference in activity by geographic region. Caspofungin has excellent in vitro activity against invasive clinical isolates of Candida from centers worldwide. Our prospective sentinel surveillance reveals no evidence of emerging caspofungin resistance among invasive clinical isolates of Candida.
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                Author and article information

                Journal
                Int Cardiovasc Res J
                Int Cardiovasc Res J
                Safnek
                International Cardiovascular Research Journal
                Safnek
                2251-9130
                2251-9149
                01 December 2014
                December 2014
                : 8
                : 4
                : 152-155
                Affiliations
                [1 ]Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
                [2 ]Cardiothoracic Surgery Unit, Shiraz University of Medical Sciences, Shiraz, IR Iran
                Author notes
                [* ]Corresponding author: Parisa Badiee, Professor Alborzi Clinical Microbiology Research Center, Nemazi Hospital, Zand Ave., 7193711351, Shiraz, IR Iran, Tel: +98-7116474296, Fax: +98-7116474303, E-mail: badieep@ 123456sums.ac.ir
                Article
                10.1016/j.ypat.2015.07.028
                4302502
                25614858
                0fb31252-388f-47bd-a12a-63456edc18c1
                Copyright © 2014, International Cardivascular Research Journal

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

                History
                : 13 April 2014
                : 08 July 2014
                Categories
                Research Article

                endocarditis,aspergillus,candida,fungus susceptibility
                endocarditis, aspergillus, candida, fungus susceptibility

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