Invasive candidiasis (IC) is a leading cause of mycosis-associated mortality in the United States. We examined data from the National Center for Health Statistics and reviewed recent literature in order to update the epidemiology of IC. IC-associated mortality has remained stable, at approximately 0.4 deaths per 100,000 population, since 1997, while mortality associated with invasive aspergillosis has continued to decline. Candida albicans remains the predominant cause of IC, accounting for over half of all cases, but Candida glabrata has emerged as the second most common cause of IC in the United States, and several less common Candida species may be emerging, some of which can exhibit resistance to triazoles and/or amphotericin B. Crude and attributable rates of mortality due to IC remain unacceptably high and unchanged for the past 2 decades. Nonpharmacologic preventive strategies should be emphasized, including hand hygiene; appropriate use, placement, and care of central venous catheters; and prudent use of antimicrobial therapy. Given that delays in appropriate antifungal therapy are associated with increased mortality, improved use of early empirical, preemptive, and prophylactic therapies should also help reduce IC-associated mortality. Several studies have now identified important variables that can be used to predict risk of IC and to help guide preventive strategies such as antifungal prophylaxis and early empirical therapy. However, improved non-culture-based diagnostics are needed to expand the potential for preemptive (or early directed) therapy. Further research to improve diagnostic, preventive, and therapeutic strategies is necessary to reduce the considerable morbidity and mortality associated with IC.

Epidemiology of Invasive Candidiasis: a Persistent Public Health Problem

Background Zygomycosis is an increasingly emerging life-threatening infection. There is no single comprehensive literature review that describes the epidemiology and outcome of this disease. Methods We reviewed reports of zygomycosis in the English-language literature since 1885 and analyzed 929 eligible cases. We included in the database only those cases for which the underlying condition, the pattern of infection, the surgical and antifungal treatments, and survival were described. Results The mean age of patients was 38.8 years; 65% were male. The prevalence and overall mortality were 36% and 44%, respectively, for diabetes; 19% and 35%, respectively, for no underlying condition; and 17% and 66%, respectively, for malignancy. The most common types of infection were sinus (39%), pulmonary (24%), and cutaneous (19%). Dissemination developed in 23% of cases. Mortality varied with the site of infection: 96% of patients with disseminated disease died, 85% with gastrointestinal infection died, and 76% with pulmonary infection died. The majority of patients with malignancy (92 [60%] of 154) had pulmonary disease, whereas the majority of patients with diabetes (222 [66%] of 337) had sinus disease. Rhinocerebral disease was seen more frequently in patients with diabetes (145 [33%] of 337), compared with patients with malignancy (6 [4%] of 154). Hematogenous dissemination to skin was rare; however, 78 (44%) of 176 cutaneous infections were complicated by deep extension or dissemination. Survival was 3% (8 of 241 patients) for cases that were not treated, 61% (324 of 532) for cases treated with amphotericin B deoxycholate, 57% (51 of 90) for cases treated with surgery alone, and 70% (328 of 470) for cases treated with antifungal therapy and surgery. By multivariate analysis, infection due to Cunninghamella species and disseminated disease were independently associated with increased rates of death (odds ratios, 2.78 and 11.2, respectively). Conclusions Outcome from zygomycosis varies as a function of the underlying condition, site of infection, and use of antifungal therapy.

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Epidemiology and Outcome of Zygomycosis: A Review of 929 Reported Cases

This revision of the classification of unicellular eukaryotes updates that of Levine et al. (1980) for the protozoa and expands it to include other protists. Whereas the previous revision was primarily to incorporate the results of ultrastructural studies, this revision incorporates results from both ultrastructural research since 1980 and molecular phylogenetic studies. We propose a scheme that is based on nameless ranked systematics. The vocabulary of the taxonomy is updated, particularly to clarify the naming of groups that have been repositioned. We recognize six clusters of eukaryotes that may represent the basic groupings similar to traditional ''kingdoms.'' The multicellular lineages emerged from within monophyletic protist lineages: animals and fungi from Opisthokonta, plants from Archaeplastida, and brown algae from Stramenopiles.

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The new higher level classification of eukaryotes with emphasis on the taxonomy of protists

A system has been developed for the identification of aerobic actinomycetes in the clinical laboratory based on analysis of whole cells for diaminopimelic acid and carbohydrates and on the ability of the organism to decompose casein, tyrosine, and xanthine media. The whole-cell analyses were performed by a simple thin-layer chromatographic procedure that is described. Eighteen reference cultures were correctly identified and, subsequently, 35 isolates from clinical material were grouped by using this system. The method is well suited for use in routine clinical laboratories.

Simplified approach to identification of aerobic actinomycetes by thin-layer chromatography.

The health-care facility environment is rarely implicated in disease transmission, except among patients who are immunocompromised. Nonetheless, inadvertent exposures to environmental pathogens (e.g., Aspergillus spp. and Legionella spp.) or airborne pathogens (e.g., Mycobacterium tuberculosis and varicella-zoster virus) can result in adverse patient outcomes and cause illness among health-care workers. Environmental infection-control strategies and engineering controls can effectively prevent these infections. The incidence of health-care--associated infections and pseudo-outbreaks can be minimized by 1) appropriate use of cleaners and disinfectants; 2) appropriate maintenance of medical equipment (e.g., automated endoscope reprocessors or hydrotherapy equipment); 3) adherence to water-quality standards for hemodialysis, and to ventilation standards for specialized care environments (e.g., airborne infection isolation rooms, protective environments, or operating rooms); and 4) prompt management of water intrusion into the facility. Routine environmental sampling is not usually advised, except for water quality determinations in hemodialysis settings and other situations where sampling is directed by epidemiologic principles, and results can be applied directly to infection-control decisions. This report reviews previous guidelines and strategies for preventing environment-associated infections in health-care facilities and offers recommendations. These include 1) evidence-based recommendations supported by studies; 2) requirements of federal agencies (e.g., Food and Drug Administration, U.S. Environmental Protection Agency, U.S. Department of Labor, Occupational Safety and Health Administration, and U.S. Department of Justice); 3) guidelines and standards from building and equipment professional organizations (e.g., American Institute of Architects, Association for the Advancement of Medical Instrumentation, and American Society of Heating, Refrigeration, and Air-Conditioning Engineers); 4) recommendations derived from scientific theory or rationale; and 5) experienced opinions based upon infection-control and engineering practices. The report also suggests a series of performance measurements as a means to evaluate infection-control efforts.

Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)

A subcutaneous fungus infection that developed in a kidney transplant patient on immunosuppressive maintenance therapy was found to be caused by a new species of Phialophora. This species, P. paras...

A Case of Phaeohyphomycosis Caused by a New Species of Phialophora

▪ Abstract When the enigmatic fish pathogen, the rosette agent, was first found to be closely related to the choanoflagellates, no one anticipated finding a new group of organisms. Subsequently, a new group of microorganisms at the boundary between animals and fungi was reported. Several microbes with similar phylogenetic backgrounds were soon added to the group. Interestingly, these microbes had been considered to be fungi or protists. This novel phylogenetic group has been referred to as the DRIP clade (an acronym of the original members: Dermocystidium, rosette agent, Ichthyophonus, and Psorospermium), as the class Ichthyosporea, and more recently as the class Mesomycetozoea. Two orders have been described in the mesomycetozoeans: the Dermocystida and the Ichthyophonida. So far, all members in the order Dermocystida have been pathogens either of fish (Dermocystidium spp. and the rosette agent) or of mammals and birds (Rhinosporidium seeberi), and most produce uniflagellated zoospores. Fish pathogens al...

The Class Mesomycetozoea: A Heterogeneous Group of Microorganisms at the Animal-Fungal Boundary*

Laboratory manual for medical mycology.

The first isolation of Penicillium marneffei , obtained from the liver of a rat captured in Viet Nam, was described in 1956. There have been no additional reports of the isolation of this fungus. Recently our laboratory identified this organism in an isolate from the spleen of a patient with Hodgkin's disease. The distinctive features of P. marneffei include the production of the dark red pigment which diffuses into the agar and the ability of this pathogen to exist in dimorphic forms. At 25 C. it develops the structures typical of the genus Penicillium, while at 37 C. the tan, rough colony has a yeast-like consistency, with small, oval or round yeast cells averaging 3 μ in diameter mixed with short, hyphal elements. Histologically, the organism may resemble Histoplasm capsulatum .

Infection caused by Penicillium marneffei: description of first natural infection in man

To measure the incidence in the United States of systemic mycoses necessitating hospitalization, we reviewed discharge records of 1,875 hospitals participating in the Professional Activity Study of the Commission on Professional and Hospital Activities. Projected incidence rates in 1976 ranged from 23.0 per million for histoplasmosis to 0.2 per million for blastomycosis. High prevalences of leukemia or lymphoma (5.9% to 10.2%) or of other malignancies (9.9% to 13.2%) were recorded in patients with aspergillosis, candidiasis, or cryptococcosis. High prevalences of chronic obstructive lung disease (9.6% to 9.9%) were recorded in those with aspergillosis or histoplasmosis. Marked increases from 1970 to 1976 were found in the incidence of aspergillosis (158%), actinomycosis (92%), cryptococcosis (78%), and coccidioidomycosis (74%). Increasing numbers of persons with immunosuppressive conditions, migration of susceptible persons into hyperendemic areas, and aging of the population contributed to the increases. ( JAMA 242:1631-1635, 1979)

Libero Ajello

Papers

A Case of Phaeohyphomycosis Caused by a New Species of Phialophora

The Class Mesomycetozoea: A Heterogeneous Group of Microorganisms at the Animal-Fungal Boundary*

Laboratory manual for medical mycology.

Infection caused by Penicillium marneffei: description of first natural infection in man

Aspergillosis and Other Systemic Mycoses: The Growing Problem